Maternal mortality, Medicaid, and how we abandon parents in their time of need

By Katie Breen

In the weeks leading up to and just after childbirth, friends and family provide all kinds of support to soon-to-be parents in a burst of new-baby energy. Meals, fresh laundry, childcare. 

But after a few weeks, and while birthing people are still healing from the physical and emotional toll of childbirth, those supporters often go back to their lives, leaving many parents feeling isolated, abandoned, and alone. At the same time they are experiencing this slowly waning stream of emotional and logistical support, many of the most vulnerable families also find themselves abandoned by the safety nets that provide access to necessary healthcare. Health risks to birthing people exist throughout the entire postpartum year, but Medicaid insurance coverage ends for many after just 60 days postpartum. Extending Medicaid coverage to one full year postpartum for all Americans would go a long way to protect the health and wellbeing of families. 

Health Risks in the Postpartum Period

Birthing people are not fully recovered from childbirth when they are discharged from the hospital. One-third of all pregnancy-associated deaths occur after 7 days post-partum – by the time many of those friends and family members have started to trickle away. Approximately 21% of deaths directly related to pregnancy occur on days 7-42 postpartum and nearly 12% on days 43-365 postpartum. Data from Utah found that 80% of late postpartum deaths were after the postpartum parent had finished their last obstetric check-up. 

The dangers are numerous, including thrombotic pulmonary embolism (the condition experienced by Serena Williams during her traumatic birth experience) and cardiomyopathy (a condition which can lead to heart failure). In most states, the leading causes of pregnancy-associated death in the late postpartum period are accidental overdose and suicide due to a combination of factors, including lowered tolerance following drug abstinence during pregnancy, postpartum depression, stress and sleep deprivation, and, notably, loss of health insurance. 

These serious medical conditions require a birthing person to have access to healthcare long after they leave the labor and delivery floor. But despite this ongoing danger, healthcare access for the neediest families among us frequently disappears at about the same time that social support does.

Abandoning the Most Vulnerable Families

Nearly half of all births in the United States are paid for by Medicaid, a public health insurance program that provides free health insurance to 74 million low-income and disabled people (23% of Americans in 2017). In every state, the federal government requires low-income pregnant persons to be eligible for Medicaid coverage from the time they become pregnant until at least 60 days postpartum. While each state Medicaid program differs, they are federally required, at a minimum, to allow any pregnant person with an income of up to 138% of the federal poverty level (FPL) – $17,236 per year or less for individuals – to qualify. 

While states typically allow pregnant persons above the federal minimum of 138% FPL to qualify for Medicaid, the income eligibility levels after birth are much lower in every state than they are during pregnancy. In other words, once pregnant people become parents, it becomes much more difficult for them to qualify for Medicaid. In the 14 states that have not expanded Medicaid under the Affordable Care Act (ACA), the median eligibility limit for parents is 40% FPL, or $8,352 per year for a family of three. In ten of these states, the eligibility limit for parents is less than half of the poverty level.

Let’s break this down. Say you are living in a two-parent, one-child household in the state of Texas. You work in a job without benefits. Your household income is exactly at the FPL for a family of three, equaling $21,330 per year. When you become pregnant with a second child, you are eligible for Medicaid coverage due to your low income.

The state of Texas only requires Medicaid coverage for 60 days postpartum, after which you must requalify for Medicaid as a parent rather than as a pregnant person. However, the income requirement for parents, unlike for pregnant people, is just 17% of the FPL in Texas, rather than 138%. This means that in order for you to be covered by Medicaid, your household income would now have to be just $4,377 per year for your family of four. In other words, between day 60 and day 61 postpartum, you would have to become nearly $17,000 poorer per year in order to keep your Medicaid as a parent. Never mind that you work an hourly minimum wage job without paid family leave and certainly have much greater economic need in the postpartum period than you did before having a new child.

At 60 days postpartum, a time when access to medical care can literally mean life or death, the system has abandoned you.

A Way Forward

We must expect more from the way our medical systems and safety nets treat new parents. In all states, and even those reluctant to undertake ACA expansion, Medicaid coverage can be extended to at least one year postpartum. In all states, Medicaid eligibility for new parents can be relaxed so that birthing people are not left uninsured during a time of great emotional, financial, and physical vulnerability. 

This year in Texas, several bills to extend Medicaid coverage to a full year postpartum were introduced in the House, in line with recommendations from the Texas Maternal Mortality and Morbidity Task Force. One of them, HB 744, passed 87-43 — before the Texas Senate failed to hold hearings or a vote on the bill. Vox and ProPublica just published stunning reporting on the extraordinary danger of being pregnant and uninsured in Texas, demonstrating the explicit link between uninsurance and maternal mortality.

At the federal level, in this Congressional session several bills have been introduced which specifically include extension of Medicaid coverage to a full year postpartum. None have yet passed into law. The Helping Medicaid Offer Maternity Services (MOMS) Act (H.R. 4996) recently passed the House Energy and Commerce Committee, but maternal health advocates say that the bill doesn’t go far enough on several measures, including its lack of adequate incentives for all states–such as Texas–to extend coverage.

This should not be an issue of partisanship or politics–because it is so clearly an issue of compassion. We cannot claim to support new parents while pulling the rug out from under them during their greatest time of need. Our mission at Expecting More is to empower all of us to raise and grow our families with dignity. Reforming Medicaid programs with the needs of new parents in mind is one step towards this goal.

If you are interested in taking action to help support necessary healthcare access for new parents, learn more about how to get involved here.

Katie Breen will complete her MPH at the Harvard T.H. Chan School of Public Health later this month, and she is a member of the Delivery Decisions Initiative (DDI) at Ariadne Labs. She focuses on social determinants of health, maternal health, and family planning through her academic work, activism, and podcast, Femtastic

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