American Rescue Plan Act Takes Landmark Step Toward Ending Our Black and Indigenous Maternal Mortality Epidemic

American Rescue Plan Act Takes Landmark Step Toward Ending Our Black and Indigenous Maternal Mortality Epidemic

With the stroke of a pen on March 11, 2021, President Biden signed the American Rescue Plan Act of 2021 (ARP) giving states the option to provide continuous Medicaid and CHIP coverage through twelve months postpartum. 

Inside the U.S.’ Maternal Mortality Epidemic

People in the U.S. are dying from pregnancy-related complications at a higher rate than in any peer high-income country—and those deaths are increasing:

  • 52% of pregnancy-related deaths (defined as death within one year of pregnancy) occur after delivery, or postpartum;
  • 21% occur between one and six weeks postpartum;
  • 12% occur during the remaining portion of the year postpartum. 

The same people who are bearing the brunt of the COVID-19 pandemic are also the most harmed by our nation’s epidemic of pregnancy-related complications, including postpartum depression, and mortality. This public health crisis is disproportionately killing people who live at the intersection of multiple identities, including Black, Indigneous, and Latinx women, transgender and non-binary people, and people with disabilities. Pregnancy-related mortality ratios are four to five times higher for Black and Indigenous women* thirty years old or younger compared to non-Latinx white women. 

Research demonstrates that more than 60% of pregnancy-related deaths are preventable. Structural racism, sexism, xenophobia, ableism, and other overlapping systems of oppression within and beyond health care delivery drive pregnancy-related health inequities. Because of these systems of oppression, Black, Indigenous, and Latinx people are disproportionately likely to experience disruptions in perinatal insurance coverage. These disruptions leave postpartum people unconscionably vulnerable to pregnancy-related complications and mortality. Ensuring continuous health coverage for the entire twelve-month postpartum period could help racial inequities in postpartum health outcomes.

Postpartum Medicaid and CHIP Eligibility at a Glance

Medicaid is the single largest payer for pregnancy-related care in the U.S. In 2016, it financed 43% of all U.S. births. For people with low incomes, Medicaid and CHIP’s coverage of pregnancy-related services without cost-sharing is a lifeline. 

The federal Medicaid statute and regulations establish mandatory and optional eligibility categories for pregnant and postpartum people. States must provide full-scope Medicaid coverage to qualified pregnant women with especially low incomes. If household income exceeds the income limits for full-scope Medicaid coverage, they may still meet the state’s income cutoff for pregnancy-related Medicaid. The income cutoffs for pregnancy-related Medicaid vary, but states cannot drop eligibility below a legal floor that ranges from 133% to 185% of the Federal Poverty Level. At a minimum, the state must cover pregnancy-related services (e.g., prenatal care, labor and delivery, and postpartum care) and “conditions that might complicate the pregnancy” for this eligibility category through the end of the month in which the sixty-day postpartum period ends. 

Individuals receiving Medicaid or CHIP on the basis of their pregnancy may be eligible to continue Medicaid after the 60-day postpartum period if they are eligible under another category. If they are ineligible to continue receiving Medicaid/CHIP, postpartum people may qualify for marketplace coverage, but may experience barriers to making that transition. In addition, marketplace plans may include premiums, co-pays, and deductibles for postpartum care. For postpartum people with low incomes, cost is often a barrier to access.

What Changed Under the American Rescue Plan Act

Until now, there was no direct legal authority for states to provide continuous Medicaid or CHIP coverage through twelve months postpartum. In a landmark win for reproductive justice, the ARP Act creates new state plan amendment options for states to extend full-scope Medicaid coverage for the entire postpartum period. The Act authorizes these options for a five-year period beginning April 1, 2022. 

International human rights standards recognize that governments have an affirmative obligation to ensure that everyone can access pregnancy-related health care, including postpartum care. Nevertheless, many people, especially Black, Indigenous, and other People of Color with low incomes, experience disruptions in health coverage during the twelve-month postpartum period. The American Rescue Plan Act takes a major step toward ending those disruptions and their role in our maternal mortality epidemic. Now, it is up to states to take up those options, and Congress to make them permanent. 

See other entries in our American Rescue Plan Act series:

*NHeLP recognizes that not all people who become pregnant and give birth identify as women. We use the more gender inclusive term “pregnant people” or “pregnant individuals” as much as possible. We use the term “pregnant women” or “pregnant woman” when explaining Medicaid/CHIP requirements for pregnancy services to conform with the language used in the statute and regulations. We do the same to conform with non-gender inclusive research findings while recognizing that more inclusive research is needed.

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