TennCare's maternal death rates are 3x those of private insurance

NASHVILLE —Tennessee has long had one of the highest maternal death rates in the nation, but newly released data shows the risks of dying from pregnancy are exponentially higher for those onTennCare.

Pregnant patients with TennCare, the state's public insurance program for people living in poverty, were three times more likely to die during or after pregnancy than those with private insurance between 2020 and 2022, a report from the state's maternal mortality review committee found.

While each death is a result of individual and often complex factors ranging from pre-existing health conditions to postpartum depression, the vast majority of Tennessee maternal deaths – 76% – were preventable, the report concluded.

Experts say the collective deaths of pregnant and postpartum women on TennCare raises urgent questions about state policy actions – and inactions – behind the tragic outcomes. Among them:

Gov. Bill Lee and the Tennessee Legislature have repeatedly rejected efforts to expand TennCare to include more people above the poverty line. States with Medicaid expansions reduced maternal mortality rates.TennCare is one of just three Medicaid programs – along with Alabama and Mississippi – that hasn't adopted a reproductive health care waiver, a narrow expansion of Medicaid to cover family planning services to those who otherwise do not qualify for Medicaid. Private insurance companies that manage the day-to-day TennCare patient oversight consistently rank in the bottom quarter of all Medicaid programs in meeting basic benchmarks of prenatal and postnatal care, including depression screenings and timeliness of pre- and post-natal visits. Efforts to address racial inequalities in pregnancy deaths, including funding for doulas, have been blocked by the Republican-controlled Tennessee Legislature

"Behind these statistics are heartbreaking tragedies, and the state should be treating this as the crisis that it is," said Michele Johnson, executive director for the Tennessee Justice Center, a public interest law firm representing TennCare patients that has advocated for TennCare expansion and quality improvements.

A TennCare spokesperson noted that maternal deaths are a national concern and that Medicaid programs such as Tennessee's are often tasked with serving higher risk populations than private insurers.

"TennCare remains committed to improving maternal health and supporting our pregnant and postpartum members," said Amy Lawrence, the spokesperson, who noted TennCare has implemented recent policy changes to address maternal outcomes.

Among them is an expansion of postpartum coverage from 60 days to 12 months following the end of a pregnancy, an effort to integrate screening tools to connect patients to food, housing and other assistance and case management services available to all maternity patients.

Improved maternal outcomes in Medicaid expansion states

About 50,000 pregnant women each year are covered by TennCare – accounting for about half of all births in the state. About two-thirds of the costs of the $18.6 billion program are shouldered by the federal government.

Tennessee taxpayers pick up about a third of the tab. The program primarily covers kids and individuals who are elderly or have a disability.

Since the adoption of the federal Affordable Care Act in 2014, states have had the option to expand Medicaid to cover more uninsured people than the programs were allowed in the past, but Tennessee lawmakers quickly adopted legislation requiring their approval before TennCare could expand. Neither the Republican-controlled legislature nor Gov. Bill Lee has supported expansion since.

But in states that have expanded their Medicaid programs – 41 thus far – maternal mortality rates are "visibly lower" than in non-expansion states, a drop particularly pronounced among non-Hispanic Black women, according to analyses of federal health data. The data found that states with expanded Medicaid programs saw a decrease of about 7 maternal deaths per 100,000 live births.

Pregnancy-associated deaths in Tennessee declined overall by 26% in 2022 after spiking during the height of the COVID epidemic. TennCare's pregnancy-related maternal death rate stands at 81 maternal deaths per 100,000 live births – nearly three times as high in Tennessee as those with private health insurance. The maternal death rate for Tenneseans covered by private insurance was 29 per 100,000 live births.

Medicaid expansion gives patients critical access to ongoing and preventative medical care before pregnancy, said Eugene Declercq, professor of community health sciences at Boston University School of Public Health.

"Maternal health is not just about birth," Declercq said. "It's about women's health and social support systems. We like to focus on maternal mortality because it's so tragic, but the reality is this is about women's overall health."

Mental health disorders, including substance abuse and cardiovascular illness accounted for the majority of all Tennessee maternal deaths – illnesses for which ongoing treatment prior to pregnancy may address.

Declercq, who sits on the Massachusetts maternal mortality review panel, praised the work of Tennessee's maternal review committee in reporting the disparities in outcomes between Medicaid and private insurance. Not all state reviews of maternal deaths do, he said.

