Center on Budget & Policy Priorities: State and Federal Policymakers Should Extend Postpartum Medicaid Coverage

WASHINGTON, Aug. 28 -- The Center on Budget and Policy Priorities issued the following commentary by senior policy analyst Hannah Katch:

States and the federal government have an immediate opportunity to expand access to care for people who have recently given birth -- and they should seize it.

The country is confronting several simultaneous crises that affect pregnancy and postpartum health, including COVID-19 and the systemic racism that has driven racial disparities in health care access and outcomes. The federal Centers for Medicare & Medicaid Services (CMS) should approve states' proposals to extend the duration of pregnancy-related coverage for low-income parents, and more states should adopt similar policies.

Medicaid plays a key role in pregnancy and postpartum health, financing 43 percent of all births nationwide in 2018. Medicaid coverage can significantly improve pregnancy-related health outcomes by increasing access to care -- particularly during the postpartum period, research shows.

State Medicaid programs are required to offer coverage to pregnant people with incomes up to 138 percent of the federal poverty line (about $30,000 for a family of three in 2020), and most offer coverage above that level. This coverage, however, ends 60 days after the birth, so many postpartum people lose coverage unless they stay covered through a different pathway. (We refer to postpartum people, rather than women, because people who don't identify as women also give birth, need pregnancy and postpartum care, and are eligible for pregnancy-related coverage through Medicaid.)

In states that have expanded Medicaid under the Affordable Care Act, postpartum people with incomes up to 138 percent of the federal poverty line remain eligible for Medicaid after their postpartum period ends. However, people with incomes above that threshold often lose their Medicaid eligibility and may have trouble enrolling in another form of coverage. And in states that have not expanded Medicaid, postpartum people with much lower incomes often lose Medicaid coverage 60 days after giving birth.

Postpartum health coverage is essential. Life-threatening conditions during and after pregnancy are distressingly common in the United States, and people with low incomes are disproportionately likely to face these conditions, according to the Medicaid and CHIP Payment and Access Commission. About 3 in 5 pregnancy-related deaths were preventable, according to a study of state maternal mortality review committee findings. Postpartum coverage is especially important for Black people, who are somewhat likelier to experience life-threatening pregnancy complications in the late postpartum period (between six weeks and one year after childbirth) than white people.

The pregnancy-related mortality rate for Black people was three times higher than for white people from 2011 to 2015 (42.8 deaths vs. 13 per 100,000 live births). These disparities are widely attributed to systemic racism, which affects many aspects of health care access and outcomes for Black people (including access to job-based health coverage, access to timely prenatal care, and the quality of the hospital where the person is delivering).

As noted, in states that have expanded Medicaid to cover adults with incomes up to 138 percent of poverty, pregnant people with incomes below the threshold can maintain their coverage beyond the 60-day postpartum period. That means better access to care: a study comparing pregnancy-related outcomes in Colorado (which expanded Medicaid) versus Utah (which did not) found that among people with severe pregnancy-related health conditions, postpartum visits in Colorado were 50 percent higher than in Utah.

In states that had not expanded Medicaid, postpartum people were three times likelier to be uninsured three to six months after childbirth than postpartum parents in states that expanded Medicaid, another study found. People who have recently given birth were also likelier to be continuously enrolled in coverage before, during, and after childbirth in expansion states than in non-expansion states (70 percent versus 56 percent, respectively), the study found.

States and CMS can significantly improve access to Medicaid for postpartum parents. Illinois and New Jersey have proposals before CMS that would provide a year of postpartum coverage for people with incomes above 138 percent of the federal poverty line, who currently lose their Medicaid eligibility 60 days after giving birth. CMS should promptly approve these demonstration projects, and additional states -- including those that haven't expanded Medicaid to all low-income adults -- should propose similar policies.

Unfortunately, the state fiscal crisis is driving some states to ill-advisedly consider rolling back planned expansions of postpartum coverage. Tennessee reversed its proposed expansion in June, citing funding constraints, and California considered similar cuts. But improving Medicaid postpartum coverage would be cost-effective for states, with much of the cost covered by the federal government, and would provide enormous benefits to postpartum people.

The President and Congress should also enact a pathway for states to expand coverage to a year postpartum without the need for a demonstration project, as several current pieces of legislation propose. But CMS and states need not wait for legislative action when they can act now to expand access to needed care.