Reducing Cardiovascular Maternal Mortality by Extending Medicaid for Postpartum Women

Abstract

Maternal mortality has been increasing in the United States over the past 3 decades, while decreasing in all other high-income countries during the same period. Cardiovascular conditions account for over one fourth of maternal deaths, with two thirds of deaths occurring in the postpartum period. There are also significant healthcare disparities that have been identified in women experiencing maternal morbidity and mortality, with Black women at 3 to 4 times the risk of death as their White counterparts and women in rural areas at heightened risk for cardiovascular morbidity and maternal morbidity. However, many maternal deaths have been shown to be preventable, and improving access to care may be a key solution to addressing maternal cardiovascular mortality. Medicaid currently finances almost half of all births in the United States and is mandated to provide coverage for women with incomes up to 138% of the federal poverty level, for up to 60 days postpartum. In states that have not expanded coverage, new mothers become uninsured after 60 days. Medicaid expansion has been shown to reduce maternal mortality, particularly benefiting racial and ethnic minorities, likely through reduced insurance churn, improved postpartum access to care, and improved interpregnancy care. However, even among states with Medicaid expansion, significant care gaps exist. An additional proposed intervention to improve access to care in these high-risk populations is extension of Medicaid coverage for 1 year after delivery, which would provide the most benefit to women in Medicaid nonexpanded states, but also improve care to women in Medicaid expanded states.

Keywords: Medicaid; health policy; postpartum.

Figure 1. Current Medicaid expansion status and legislation extending Medicaid coverage for postpartum women.

A, Current status of Medicaid expansion in each state. B, Current status of legislation extending Medicaid coverage for postpartum women beyond 60 days postpartum. Minnesota has pending legislation that would require the commissioner of human services to examine extending postpartum Medicaid coverage for an unspecified length of time. Postpartum Medicaid coverage extension is limited to individuals who have been diagnosed with a maternal mental health condition in California and individuals with substance use disorders in South Carolina. Indiana is pending legislation to extend coverage to only those with opioid use disorder., , , , , ,

Figure 2. Pregnant woman vs parent Medicaid eligibility in 50 states and the District of Columbia.

For states with Medicaid expansion, women are eligible for Medicaid if their income falls below 138% of the federal poverty level (FPL). For states without Medicaid expansion, such as Alabama, Missouri (recently passed), Tennessee, and Texas, eligibility is significantly more restrictive, falling as low as 17% to 21% of the FPL. During pregnancy, Medicaid eligibility is expanded such that even those states with Medicaid expansion have much broader income eligibility criteria, as high as 380% the FPL. Although nonexpansion states will see the greatest number of women benefit, even women in expansion states will see benefit from extension of postpartum Medicaid.