To date, 29 states and the District of Columbia cover a person up to one year postpartum, and at least twelve more states are exploring the postpartum coverage extension. Given the state plan option has only been available to state Medicaid programs for about a year, it is just one metric that exemplifies Medicaid leaders’ commitments to advance maternal health outcomes. And while the postpartum extension is an important lever, state Medicaid leaders recognize that they must build on this option by layering on complementary features to address the poor outcomes and disparities for people in the postpartum period.
Maternal and infant mortality in the United States is higher than any of our peer countries, and according to the Center for Disease Control and Prevention (CDC) over 80 percent of pregnancy-related deaths in the United States are preventable. In 2021, 1,205 women died of maternal causes in the United States, which represents nearly a 40% increase from 2020.
While the increased prevalence of chronic conditions contributes to the major causes of pregnancy-related deaths (e.g., cardiovascular conditions), it is important to recognize that existing socioeconomic and racial disparities exacerbate poor maternal health outcomes. For example, non-Hispanic Black persons are more than twice as likely as their non-Hispanic Asian or Pacific Islander counterparts to die of heart disease. Black and American Indian/Alaskan Native women also experience pregnancy-related deaths at a rate two to three times higher than white, Hispanic, and Asian/Pacific Islander women. While these maternal health disparities exist regardless of income, a majority of pregnancy-related deaths occur among birthing people covered by Medicaid at the time they gave birth.
Given Medicaid covers over 40 percent of births in the country, Medicaid leaders understand the program’s outsized role in improving maternal health in the postpartum period. While forty-one states and the District of Columbia have either already extended postpartum coverage, or are actively pursuing coverage extension, policymakers recognize the need for a multi-faceted approach to address the poor outcomes and disparities for people in the postpartum period. State Medicaid leaders are focused on driving improvement in three key areas, including:
- Addressing mistrust in the healthcare system;
- Reducing fragmentation of care; and
- Improving behavioral health.
Addressing Mistrust in the Healthcare System
Health care discrimination has engendered deep mistrust between the health care community, Black Americans, and American Indian/Alaskan Native Americans. While historical exploitation like the horrific Syphilis Study at Tuskegee and the unauthorized sterilization of American Indian/Alaskan Native women contribute to this lack of trust, mistreatment in the present day also leads to distrust. For instance, implicit bias training and cultural competency has not traditionally been part of medical training, and studies have shown that providers often undertreat pain, spend less time with, and under communicate with Black patients. So, it is not surprising that more than one in five Black mothers reported they are treated unfairly because of their race or ethnicity while obtaining health care. In addition to poor quality care, this type of stress associated with racial discrimination can contribute to adverse maternal and child health outcomes. State Medicaid leaders are highly attuned to these issues and are identifying unique Medicaid levers to ameliorate this mistrust in their specific state environment. Two examples of how state Medicaid agencies are using the program’s levers to rebuild trust include:
- Leveraging Doulas: Doulas are non-medical paraprofessionals that serve as an advocate and provide physical and emotional support for an individual during pregnancy, childbirth, and the period shortly after childbirth. Research studying the effectiveness of doulas showed that people leveraging doula supports are less likely to have preterm births, less likely to experience postpartum depression, and more likely to breastfeed. At least 11 states actively reimburse for doula services, with five more states in the process of implementing the benefit. For example, New Jersey covers community-based doula services in their Medicaid program. Community-based doulas are trained in culturally competent care and in connecting clients to social services and community based organizations that meet the unique needs of the communities they serve. New Jersey Medicaid implemented several strategies to attract and retain community-based doulas to participate in the Medicaid program. For instance, the agency 1) waives any application and background check fees, 2) provides some approved doula trainings free of charge, 3) provides technical assistance on enrollment in fee-for-service, managed care enrollment, and key Medicaid provider issues (e.g., billing), and 4) maintains doula-to-doula peer supports, including a statewide NJ Doula Learning Collaborative to support workforce retention.
