What State Officials Should Do Right Now to Support Maternal Health

Milbank State Leadership Network State Health Policy Leadership

The US Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization overturning Roe v. Wade continues to reverberate across the country. While the immediate implications of the decision differ dramatically based on each state’s laws, all state officials and their community partners should act on longstanding, shared commitments to improving maternal health and eliminating racial disparities by:

  • developing a working knowledge of Dobbs and their state’s laws governing abortion;
  • refreshing themselves on evidence and experience related to pregnancy in the United States, particularly focusing on well-documented racial disparities;
  • ensuring that women and other birthing people have a clear understanding of the current status of state-funded reproductive health care and can make informed choices about their options by:
    • collaborating to draft and issue plain-language messages to women and other birthing people in their states, outlining the status of publicly funded reproductive health care coverage; and
    • promoting the use of primary care services that are offered by reproductive health providers; and
  • if they have not already done so, maximizing use of Medicaid coverage options that have been demonstrated to improve outcomes:
    • the American Rescue Plan Act (ARPA) option to extend Medicaid coverage to women and other birthing people on a post-partum basis; and
    • the Affordable Care Act (ACA) Medicaid family planning eligibility group option.

What Evidence and Experience Tells Us About Maternal Mortality and Morbidity in the United States

State officials should make sure they know what the literature and self-report of experience by women and other birthing people tells us about giving birth in the United States. There is incontrovertible evidence showing high rates of maternal mortality and morbidity, particularly for Black people and those who are low income and live in rural areas. Troublingly, the US also has the highest maternal mortality rate among developed countries.

A December 2021 report by the Assistant Secretary for Planning and Evaluation (ASPE) indicates that:

  • one-third of pregnancy-related deaths occur between one week and one year postpartum;
  • a majority of pregnancy-related deaths occur among birthing people covered by Medicaid at the time they gave birth;
  • insurance coverage improves continuity of care for chronic conditions (e.g., diabetes, hypertension, cardiac conditions, substance use disorder, and depression) that can be exacerbated postpartum; and
  • continuity of postpartum coverage is an important means of addressing pregnancy-related deaths and severe maternal morbidity.

Racial disparities in morbidity and mortality among women and other birthing people are well-documented and extremely urgent. Non-Hispanic Black people are more than twice as likely as non-Hispanic white people to experience severe maternal morbidity and maternal mortality. These disparities exist among both commercially covered women and other birthing people and those covered by Medicaid. It is especially critical that Medicaid officials address these disparities given that women and other birthing people of color make up a substantial portion of the program’s enrollees. The National Center for Health Statistics indicates that in 2019, the percentage of women for whom Medicaid was the source of payment for delivery was as follows:

  • 42.1 % of all women
  • 65% of Black women
  • 59% of Hispanic women

A number of available policy options are associated with improvement in maternal outcomes. Continuous insurance coverage (prenatal through postpartum), access to comprehensive primary care (including services delivered at reproductive health centers), use of nurse midwives, and proximate and timely access to family planning, care between pregnancies (interconception support), and pregnancy services have been demonstrated to improve outcomes, especially for the significant percentage of women and other birthing people whose pregnancies are covered by Medicaid. Emerging data also points to the value of an expanded care team that includes culturally capable doulas, lactation consultants and other types of community health workers.

Plain Language Explanations of Current Coverage

Officials and their community partners should collaborate to release and actively disseminate clear, accessible messages about state coverage of reproductive health care. Regardless of whether major changes are occurring or policies remain intact, there is an opportunity to reduce the stress and anxiety of the current information vacuum. It is also an essential time for state leaders to engage with people who receive publicly funded services and community partners to gauge what they want to know, test content and clarity of messages, and plan for how messages can most effectively be distributed. It is especially important to include people who don’t agree with state policy in the conversations.

Background on Medicaid coverage of family planning services: Federal law identifies family planning as a mandatory benefit for standard Medicaid and alternative benefit plans (ABPs). This benefit includes services and supplies to prevent or delay pregnancy and may include “education and counseling in the method of contraception desired or currently in use by the individual, a medical visit to change the method of contraception,” and a state option to include infertility treatment. The ACA built on this by giving states the option to elect coverage of a distinct family planning eligibility group. See the last section below for more detail on the ACA option.

Background on use of federal funds to cover abortions: While the federal Hyde Amendment prohibits use of federal Medicare, Medicaid, CHIP, and Indian Health Service for abortion other than in situations of rape, incest or risk of death to the mother, and numerous states have implemented or are in process of implementing more restrictive standards, as of May 1, 2022, 16 states were using state funds to provide abortion services to eligible people.

Maximize Use of Available Medicaid Coverage Options 

If they have not already done so, state officials should examine opportunities to improve maternal outcomes and reduce racial disparities by extending their Medicaid coverage of postpartum care and family planning under Medicaid.

The Kaiser Family Foundation indicates that as of June 23, 2022, the status of state adoption of the ARPA option to expand Medicaid post-partum coverage, from the 60-day period required historically under federal law to one year, was as follows:

  • 19 have already implemented
  • 12 are planning to implement
  • 4 are pending legislation to implement
  • 4 have implemented limited coverage extensions

As of September 1, 2021, 30 states cover expanded family planning services, either through Medicaid or via state funding.

Background on ARPA postpartum option: Effective April 1, 2022, Sections 9812 and 9822 of the ARPA enabled states extend Medicaid and CHIP postpartum coverage from 60 days postpartum to one year postpartum. This provision is effective for a 5-year period from the effective date.

This State Health Official letter details important background and instructions for election of the ARPA postpartum option.

Background on the ACA family planning eligibility group. States also have the option to elect a distinct Medicaid family planning eligibility group. Services for this group are limited in scope to the mandatory Medicaid state plan services and “family planning related services.” These include:

“medical, diagnostic, and treatment services provided pursuant to a family planning visit that address an individual’s medical condition and may be provided for a variety of reasons including, but not limited to: treatment of medical conditions routinely diagnosed during a family planning visit, such as treatment for urinary tract infections or sexually transmitted infection; preventive services routinely provided during a family planning visit, such as the HPV vaccine; or treatment of a major medical complication resulting from a family planning visit.”

Building on previously issued guidance, this State Health Official letter provides details around the family planning eligibility group. Related, this George Washington University report provides detailed recommendations for building coverage into Medicaid managed care.

Support for Informed Decisions and Healthy, Planned Pregnancies

State officials and their community partners have an obligation to help women and other birthing people, especially those of color who are served by Medicaid, to understand current coverage of family planning, pregnancy, and abortion services, so they can make informed decisions about accessing needed care. Officials should also maximize use of the Medicaid supports that have been shown to enable planned healthy pregnancies, improve maternal and child outcomes and reduce racial disparities.