Failed legislation

Local advocates criticized a lack of action by lawmakers in supporting policies shown to improve maternal outcomes, among them state funding for TennCare doula services to aid pregnant patients – a measure repeatedly rejected by lawmakers in the state's supermajority GOP.

"It's been a five-year uphill battle," said Briana Perry, interim director of the nonprofit Healthy and Free Tennessee. "While we know that doulas aren't the only solution, we know doulas are supportive players that have a critical role in intervening."

Doulas are trained advocates who provide physical, emotional, and informational support during pregnancy, labor, birth, and postpartum, improving health outcomes.

Perry said doulas can also play a critical role in reducing discrimination and differential treatment by medical professionals. Black women overall in Tennessee are twice as likely to die as a result of pregnancy than white women. A Tennessee's maternal mortality review report released in 2023 concluded discrimination contributed to 22% of pregnancy-associated deaths in Tennessee; most of those deaths, which occurred in 2021, were preventable, the report found.

Sen. London Lamar, a Memphis Democrat, first introduced legislation to require TennCare coverage of doulas in 2022. After pushback from Republicans, the bill was rewritten to require a study of the benefits of doulas, ultimately becoming law. That study remains ongoing.

Lamar unsuccessfully reintroduced legislation requiring coverage of doulas in 2023 and again 2024. She reintroduced the legislation last week for a fourth time.

Thirteen states and the District of Columbia, all with lower rates of maternal death than Tennessee, have implemented some form of doula coverage while 12 other states are in the process of implementing doula coverage, according to Georgetown University Center for Children and Families.

Lamar said she is frustrated, not only by colleagues who have blocked bills in the past, but by TennCare officials who, she said, have failed to advocate for maternity patients.

"I think they have a huge responsibility to speak up," she said of TennCare. "Our inability to take on more solution-based initiatives is directly contributing to more deaths."

Among Lamar's past efforts was a bill to create evidence-based implicit bias training for healthcare professionals related to maternal and infant mortality. A separate bill would have created an 11-member maternal health equity advisory committee within the Tennessee Department of Health.

Discrimination was a contributing factor in 22 percent of Tennessee maternal deaths in 2021, a state report found..

The training measure failed to pass and the 11-member maternal committee measure succeeded only after it was rewritten to simply add four community members to the state's existing maternal mortality review board.

"I am not shocked to see more women dying on TennCare," Lamar said. "TennCare is just as responsible for being silent on these deaths and these racial inequities as my Republican colleagues."

TennCare managed care organizations rank in bottom 25% on pre-, postnatal measures

Medicaid programs such as TennCare typically do not offer the same choices in selecting a physician or access to the same medications covered by privately-paid insurance coverage, noted Dr. Karen Scott, an OB-GYN and founder and CEO of Birthing Cultural Rigor in Nashville.

"These systems are not getting the same resources," Dr. Scott said. "And patients are often not in optimal health or have housing, food and other challenges."

Scott advocates for better data on severe maternal morbidity: patients who survive but have poor health outcomes as a result of pregnancy, childbirth or postpartum complications.

Tennessee has yet to study these outcomes; the state's health department is currently developing a report to measure them.

But one measure of Medicaid programs is the performance of privately operated managed care organizations the state contracts with to administer the TennCare program.

Each of TennCare's managed care organizations ranked in the bottom 25% of all Medicaid managed care plans for timeliness of prenatal and postpartum care in at least one of the regions of the state, according the National Committee on Quality Assurance (NCQA), which measures quality and performance of health care insurance companies.

One TennCare managed care organization also ranked near bottom inhow effectively its healthcare providers followed up after a patient screened positive on pre- and postnatal depression screenings.

"TennCare covers a population that is at higher risk due to lower income and greater incidence of preexisting chronic conditions," said Johnson, the executive director of the Tennessee Justice System.

"But good, timely care can mitigate those factors. TennCare quality reports cast a disturbing light on the poor performance of TennCare managed care contractors to provide adequate pre- and post-natal care, even as compared to Medicaid programs in other states."

Tennessee Lookout is part of States Newsroom, the nation's largest state-focused nonprofit news organization. Follow Tennessee Lookout on Facebook and Twitter.

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