- Supporting Midwives: New Mexico has a rich history of midwifery with curandera-parteras (traditional Hispanic midwives) supporting the birthing process for over a century. Understanding the immense value these providers bring, the state Medicaid agency expanded covered provider types to include licensed midwives. These midwives can be trained in accredited programs or through traditional apprenticeship models outside of nursing school. The New Mexico Medicaid agency also empowers these midwives to provide at-home births for low-risk individuals through their Birthing Options Program. The program addresses key challenges midwives face in obtaining malpractice insurance and allows licensed midwives and certified nurse midwives to bill Medicaid for at-home births. Among low-risk pregnancies, midwives achieve better health outcomes, including lower rates of pre-term births, than physicians. In this instance, the state Medicaid agency used their policy levers to expand the reach of providers (midwives) that have already earned the trust of this population.
While state policymakers are identifying and pulling Medicaid levers to address mistrust, advancing this work will require the partnership of others in state government, the health care delivery system, and communities. For example, research indicates when a patient has a provider that looks like them and is more similar to them, it can boost communication and trust within the patient-provider relationship. With 80 percent of certified nurse midwives and certified midwives being white, it can take years to achieve more diversity in the healthcare workforce. Incorporating impactful strategies to build trust and foster open communication into medical training and in the healthcare system at-large will also require focus that spans multiple years among stakeholders. In this example, and others like it, other parts of state government and partners are well positioned to play a leading role.
Reducing Fragmentation of Care
Many state Medicaid leaders are focused on helping postpartum individuals navigate a fragmented system of care and incentivizing greater coordination in the delivery system. New moms must transition from postpartum care to primary care, navigate pediatric care for their child, and connect with other specialty health care needs (e.g., behavioral health). Finding appointments can be challenging and inconvenient for a new mom, and providers do not often communicate with one another. In addition to navigating health care needs, new moms must meet the new demands of parenthood, including navigating additional social needs. State Medicaid agencies have identified and begun using various policy levers to support postpartum people, such as:
- Leveraging Community Health Workers: Community Health Workers (CHWs) are non-medical paraprofessionals who have strong ties to the community and specifically support an individual’s social needs. Some CHW programs have been associated with lower rates of preterm births and more engagement in care. At least 21 states pay for certain CHW services in their Medicaid program. For example, Rhode Island reimburses CHWs for supporting individuals in navigating the healthcare system, as well as accessing necessary covered benefits and other social services. Community-based organizations, medical practices, hospitals, and individuals can enroll as CHW providers and submit claims to Rhode Island Medicaid for community health worker services.
- Promoting Access to Medical and Non-Medical Transportation: Pregnant and postpartum individuals can leverage the non-emergency medical transportation (NEMT) benefit for medical appointments. Many states are focused on strengthening this benefit to support access to care. In addition to access to medical transportation, new parents may lack adequate access to transportation to address their social needs like getting to and from a WIC (Special Supplemental Nutrition Program for Women, Infants and Children) office or a grocery store. For instance, many states leverage their managed care organizations (MCO) to support this need through the MCO’s value-added benefits.
- Leveraging Pregnancy Medical Homes: State Medicaid agencies are using value-based payment strategies to reduce fragmentation through pregnancy medical homes, which are team-based approaches that foster care coordination and more whole-person care. For example, North Carolina Medicaid has a longstanding pregnancy medical home to enhance coordination and support individuals in navigating the health care system. The state pays a per member per month fee to a primary care case management entity to support care coordination. Providers participating in the program must commit to several requirements, including providing patient-centered care, administering standardized screenings, and referring patients to care management.
Reducing fragmentation in the healthcare system and building connections to social services has long been a priority for Medicaid leaders. As noted in our section above, this work will also require a multidisciplinary approach that extends beyond Medicaid, such as creating more interoperable data systems. But state Medicaid agencies play an important role in this work and have taken creative steps to reduce fragmentation.
