Friday, January 22, 2021

Protecting Postpartum Women: The Need to Extend Medicaid Postpartum Coverage in Texas

Rebecca Teng, MD
Austin Obstetrician and Gynecologist
Member, Texas Medical Association Committee on Reproductive, Women’s and Perinatal Health

While traditional obstetric care often focuses on the time of a woman’s pregnancy through the time of the delivery of the baby, there is a growing recognition about the need for more attention to the time after she delivers. During this postpartum period – increasingly referred to as the fourth trimester – a new mother will need medical care, and she needs health insurance to help her obtain that care. Medicaid, which covers 53% of all Texas births, should cover women not only throughout their pregnancies but also for a full year after they give birth.  

During the pregnancy, women see the physician more frequently than at any other time of a typical healthy person’s life. Visits ramp up near the end of pregnancy, as physicians who provide obstetrical care and their medical teams are looking for any condition that may affect the mother or an infant and might change their recommendation about the baby’s delivery. After delivery, the postpartum period is a time of potential vulnerability for the new mother. As every parent knows, the arrival of a newborn, no matter how loved, means many sleepless nights, new stress, and relationship challenges; but this period is especially dangerous for those who might have unstable insurance coverage or who are uninsured. Even before the pandemic, one-quarter of Texas women of reproductive age lacked health insurance. Without coverage, women are less likely to access primary, specialty, and preventive care services to be healthy, increasing the risk of preventable issues and tragedies.

Following childbirth, postpartum women need ongoing treatment for any underlying chronic health conditions, such as hypertension or diabetes, or to treat complications that might arise in the following year, some of which are life-threatening if untreated. These complications include severe postpartum depression and heart disease. 

In addition, healthy pregnancies do not begin at conception, but well before. Once a woman becomes pregnant, an obstetrician-gynecologist or family physician caring for her cannot undo cumulative years of poor health stemming from little or no care prior to getting pregnant. For example, if a woman has had uncontrolled diabetes, this can increase the risk of birth defects in the infant and the risk of complications. One example is shoulder dystocia (a condition when one or both of a baby’s shoulders get caught inside the mother’s pelvis during labor); another is a potentially greater need for the mother to have a cesarean delivery (commonly known as a C-section, surgically delivering the baby). Also, if deliveries are less than 18 months apart, there can be a higher risk of preterm labor, growth issues, and placental issues. 

According to Texas’s own expert panel, women’s lack of access to regular, preventive primary and specialty care before and after pregnancy contributes to Texas’ high rate of maternal deaths. Nearly one-third of new mothers’ deaths occur 60 days or more postpartum – the same time many low-income women lose their pregnancy-related Medicaid coverage. Among Black women, the numbers are far worse: Black women account for 31% of maternal deaths but only 11% of births. 

As tragic as maternal deaths are, they are only one part of the story. For every woman who dies in conjunction with having a baby, 50 to 100 women suffer a severe illness or complication, often with lasting consequences. According to the American College of Obstetricians and Gynecologists, nearly seven in 10 women report at least one physical problem in the first year after delivery, and one in nine women may experience symptoms of postpartum depression. Extending women’s Medicaid coverage for a full year after they have their baby would prolong their care to help address and resolve these complications.

Fortunately, the Healthy Texas Women (HTW) program – and the new Healthy Texas Women Plus program – help fill the coverage gap by providing low-income women preventive and basic primary care before and after pregnancy as well as some specialty services for the 12 months following delivery. HTW Plus, launched in September 2020, builds on HTW by providing one year of limited specialty care coverage for the three conditions and illnesses most likely to contribute to maternal mortality or morbidity: postpartum depression, which one in eight women develop; cardiovascular and other coronary conditions; and substance abuse disorders. 

However, these programs do not provide comprehensive coverage like Medicaid does, meaning women with complex medical needs will not have coverage for all the services they need. 

Comprehensive coverage matters. Women who live in states with prolonged coverage are more likely to have ongoing access to health care before, during, and after pregnancy, and they are more likely to get postpartum treatment when they suffer severe complications. They also are less likely to die after having their baby. 

Extending postpartum Medicaid coverage would give eligible women health insurance longer, allowing them to continue treatment for any known health conditions. Women also could obtain treatment for any other conditions that may develop, such as diabetes  or cancer. Protecting continuity of care also would allow women to have one fewer transition in the tumultuous time of the first year after delivery and bolster their ability to have the continued support of their medical team. Extending postpartum Medicaid coverage for a year would align mothers’ care with that of their infants, who have guaranteed Medicaid coverage for the first year of their lives. This improvement might also decrease the likelihood the mother would need to seek emergency care (and face that extra expense) as women probably could be cared for in outpatient offices and clinics rather than having to rush to the hospital with an emergency.

It is for these reasons that the Texas Medical Association supports enactment of comprehensive health care coverage initiatives, including extending full Medicaid coverage for 12 months to postpartum women who otherwise lose coverage 60 days postpartum, as well as extending comprehensive coverage to low-income, uninsured, working-age adults.* Extending postpartum Medicaid coverage has wide support among many physicians, medical societies, and hospitals, including the Texas Pediatric Society, Texas Association of Obstetricians and Gynecologists, American Congress of Obstetricians and Gynecologists District XI (Texas), Texas Academy of Family Physicians, and Texas Hospital Association, along with numerous national societies. There also is bipartisan congressional support. By extending postpartum Medicaid coverage to a full year, we can better support the health of Texan mothers, infants, and families. 

*As a result of federal public health emergency (PHE) COVID-19 legislation, states must maintain Medicaid coverage for anyone enrolled in Medicaid on or after March 18, 2020, including postpartum women. This temporary coverage extension is currently set to expire in June 2021, but will renew with every extension of the PHE.

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