By Stacey McMorrow, Lisa Dubay, Genevieve M. Kenney, Emily M. Johnston, and Clara Alvarez Caraveo
Urban Institute, May 28, 2020
Alarming increases in US maternal mortality have generated national attention, a search for policy solutions to promote maternal health, and an increased recognition of how important the postpartum period is for mothers’ and infants’ health and well-being. Without access to consistent, comprehensive health insurance coverage, many new mothers can face extreme challenges obtaining the care they need to support their and their infants’ health. This analysis uses 2015–18 data from the National Health Interview Survey (NHIS) to document access and affordability challenges facing uninsured new mothers and 2015–17 data from the Pregnancy Risk Assessment and Monitoring System (PRAMS), a state-specific surveillance system of pregnancies resulting in a live birth, to describe the health status of women who lost Medicaid coverage following their pregnancies. Together, our analysis provides new evidence on the access and affordability barriers that could be reduced and the health problems that could be treated if these uninsured new mothers were to gain coverage through a postpartum Medicaid extension or broader Medicaid expansion.
From the Discussion
Despite documented increases in insurance coverage for new mothers under the ACA, more than 1 in 10 new mothers remained uninsured from 2015 to 2018, and over half of those women were Hispanic and nearly two-thirds lived in the South. About 1 in 5 uninsured new moms reported at least one unmet need for medical care because of cost, and over half were very worried about paying their medical bills, emphasizing that health care affordability is a problem for many new mothers. Moreover, about half of all uninsured new mothers reported that losing Medicaid or other coverage after pregnancy was the reason they were uninsured. Thus, it appears many new mothers could benefit from the financial protection that insurance can provide and would likely benefit from the extensions of postpartum Medicaid coverage that have been proposed at both the federal and state levels.
Even if a permanent postpartum extension were adopted, however, not all uninsured new mothers would qualify. Access to postpartum coverage under current rules depends critically on state-specific eligibility criteria for pregnancy-related Medicaid coverage, based both on income and immigration status and on which women actually enroll in Medicaid during their pregnancies. These same factors will determine who is eligible for the maintenance-of-effort provisions under the Families First Coronavirus Response Act and state-specific implementation of the provisions may vary. Moreover, the economic downturn may extend well beyond the public health emergency, leaving many new mothers at higher risk of being uninsured when the maintenance-of-effort provision expires or if they lose other coverage sources because of rising unemployment. Without additional federal or state action to expand access to affordable coverage options, many new mothers may remain uninsured both during and after the public health crisis.
Our findings suggest that if new mothers were to gain coverage through an extension of postpartum Medicaid eligibility, they could experience reduced affordability problems and an improved ability to manage chronic conditions during that critical period after giving birth. However, longer-term solutions to addressing the maternal morbidity and mortality crisis would involve achieving continuous coverage and care throughout a woman’s reproductive years. A more comprehensive Medicaid expansion, for example, would allow more low-income women to identify and manage their chronic conditions, plan and support wanted pregnancies, and maintain good health to support ongoing maternal and child well-being.
By Don McCanne, M.D.
“And poor people who are uninsured? They can always get Medicaid.”
No. There are a great many reasons why uninsured, low-income individuals may not be able to enroll in Medicaid, ranging from qualifications based on their own personal situations to public policies that vary by the state in which they reside. This Urban Institute study shows that even those who may have been enrolled in Medicaid during a pregnancy can lose that coverage in their postpartum period. That certainly indicates a serious policy deficiency.
The authors suggest that the incremental reform of expanding coverage during the postpartum period can close the gap for some of them, though there will always be others who remain uninsured for various reasons.
The authors then make what at first glance seems to be an excellent suggestion of providing Medicaid coverage throughout a woman’s reproductive years. But what happens when that woman moves to a different state with different rules, or her income no longer falls within the qualifying level, or she has stuttering coverage through her spouse’s employer-sponsored plan(s), or qualifications change based on Medicaid waivers or budgetary constraints, or whatever? Also, why cover her only through her reproductive years and not in childhood and beyond menopause? And why not automatically cover the infant produced by that pregnancy? And what about other women not eligible for the Medicaid program? And, while we’re at it, what about everyone else throughout their entire lives?
Incremental reforms such as expanding postpartum coverage fail to correct the gross fundamental defects in our health care financing system such as the lack of universality, the profound, expensive administrative excesses, the lack of affordability for far too many individuals and families, and the profound inequities that should not exist in the most expensive system in the world. Most of the proposed incremental reforms add to the administrative complexity and costs while falling far short of the essential goals of universality, comprehensiveness, high quality, effectiveness, efficiency, equity, and affordability.
Instead of tinkering with postpartum coverage of Medicaid patients, the Urban Institute should look at their own study of single payer Medicare for All, correct its deficiencies (we’ll help them), and then advocate for its adoption since it would truly ensure health care for all of us, with postpartum care automatically included.
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