Medicaid beneficiaries are 82% more likely to experience severe maternal morbidity and mortality than women with private health coverage, according to new research presented at the Medicaid and CHIP Payment and Access Commission meeting Friday.
People of color and women in rural areas are at the greatest risk for severe maternal morbidity and mortality among Medicaid recipients, said Katy Kozhimannil, associate professor at the University of Minnesota's School of Public Health and director of research for the Rural Health Research Center. Black and indigenous women are about three times as likely to die from a pregnancy-related cause as white women.
The findings are consistent with other evidence that race, geography and health affect income and, consequently, Medicaid eligibility. Women with low socioeconomic status are more likely to be high-risk than wealthier women and have fewer resources to ensure good health.
But improvements to Medicaid policy could help reduce severe maternal morbidity and mortality because the program disproportionately covers people of color and women living in rural areas.
"I believe we can do better—with regards to the quality of maternity care in this country—than 'did you die?'" Kozhimannil said. "Maternal deaths are just the tip of the of the iceberg."
Hospitals and clinical practices face financial challenges because Medicaid only pays about half of what private insurers pay for childbirth-related services. But reimbursement varies significantly within Medicaid between fee-for-service and managed care. Higher reimbursement rates could increase Medicaid beneficiary access to care, which could improve health outcomes for women.
"Healthcare delivery systems are always aware of their payer mix," Kozhimannil said. "It is no more evident than in obstetrics, which is known as a loss leader."
New payment models like bundled or blended payments could also help by increasing provider responsibility for the total cost of care and improving the financial stability of rural hospitals.
Rural hospitals have a hard time covering the high fixed costs of obstetrics care because they serve fewer patients, many of whom are covered by Medicaid and its lower reimbursement rates. That can lead rural providers to close their obstetrics units, which hinders access to care and increases maternal morbidity and mortality, as well as preterm births.
Medicaid's current system could also incentivize rural providers to deliver more babies by caesarian section because the reimbursement rates are much higher under Medicaid, Kozhimannil said.
Extending pregnancy-related Medicaid eligibility could lower rates of severe maternal morbidity and mortality. About one-third of maternal mortality occurs within one year of giving birth, but Medicaid postpartum coverage ends 60 days after birth, which leads to coverage gaps for nearly half of new mothers. Expanding that eligibility could cut maternal mortality by making sure that new moms get the care they need.
Expanding Medicaid eligibility overall could improve health outcomes too.
"If women enter pregnancy healthier, then any chronic condition is picked up, diagnosed and taken care of (in a timely fashion)," said MACPAC commissioner Martha Carter, founder and former chief executive officer of FamilyCare Health Centers, a community health center.
Additional coverage for non-clinical services such as doulas, community health workers, transportation and housing could address the social determinants of health that contribute to higher morbidity and mortality rates for low-income women.