Fostering Maternal Health Equity Through Budget Reconciliation

Fostering Maternal Health Equity Through Budget Reconciliation

Three Critical Opportunities for The Next Package

The United States has the worst maternal mortality ratio among high-income countries. For over two decades, we have been one of only two countries to report a significant increase in maternal mortality rates. Most of these deaths are preventable. While this epidemic is pervasive nationwide, it does not burden all communities equally. Black and Indigenous women and birthing people are dying at exponentially higher rates than white peers. Racism, not race, is responsible for those inequities. Embodied histories of reproductive control and exposure to structural, institutional, and interpersonal racism and gender oppression in every facet of our society can make pregnancy, a fundamentally human experience, unsafe for Black, Indigenous, and other women and birthing people of color. This horrific reality is a policy choice.

A comprehensive whole-of-government approach, including health policy reform, is urgently needed to liberate our country from the maternal mortality epidemic and build a healthier and more equitable future for Black moms and birthing people and their families. This Spring, Congress can help foster that future by constructing and advancing a new budget reconciliation package that includes Medicaid eligibility, payment, and service delivery reforms as well as holistic public health solutions for Black moms and birthing people. This blog post discusses three critical areas of opportunity.

1. Reforming pregnancy-related Medicaid and CHIP eligibility

Medicaid covers forty percent of births and sixty-five percent of Black births nationwide, making it a crucial battleground for improving maternal health outcomes and equity. The Medicaid Act requires that states provide pregnancy-related Medicaid to people with incomes up to at least 133 percent Federal Poverty Level (FPL). This limited-scope coverage must only include “pregnancy-related services” and services for “conditions that might complicate the pregnancy.” And while more than half of maternal deaths occur after the date of delivery, and twelve percent happen between forty-three and 365 days postpartum, pregnancy-related Medicaid eligibility lasts only until the last of the month in which the 60th day after the end of the pregnancy. It’s not long enough or comprehensive enough to prevent late maternal deaths. Black and other underserved moms and birthing people urgently need continuous coverage for at least one year after their pregnancies end.

Last year, the American Rescue Plan Act (ARP) created a temporary state plan amendment option for states to extend pregnancy-related Medicaid and CHIP coverage to one year after pregnancies end. That option went into effect earlier this month on April 1, 2022. The U.S. Centers for Medicare and Medicaid Services announced that under ARP’s new option for states, as many as 720,000 people across the U.S. could become eligible for full-scope Medicaid and CHIP coverage for a full twelve months after pregnancies end. Louisiana, the first state CMS approved to use ARP’s pregnancy-related coverage extension SPA authority, began offering its enhanced coverage to an estimated 14,000 pregnant and postpartum people. CMS is also working with nine additional states to extend pregnancy-related coverage. State advocates are working hard to champion uptake of the ARP option. 

Experience from continued state Medicaid expansion fights suggests that, when implementation is optional, some legislatures will withhold coverage. That recalcitrance is connected to structural racism, gender oppression, and other barriers. Several federal bills, such as the MOMMA’s Act, MOMMIES Act, and most recently Build Back Better Act (BBB), include provisions that would amend pregnancy-related Medicaid and CHIP eligibility to cover moms and birthing people with full benefits and for twelve months after their pregnancies end. Congress must incorporate the House-passed BBB provision in its new reconciliation package.

2. Closing the Medicaid coverage gap

Equitably closing the Medicaid coverage gap would also help alleviate our Black maternal health crisis. Twelve years after ACA enactment, millions of adults with low incomes still have no pathway to affordable coverage because their states refuse to expand Medicaid. Black, Latinx, and other people of color disproportionately fall into the resulting Medicaid coverage gap. Two-thirds of uninsured women of reproductive age in the gap are people of color. One in three people in the gap are parents with children at home. The coverage gap denies millions of uninsured people with low incomes the gains in access to coverage, overall maternal health outcomes, and Black maternal health equity that expansion enrollees have experienced. State lawmakers’ refusals to implement expansion kill tens of thousands of people each year.

Last year, ARP temporarily increased existing financial incentives for states to expand Medicaid, which Oklahoma and Missouri, the most recent states to expand, will receive.  Congress also considered new federal fallback coverage for people in non-expansion states, and included various approaches in iterations of the Build Back Better Act. As Congress constructs its new reconciliation package, it must ensure that any federal fallback program provides access to the full range of services and consumer protections that Medicaid expansion enrollees currently receive. Absent parity, a coverage gap fix could enshrine in federal law a separate and unequal system of health coverage for millions of underserved people, particularly Black and Latinx people in the South. ​​Unequal coverage could also lead current expansion states to abandon expansion, leaving residents to that lower standard of coverage, and set precedent for a future Congress to lower Medicaid’s standard of coverage nationwide. These ramifications could undermine our ability to alleviate the Black maternal mortality epidemic and other interconnected racial and reproductive injustices in health. NHeLP previously published a framework with essential policy elements for designing equitable fallback coverage that does not undermine Medicaid more broadly. 

3. Holistically addressing Black maternal health inequities

Congress should ensure that the next reconciliation package includes policies designed to holistically address Black maternal health inequities. First, it should incorporate the same critical provisions from the Black Maternal Health Momnibus Act—legislation designed by, with, and for Black women and birthing people—that the House included in and passed through BBB last year. For example, the package should incorporate BBB’s historic investments to grow and diversify the perinatal health workforce, including nurses, doulas, midwives, physicians, and maternal mental and behavioral health professionals. This includes $50 million dedicated to doulas, including education and training programs, scholarships, and efforts to recruit and retain students from underserved communities, particularly those disproportionately burdened by high rates of maternal mortality and severe maternal morbidity. The package should also invest heavily in bias training for health care professionals. It should financially support representative community engagement in Maternal Mortality Review Committees and invest in maternal mental health equity programs, community-based organizations working to promote maternal health equity, maternal health research and Minority-Serving Institutions, and federal maternal health programs. In addition, the package should incorporate BBB’s reforms to address social determinants of maternal health, such as housing, nutrition, and environmental conditions, as well as maternal and infant health harms from climate change. It should also expand access to digital tools that promote maternal health equity. 

Second, the new package should carry forward BBB’s creation of a new state plan amendment option for Medicaid maternal health homes. Research suggests that maternal health home models can improve outcomes and patients’ experiences. Under the proposed Medicaid maternal health home option, maternal health homes would work with eligible enrollees in a culturally and linguistically appropriate manner to co-develop and co-implement individualized and comprehensive care plans consistent with individuals’ needs and choices. Adopting a whole-person care philosophy, these plans would cover primary, acute, and behavioral health services; social support services; and care management and planning for changes in Medicaid eligibility or coverage. The maternal health homes would coordinate all necessary services to support prenatal, labor and delivery, and postpartum care. Health home teams could include doulas, physicians, community health workers, behavioral health specialists, translators, and other providers and supports. The option would offer states planning grants and a temporary enhanced Federal Medical Assistance Percentage.

Looking ahead

The policies that lawmakers ultimately include in the next budget reconciliation package will reflect evolving budget constraints, competing priorities, and what they most value. We hope that Congress will give priority to health and health-related policies designed to help save the lives of Black and Indigenous moms and birthing people.

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