Sens. Booker, Gillibrand, Harris, Smith Press Senate Leaders for Maternal Health Policies in Next COVID-19 Package

WASHINGTON, May 30 -- Sen. Cory Booker, D-New Jersey, issued the following news release:

U.S. Senators Cory Booker (D-NJ), Kirsten Gillibrand (D-NY), Kamala Harris (D-CA), and Tina Smith (D-MN) are urging Senate leaders to include an array of key maternal health policies in the next COVID-19 legislative package as the pandemic threatens to stress our maternal care system and worsen pre-existing racial disparities.

"The maternal mortality rate in the United States exceeds that of almost all of its peer countries, and in fact, the U.S. is one of only a few countries in the world that experienced an increase in maternal mortality between 2000 and 2014," the Senators wrote in a letter sent today to Senate Majority Leader Mitch McConnell (R-KY) and Minority Leader Chuck Schumer (D-NY). "The same communities that are at greatest risk for maternal death and illness are disproportionately affected by COVID-19. It is clear that this pandemic is placing further strain on our nation's maternal care system and on pregnant people."

The Senators asked leadership to include the following policy solutions in the next COVID-19 relief package:

* Extend Medicaid coverage for postpartum women from the current 60 day minimum requirement to one full year (Medicaid covers 43 percent of births each year, and the abrupt 60-day cut-off for postpartum women covered by Medicaid is harmful for new mothers, particularly as one-third of pregnancy-related deaths occur between one week and one year after delivery).

Expand Medicaid coverage beyond simply "pregnancy-related services" to include full-scope care (the current restriction of care to "pregnancy-related services" only may prohibit individuals from receiving care for other health conditions and comorbidities that impact maternal health, including those related to COVID-19).

Make Maternal Mortality Review Committees (MMRCs), which regularly review maternal health data, universal for all states, with consistent data collecting and reporting norms, and ensure they are representative of the U.S. population.

Boost resources and support for states to implement maternity care telehealth services nationwide, particularly those covered under Medicaid.

Improve access to doula and other perinatal support services, such as lactation counselors and childbirth educators (doula support has been linked to improved perinatal outcomes, particularly for people of color).

Boost funding for midwifery education programs in order to grow, strengthen, and diversify the midwifery workforce, especially for midwives of color and those working in health professional shortage areas (midwifery care is associated with fewer unnecessary interventions, increased patient satisfaction, and lower health care costs).

Provide dedicated funding to states and hospitals to help reduce maternal deaths, and prevent and respond to complications arising from pregnancy and childbirth.

Improve access to freestanding birth center services for people with low-risk pregnancies (freestanding birth centers are evidence-based, safe alternatives to in-hospital birth, which can?help?relieve?pressure on the physician workforce, minimize COVID-19 transmission, and direct health system resources more effectively as the country continues to respond to the COVID-19 pandemic).

This letter was also signed by Senators Michael Bennet (D-CO), Gary Peters (D-MI), Tammy Baldwin (D-WI), Richard Durbin (D-IL), Chris Van Hollen (D-MD), Elizabeth Warren (D-MA), Maggie Hassan (D-NH), Amy Klobuchar (D-MN), Ed Markey (D-MA), Deborah Stabenow (D-MI), and Richard Blumenthal (D-CT).

* * *

May 29, 2020

To: The Honorable Mitch McConnell, Majority Leader, United States Senate, S-230, U.S. Capitol, Washington, D.C. 20510

The Honorable Charles Schumer, Minority Leader, United States Senate, S-220, U.S. Capitol, Washington, D.C. 20510

Dear Majority Leader McConnell and Minority Leader Schumer:

As the Senate continues to work on the next legislative package to address COVID-19, we write to urge you to include policies that will improve maternal health. While this should be a constant priority for Congress, it is especially important now as we work to respond to COVID-19.