Improving Behavioral Health
Finally, state Medicaid leaders are advancing innovations to address behavioral health needs in the postpartum period. While immediate physical health needs (e.g., infections) drive pregnancy-related deaths in the early postpartum period, behavioral health plays a larger contributing factor in maternal morbidity and mortality in the later postpartum months. For example, several studies indicate that suicide and self-harm are the leading cause of maternal mortality in the later postpartum period. A few examples of how state Medicaid agencies are supporting behavioral health, especially in the later postpartum months, include:
- Use of Home Visiting: Home visiting is a two-generational approach to support early childhood development, safe and secure environments for families, and family self-sufficiency. Through this high-touch approach, home visitors may be able to identify new moms who have higher behavioral health needs and support them in accessing services. At least twenty state Medicaid agencies cover evidence-based home-visiting models. States like West Virginia have taken a similar approach in their Medicaid program to support new moms in recovery through the Drug Free Moms and Babies program. In addition to long-term follow up via home visits, the program also supports new moms and babies via peer supports, community health workers, and a care coordinator. West Virginia found that these wraparound services both supported new moms in staying in recovery and positive infant/birth outcomes.
- Leveraging Dyadic Care: Many Medicaid agencies are beginning to explore the use of dyadic services for the maternal and child health population. Dyadic care encompasses treatments that are simultaneously delivered to both the child and the parent. For example, California covers family therapy for a child and their caregiver, even when the child does not have a mental health diagnosis but may be at risk for one later in life. The program also covers integrated physical and behavioral health screenings and services for not just the child (i.e., patient), but the whole family. When a caregiver is present at their child’s visit, a Medicaid provider may use the child’s Medicaid to bill for dyadic services provided to the caregiver. These services can include tobacco cessation counseling, depression screening, psychiatric diagnostic evaluation, health behavior assessment and interventions, and screening, brief intervention, and referral to treatment (SBIRT) for drug and alcohol use.
- Supporting the Behavioral Health Workforce: Nearly every state Medicaid agency has taken steps to support the behavioral health workforce. This includes efforts to ensure adequate reimbursement, reducing administrative burden, and extending the workforce so that more providers can practice at the top of their license. For example, North Carolina incentivizes participation in the Medicaid program through the adoption of prompt payment policies for behavioral health providers.
- Using Financial Incentives: Some states are using bundled payment programs, which are tied to a holistic set of quality measures, to support behavioral health in the postpartum period. For example, Pennsylvania requires MCOs to utilize a maternity bundled payment program for network providers who elect to participate in the model. The model encompasses a maternity care team and is associated with several HEDIS® metrics that support behavioral health. Some metrics in the program include Initiation of Alcohol and Other Drug Abuse or Dependence Treatment (IET), Prenatal and Postpartum Care (PPC), and Postpartum Depression Screening and Follow-up (PDS). The program also includes metrics on social determinants of health screenings and a health equity score as an incentive in the bundled payment.
Medicaid leaders are keenly aware of the increasing behavioral health needs among the population at-large, but especially among young women, which may ultimately impact maternal and child health outcomes in the future. While Medicaid is the largest payer for behavioral health, and Medicaid leaders are focused on innovative policies to meet this growing need, we still need a unified approach among all stakeholders to create an accessible behavioral health system. For instance, Health and Human Services (HHS) estimates that 160 million Americans live in a health professional shortage area for mental health services. Waitlists to obtain care in behavioral health clinics increased over the past years, as well. There needs to be new and strengthened partnerships to address these workforce challenges.
There is growing attention and focus on how Medicaid can make an impact on maternal and infant health. State Medicaid agencies are focused on using the program’s levers – eligibility, covered benefits, eligible provider types, payment, and quality – to rebuild trust in the health care system, reduce fragmentation, and support behavioral health among postpartum individuals. At the same time, we need new and strengthened partnerships amongst the health care community, state government, the federal government, and payers to make a meaningful and sustained impact on maternal and infant health. Moving the needle on this goal will require stakeholders to align efforts so that we can provide a cohesive set of additional supports for new moms and infants.