The well-being of North Carolina women during pregnancy, delivery, and the postpartum period is paramount to mothers' health and the health of their children, the next generation of North Carolinians. Access to quality health care during pregnancy and the postpartum period provides an opportunity to identify existing health risks and issues in women and help prevent negative health outcomes, such as diabetes, depression, hypertension, cardiovascular disease, substance use, and maternal and infant death, for both mothers and their children.1
However, North Carolina maternal mortality and morbidity data show that efforts are needed to address the growing number of women of childbearing age who are dying due to pregnancy-related and associated complications. North Carolina's maternal mortality rate is 27.6 per 100,000 births, slightly lower than the national rate of 29.6 deaths per 100,000 births, but the state ranks 30th in maternal mortality compared to other states.2 In addition, there are drastic disparities in maternal mortality among women in North Carolina, with Black women having a maternal mortality rate of 56.8 deaths per 100,000 births, nearly two times that of white women.3,4 There are opportunities for health care leaders and policymakers to prevent many of these deaths. A review of 2014-2015 pregnancy-related and associated deaths by North Carolina's Maternal Mortality Review Committee found that 63% of maternal deaths were preventable.3
One avenue for preventing maternal mortality and improving maternal health outcomes in North Carolina is extending pregnancy Medicaid coverage to up to one year after delivery. This is particularly promising for expanding health care access because over 50% of births in North Carolina are covered by Medicaid.5 Under current North Carolina Medicaid for Pregnant Women (MPW) requirements, pregnant and postpartum women whose monthly family income does not exceed 196% of the federal poverty level are eligible for Medicaid coverage services related to pregnancy, such as prenatal care, labor and delivery, medical conditions that might complicate the pregnancy, behavioral health, childbirth classes, and family planning up to 60 days after delivery.6,7 After those 60 days, postpartum women receiving MPW may still be eligible for coverage under Medicaid for Families with Dependent Children (MAF), but the income eligibility is much stricter for MAF than MPW. For example, a family of three earning up to $3,484 monthly qualifies for MPW; but a family of three that earns over $667 monthly earns too much for parents to qualify for MAF. This difference in income eligibility results in many low- and moderate-income women losing Medicaid eligibility after 60 days postpartum.8
North Carolina’s coverage gap between Medicaid eligibility and the ACA Marketplace also leaves many women vulnerable to losing coverage in the postpartum period. Women ineligible for MAF can seek coverage on the ACA Marketplace, however, Marketplace premiums, co-pays, and deductibles can be barriers to access for low- and moderate-income women. In addition, Marketplace subsidies are only available to people earning 133% of the federal poverty level, resulting in a coverage gap. A family of three in North Carolina earning between roughly $8,000 and $23,000 annually would find that their family income is too high to qualify for MAF and too low to qualify for Marketplace subsidies; this gap results in many women losing their medical coverage just 60 days after giving birth.8 An analysis completed by the Urban Institute in 2020 found that half of all uninsured new mothers reported that losing Medicaid or other coverage after pregnancy was the reason they were uninsured, suggesting that they would likely benefit from an extension of postpartum Medicaid coverage. Approximately one-third of pregnancy-related and associated deaths occur between one week and one year after delivery.9 In addition, almost one-third of women who lost Medicaid coverage and became uninsured in the postpartum period were obese before their pregnancy, 18% reported either gestational diabetes or pregnancy-related hypertension, and over one-quarter reported being depressed sometimes, often, or always in the months after giving birth.10
In response to the COVID-19 pandemic, the Families First Coronavirus Response Act passed by United States Congress and signed by President Donald J. Trump in March 2020 provided enhanced federal funding for state Medicaid agencies to provide care over the course of the health crisis. One of the conditions for receiving funding is that states are expected to provide continuous coverage throughout the health emergency to ensure that people do not lose their Medicaid coverage. This also applies to women enrolled in Medicaid on the basis of being pregnant, guaranteeing that during the pandemic all women covered under MPW have access to pregnancy-related care.11 However, once the COVID-19 health emergency ends, the coverage gaps that already exist will persist. In July 2020, the American College of Obstetricians and Gynecologists, the nation's leading professional association for obstetrician-gynecologists, advocated to members of the United States Congress the importance of extending continuous postpartum Medicaid coverage to up to one year after delivery and called on them to include language extending Medicaid postpartum coverage in any additional COVID-19 relief legislation. One such provision was included in the American Rescue Plan Act of 2021, signed into law in March 2021.12 Among the provisions included in the Rescue Plan, a new policy would allow states to extend Medicaid postpartum coverage to one year after delivery and provides federal funding to do so. The new provisions would allow states to extend coverage to a year by filing a State Plan Amendment to their Medicaid programs. States can implement this new policy on April 1, 2022, and it would be effective for five years.13
This new option can lead to improved maternal health outcomes and help address the continuing rise in maternal mortality and morbidity in North Carolina, and across the country, by expanding access to care during the critical postpartum period. Implementing this new policy could lead to improved maternal health outcomes, especially for Black women in North Carolina who are the most likely to die from pregnancy-related complications and have worse birth outcomes compared to other populations.
Efforts are already underway in the North Carolina General Assembly to provide North Carolinians with health coverage for one year after delivery. If passed, Senate Bill 530 and House Bill 316 would direct the North Carolina Department of Health and Human Services to implement the continued Medicaid eligibility of pregnant women for 12 months postpartum to begin on April 1, 2022, as allowed under the American Rescue Plan. As of the publication of this post, both bills are currently being considered by their respective chambers, with Senate Bill 530 having bipartisan support.
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