As you know, the maternal mortality rate in the United States exceeds that of almost all of its peer countries, and in fact, the U.S. is one of only a few countries in the world that experienced an increase in maternal mortality between 2000 and 2014./1

Each year about 700 people in the United States die from pregnancy-related complications, and a majority of these deaths are preventable./2

Troubling racial and geographic disparities plague maternal health. American Indian and Alaska Native (Indigenous) people and black people are more than two and three times likely to die, respectively, than white people due to pregnancy-related complications./3

Additionally, pregnant people in rural areas are more likely to die or experience severe complications around the time of childbirth./4

The same communities that are at greatest risk for maternal death and illness are disproportionately affected by COVID-19. It is clear that this pandemic is placing further strain on our nation's maternal care system and on pregnant people. For instance, there have been reports of expectant mothers forced to delay or forego check-ups and other needed care due to fears that they might contract COVID-19, which is particularly troubling for people of color, rural residents, and other medically underserved individuals who already face barriers to care./5 /6

Many pregnant people are also having to give birth without their full support system, including family members and doulas, due to the social distancing measures that hospitals have implemented./7

Other pregnant people are looking for alternatives to giving birth in a hospital but are burdened by restirctions. In addition, pregnant and postpartum individuals are dealing with significant stressors related to the COVID-19 pandemic, including those related to employment, health, income, and housing./8

Furthermore, preliminary data indicates that Black and Indigenous people make up a disproportionate amount of those who are contracting and dying from COVID-19 across the country, and rural residents are increasingly affected. This, intersected with their already higher rates of maternal mortality, may put pregnant Black and Indigenous people, especially those in rural areas, at particular risk of experiencing poor health outcomes during this pandemic. To support and address the needs of pregnant people, particularly during this time, we encourage you to include the following policies in the next legislative package Congress considers: Postpartum Medicaid Medicaid is a primary payer of maternity care in the United States, covering 43 percent of births nationwide./9

One in three women experience a disruption in insurance coverage before, during, or after pregnancy, and nearly 60 percent of these perinatal insurance disruptions include a period of uninsurance./10

Under current law, many pregnant people who are covered by Medicaid as a result of their pregnancy are only guaranteed coverage for up to 60 days postpartum. This abrupt cut-off during the postpartum period is harmful for new mothers, particularly as one-third of pregnancy-related deaths occur between one week and one year after delivery./11 /12

Deaths from cardiovascular disease, including cardiomyopathy, and other preventable causes, including overdose and suicide, occur more frequently during this 12-month postpartum period, than before./13

Ensuring continous Medicaid coverage for postpartum individuals can save lives and reduce disparities; for example, Medicaid expansion has helped lead to 1.6 fewer maternal deaths per 100,000 women, and racial disparities in states that have expanded Medicaid are smaller than in those that have not./14

As the nation continues to respond to the COVID-19 pandemic, it is particularly important that postpartum patients have continuous health coverage. We urge you to extend pregnancy-related Medicaid coverage for all postpartum beneficiaries to one full year post-birth. Full-Scope Medicaid Coverage and Increased Reimbursement In addition to ensuring that pregnant Medicaid beneficiaries may remain covered for at least a year postpartum, it is also critically important that coverage is comprehensive. Currently, many Medicaid beneficiaries are restricted to coverage for "pregnancy-related" services only. This restriction may prohibit individuals from receiving care for other health conditions and comorbidities that impact maternal health, including those related to COVID-19. We urge you to ensure that all pregnant and postpartum beneficiaries have full-scope Medicaid coverage, which includes coverage for critical services like oral health care as well. In addition, even before the COVID-19 pandemic, Medicaid reimbursement rates for maternal health and other services were very low. Maternal health providers, like all medical providers, are suffering deep losses due to the pandemic and have received limited federal funding. Upcoming legislation should also include a reimbursement rate increase for maternal and childbirth services, including parity with Medicare rates as appropriate. Maternal Morbidity and Mortality Review Committees (MMRCs) Most, but not all, states have maternal mortality review committees that regularly review maternal death data. It is essential that MMRCs be universally established and equitably resourced; establish consistency in data collection and reporting; and include people who have been most affected by maternal mortality./15

Federal guidelines and resources for reporting maternal deaths should be equitably provided across states. Additionally, federal leadership can ensure consistency in how deaths are identified, defined, systematically collected, managed and how to report on subpopulations at greatest risk (including different racial and ethnic groups, rural populations, and people experiencing domestic violence.) Committee representation should include people who have given birth, family members of those lost to maternal mortality, and those who are disproportionately affected by maternal morbidity and mortality - including Black, Indigenous, and rural people. Expanding Telehealth and Related Equipment Telehealth may play an important role in providing maternal health care, particularly as many Americans continue to observe social distancing. The Centers for Medicare and Medicaid Services (CMS) recently published a toolkit to assist states in increasing the use of telehealth services through Medicaid and CHIP./16

