The Medicaid and CHIP Payment and Access Commission will likely recommend Congress extend Medicaid's postpartum coverage, but its members are split on whether to make the expansion mandatory or optional for states, according to comments made during MACPAC's October meeting on Friday.
The congressional advisory panel agreed that Congress should expand Medicaid's postpartum coverage to 12 months with full benefits for new mothers and that Medicaid's coverage should align with the State Children's Health Insurance Program. Experts said extending coverage would help address a wide range of pregnancy-related health issues by ensuring women could access care after birth.
The 12-month postpartum coverage period makes sense because "clinically we consider postpartum 12 months," said MACPAC commissioner Martha Carter, a consultant and founder of West Virginia-based FamilyCare Health Centers.
According to MACPAC, 25% of women experienced a change in insurance coverage before birth, and almost 29% experienced one after birth. But those topline figures hide significant racial disparities in coverage stability. While 75% of white, non-Hispanic women kept coverage, just 55% of Black, non-Hispanic women, 50% of indigenous women and 20% of Hispanic, Spanish-speaking women did.
In addition, a third of pregnancy-related deaths occur postpartum, and up to a quarter of pregnant women may have a chronic illness. Another one in seven pregnant and postpartum women suffer from perinatal mood and anxiety disorders.
Maternal health in the U.S. is significantly worse compared to other wealthy countries. According to the Centers for Disease Control and Prevention, the maternal mortality rate in 2018 was 17.4 deaths per 100,000 live births. That would place the U.S. between Russian and Ukraine in the World Health Organization's most recent maternal mortality rankings.
Expanding coverage is crucial because kids "need their mothers" to lead healthy lives, said MACPAC commissioner Dr. Christopher Gorton, a pediatrician and former president of public plans at Tufts Health Plan.
But MACPAC's members were divided over whether to make the expansion mandatory or optional for states. Although several commissioners wanted to make it mandatory, they worried about a mandate's effect on state finances in the wake of the COVID-19 pandemic. Tennessee was gearing up to expand coverage, but it had to cancel those plans because the outbreak has wreaked havoc on state Medicaid budgets, said MACPAC Commissioner Darin Gordon, a consultant and former director of Tennessee's Medicaid program.
"There's a will and a desire there, but the financing of it … is hard to pull off during COVID," he said.
Experts also wondered how it would play politically.
"There's going to be a lot of demand on Congress for a lot of investments," MACPAC vice chair Charles Milligan said.
He predicted the Congressional Budget Office would give an optional expansion a lower price tag, which would make it more palatable to politicians.
"That might make it more viable … in the aftermath of the pandemic," he said.
But there are significant drawbacks to making it optional for states to expand postpartum coverage.
"When we look at the states that haven't expanded Medicaid, you're going to see high disparities in their birth outcomes and maternal outcomes. I think that's one of the more persuasive arguments for mandatory," said MACPAC commissioner Tricia Brooks, a research professor at the McCourt School of Public Policy at Georgetown University.
