Can Postpartum Medicaid Coverage Solve the Black Maternal Health Crisis?

Today marks the last day of Black Maternal Health week, a time to raise awareness about the deplorably high rate of maternal mortality among Black women in the United States. A key policy response has been to extend Pregnancy Medicaid (the type of Medicaid you may only be eligible for when pregnant) from 60 days to 12 months postpartum. Currently 46 states have implemented such legislation, making it one of the single biggest actionable items society has done to address the maternal mortality crisis. Such national consensus is a major accomplishment and should be applauded. While Medicaid extensions are a critical step in the right direction, our research suggests that alone it will do little to solve the Black maternal health crisis in many states.

States where Medicaid extension postpartum is unlikely to have a large impact are those which already have relatively generous Medicaid policies – but even many of these states have appalling outcomes when it comes to Black mothers. Take New York, for example, where a recently released maternal mortality review reported that non-Hispanic Black women had a pregnancy-related mortality rate five times that of non-Hispanic White women, and non-Hispanic Black women comprised 42% of pregnancy-related deaths but only 14% of live births.

It’s now been nearly a year since New York policymakers passed legislation to prevent postpartum maternal deaths by extending pregnancy Medicaid coverage from 60 days to 12 months postpartum. New York’s law grants this coverage regardless of immigration status (we discuss later why this is crucial). While it is too soon to measure the law’s impact on Black maternal morbidity and mortality, our ongoing research suggests that it is likely to have minimal impact on U.S.-born Black women in New York (and similar states), because they are not the ones who were losing insurance postpartum.

Our own analysis of 2019 American Community Survey data estimates that in New York only 5% of Black women were uninsured in the postpartum period, possibly due to the earlier success of Medicaid expansion under the Affordable Care Act (ACA). The percentage is similar in all ACA expansion states combined (6%), compared to 16% in non-expansion states. Digging deeper, we found that the subset of Black women most likely to be uninsured postpartum is non-citizens: 12% in expansion states and 30% in non-expansion states. That means that the New York law is likely to have the biggest impact on immigrant Black women (as well as immigrants of other race or ethnicity), and lower impact on U.S.-born Black women.

Nevertheless, there are reasons for hope that this policy can improve Black maternal health in New York and other ACA expansion states.

First, for states that elected to extend coverage regardless of immigration status, access to postpartum health care will dramatically increase among Black immigrants. Black immigrant women are at increased risk of poor maternal health outcomes compared to the population average, including severe maternal morbidity and gestational diabetes. Therefore, inclusive postpartum Medicaid extensions may have a substantial impact on the approximately 4.6 million Black immigrants in the U.S. who are often overlooked by policy-makers and public health agencies. (Conversely, it means states who have excluded undocumented immigrants from postpartum Medicaid extension, such as New Jersey, are losing out on a key avenue to effectiveness.)

Second, reducing the number of women losing Medicaid postpartum will strengthen health systems serving low-income communities by reducing administrative burden. Continuous enrollment in the postpartum period may increase health care access and improve quality of care. Thus, postpartum Medicaid coverage extension may bolster the healthcare safety net serving low-income women, and improve quality of care for all postpartum women, regardless of whether they individually were affected by the coverage extension.

Finally, from the patient perspective, guaranteed continuous eligibility until 12 months postpartum may serve to relieve stress and uncertainty during a period of new motherhood (or bereavement, in the case of pregnancies not ending in a healthy baby) that is physically and psychologically demanding. Our research team has spoken with women who were insured by Medicaid who told us that it was calming and reassuring to know they were covered should they have any health issues.

Because of these benefits, even in states where there is not a large number of Black women losing postpartum coverage (and even larger benefits in states where there is), the extension of Medicaid to 12 months is an achievement. At the same time, policy makers must double-down on other policy avenues to address the ongoing crisis.

Dismantling the structural racism that is the root cause of the crisis has no quick fix, but it  should start with listening to Black women. Medicaid coverage needs not only to exist, but to be comprehensive, covering evidence-based care such as home blood pressure monitoring, continuous glucose monitoring, expanded access to lactation services, fair reimbursement to doulas, and home health visits. Black women need access to high-quality care and providers who listen to them. Policies mitigating structural racism such as equitable access to paid family leave, affordable housing, healthy food, and a healthy environment in which to live and work are all critical. Policies need to be continually evaluated to ensure that they are equitably implemented and inclusive of the perspective of Black women. Timely maternal health surveillance data needs to be accessible to the public, and disaggregated to identify communities who can be offered additional support.

On this Black Maternal Health Week, the promise of postpartum Medicaid extension legislation should be applauded, while understanding its limitations and not losing policy momentum to seek additional solutions.

Teresa Janevic is an associate professor of Epidemiology at Columbia University Mailman School of Public Health.

Britney P. Smart, Ellerie Weber, and Ashley Fox contributed research.

This column is editorially independent of Columbia News.