Currently, the United States (U.S.) has the highest maternal mortality rate1 among all developed countries. According to the most recent statistics2 from the Centers for Disease Control and Prevention, the maternal mortality rate in the U.S. in 2019 was 20.1 deaths per 100,000 live births, which is an increase from 17.4 in the previous year. For Black, Indigenous and people of color (BIPOC), the rates are 2.5 to 3.5 times higher3 than those for non-Hispanic White individuals. The rate of preterm births also continues to rise, particularly among BIPOC, and overall one in ten infants4 is born preterm. With approximately half of all births5 in the U.S. covered by Medicaid, state Medicaid programs and their managed care partners are uniquely positioned to address these poor health outcomes and the disparities that are present in the maternal health space.
With increased awareness of these adverse outcomes, federal and state policymakers have put forward various proposals for how the Medicaid program can address them. Four trends have emerged in these policy conversations. As Congress and state legislatures continue to develop and refine new policies and regulations, there are important elements that should be considered to help our collective effort to support healthy pregnancies, ensure positive birth outcomes, and address disparities and health inequities to best meet the needs of pregnant and parenting Medicaid members.
Trend 1: Address disparities that lead to inequities in maternal health outcomes
The Biden administration and Congress have both elevated the need to address the inequities that exist in maternal health outcomes. During Black Maternal Health Week6, the Department of Health and Human Services (HHS) announced funding and policy actions focused on addressing health disparities among pregnant and parenting individuals. Legislation has been introduced in both the U.S. House of Representatives and the U.S. Senate that includes various new policies7 to address maternal health disparities. Similarly, state legislatures have advanced various pieces of legislation8 to study and address maternal health outcomes.
Access to data is critical to identifying disparities and addressing inequities. The ability to readily and reliably disaggregate and monitor metrics by data points, such as race and ethnicity, is an important consideration in this policy discussion. As policymakers debate legislation and draft regulations related to disparities and inequities, they should be sure to include a focus on consistent data collection and data access among providers and health plans. This will help support identifying trends in care quality and provider progress toward reducing disparities.
Trend 2: Extend postpartum coverage beyond current 60-day limit
The postpartum period can be a medically vulnerable time, with upwards of 50 percent of maternal health deaths9 occurring during this period (one day to one year after delivery). However, current Medicaid coverage extends only 60 days post-delivery. More than 30 states have introduced legislation and/or have already submitted waivers focused on extending coverage beyond the current 60-day authorized coverage limit to the Centers for Medicare and Medicaid Services (CMS). At the federal level, the American Rescue Plan10 recently provided an option for states to expand postpartum coverage to 12 months for up to five years through a state plan amendment. To date, CMS has approved extension of postpartum coverage in three states (Georgia, Illinois and Missouri).
As states consider this policy shift, not all will authorize extension to a full year (Georgia’s waiver approves coverage up to 6 months)11 or for all populations (Missouri’s waiver extends coverage only for individuals diagnosed with a substance use disorder [SUD])12; however, access to both physical (pregnancy and non-pregnancy related) and behavioral health services should be a part of any request. Some contributions to maternal deaths are pregnancy related (e.g., bleeding, infection), but deaths later in the postpartum period may be attributed to physical health issues (e.g., heart disease) that were present before the pregnancy. Additionally, the physical and emotional challenges associated with caring for a newborn and recovering from a pregnancy can lead to exacerbated behavioral health conditions, can trigger relapses in those with SUDs, and can increase suicidal ideations.13
Trend 3: Cover comprehensive array of clinical and non-clinical services and supports
Studies have shown that support from non-traditional providers such as doulas14 and midwives15 are associated with lower cesarean rates, as well as fewer obstetric interventions, fewer complications, less pain medication, shorter labor hours and higher scores on the APGAR test. Though midwife services are a mandatory Medicaid benefit, state regulations vary coverage and may limit access. To date, only a handful of states have implemented Medicaid coverage for doula services (Florida, Minnesota, New Jersey and Oregon); however, dozens16 have introduced and/or have legislation moving in their state legislatures to authorize coverage.
Whether covered through a traditional Medicaid pathway or under a pregnancy-only pathway, states should ensure that all pregnant Medicaid members are afforded the opportunity to access the array of physical and behavioral health services and supports needed to adequately meet their health care needs. This includes decreasing any unnecessary barriers to already covered clinical benefits (e.g., midwives, birth centers), and coverage of non-clinical services and supports (e.g., doulas) and home visiting programs that help improve maternal and infant outcomes, enhance engagement and reduce spending.
Trend 4. Support the use of digital modalities and mobile-friendly strategies
Decreasing barriers to health care access includes the use of digital platforms and mobile-friendly devices. Though there was an increase in telehealth use before the COVID-19 pandemic, communication preferences continue to shift toward using telehealth and other virtual means to access services and communicate with health care providers. All 50 states allow for some form of telehealth coverage in Medicaid, but only a handful specifically address maternal health care access17 in those policies. Due in large part to the pandemic, the federal government18 and states19 are actively pursuing new policies that authorize telehealth coverage, expand supported modalities, and invest in provider and patient capacity to engage in digital/virtual visits that have implications for maternal health care.
As a part of these policy discussions, policymakers need to consider coverage for devices and for technical support and education to prevent further inequities in access to care. Access to appropriate and reliable devices, available and consistent broadband access, and adequate digital literacy are all required in order to support all individuals in digital health care monitoring and engagement. Additionally, coverage of remote patient monitoring and two-way texting, along with allowance for reimbursement of services via telehealth delivered at home, should all be included in new policies and regulations to specifically support the use of telehealth in addressing the needs of pregnant and postpartum Medicaid members.
Though these are not the only policy discussions taking place related to maternal health and Medicaid, they are four critically important areas where both the federal government and states have shown active interest through legislative, regulatory and funding action. Given the role of managed care in supporting those accessing Medicaid who are pregnant or have given birth, managed care organizations should work with their state partners to develop these policies and regulations and execute on strategies that will address the adverse maternal and birth outcomes in the U.S., with particular focus on the inequities in those outcomes among BIPOC communities.