We urge you to provide additional support and resources to help states implement telehealth services for maternity care, particularly for Medicaid, which covers almost half of all births in the United States. This should include covering equipment and devices that are necessary for providing maternal health services via telehealth, such as blood pressure cuffs. Currently, many women enrolled in Medicaid do not have access to the equipment that is required for remote patient monitoring services. Allowing clinicians to write prescriptions for at-home equipment will ensure equitable access to evidence-based telehealth services for pregnant and postpartum women, as well as reduce their risk of exposure to COVID- 19. Congress should also do all it can to ensure that a range of providers are able to provide telehealth services and receive reimbursement for such services, including midwives. Additionally, similar guidance, requirements and resources should be applied to private insurers to ensure their patients have the ability to appropriately access critical maternity care services through telehealth at this time.

Access to Doula and Other Perinatal Support Services

Doulas are support personnel who provide pregnant people with non-clinical, emotional, physical, and informational support before, during, and after birth. Doula support has been linked to improved perinatal outcomes, particularly for people of color./17

Doula support also plays an important role in helping expectant or new mothers relieve stress, which is particularly important now. Other perinatal support services like lactation counselors and childbirth educators can also aid expectant and new mothers by providing support and helping to navigate resources and systems during this time. In the next COVID-19 package, Congress should require CMS - in coordination with patients and perinatal support workers, including community-based doulas - to provide guidance and additional support to states to reimburse and better facilitate access to doula and other support services, including through telehealth, for Medicaid and CHIP beneficiaries throughout the country.

Access to Midwifery Care

Midwifery care is associated with fewer unnecessary interventions, increased positive experience of care and patient satisfaction, and lower health care costs. However, restrictive regulations and insufficient Medicaid and commercial insurance reimbursement rates make midwives inaccessible for many, particularly people of color and people enrolled in Medicaid. We urge you to provide funding for midwifery education programs in order to grow, strengthen, and diversify the midwifery workforce, especially for midwives of color and those working in health professional shortage areas. Specfically, a funding stream should be established within the Health Resources and Services Administration's (HRSA) Title VIII and Title VII programs specific to Advanced Midwifery Education Grants, to support university-based accredited schools of midwifery and to establish programs for increasing the number of midwife preceptors across the country. In addition, certified-nurse widwives should be eligible for reimbursement under Medicare's Graduate Medical Education program, in order to ensure that midwives who work in obstetrical training and teaching facilities can be explicitly reimbursed for performing those services. Midwives should be reimbursed at 100 percent of physician rates for identical services under Medicaid and guaranteed inclusion in Medicaid managed care plans and equity and inclusion within private insurance plans. We also urge HHS to work with states to ensure that midwives are being allowed and supported to practice to the full scope of their certification in all states. Funding to Help Hospitals Prevent and Respond to Pregnancy Complications States and hospitals need dedicated funding to purchase supplies, train staff, and fully implement standardized best practices to help reduce maternal deaths, and prevent and respond to complications arising from pregnancy and childbirth. The next COVID-19 relief package should include dedicated funding to support emergency responses at hospitals to protect women before, during, and after childbirth. Funding to Support Birth Centers Freestanding birth centers are evidence-based, safe alternatives to in-hospital birth, which can help relieve pressure on the physician workforce, minimize COVID-19 transmission, and direct health system resources more effectively as the country continues to respond to the COVID-19 pandemic, while also achieving cost savings.18 19 We urge you to improve access to freestanding birth center services for people with low-risk pregnancies, especially those enrolled in Medicaid, by funding a Medicaid demonstration program to develop and advance innovative payment models for birth center care. CMS should also publish guidance for states to implement payment for birth center facility fees and birth attendant provider fees. Additionally, in response to the COVID-19 pandemic, regulations and financial support must facilitate the rapid opening and expansion of birth centers and auxiliary maternity units to meet the increasing demand for out-of-hospital birth, following guidelines from national birth center accreditation organizations. These options require adequate reimbursement rates and facility fees to sustain their operations and serve patients enrolled in Medicaid.

Thank you for your consideration of our request. We look forward to continuing to work with you on policies that will help all Americans as our nation continues to respond to the COVID-19 pandemic.

Sincerely,

See signatories and footnotes here https://www.booker.senate.gov/imo/media/doc/CV4-Maternal%20health%20letter%20FINAL_.pdf