As Congress considers proposals to be included in the upcoming budget reconciliation package, a number of health care measures are on the table. Among these potential reforms are pathways to close the gap in Medicaid coverage that exists in the twelve states that declined to expand Medicaid after the passage of the Affordable Care Act (ACA). A Supreme Court ruling in 2012 made Medicaid expansion voluntary on a state-by-state basis, dealing a blow to the ACA’s approach to achieving universal health care coverage. As a result, in non-expansion states, 2.2 million people fall into a gap in coverage, wherein their income is too low to qualify for subsidies on the ACA Marketplace, but too high to qualify for Medicaid.
By its nature, the coverage gap impacts a vulnerable population: adults below 138 percent of the federal poverty level (FPL), without health insurance. The majority of these individuals are people of color, most are in the labor force, and about a third are parents. The geographic breakdown of Medicaid expansion—driven by partisan political decisions on the part of state legislatures and governors—means that most people in the coverage gap reside in the South and Midwest. Closing the coverage gap is a crucial step in lessening the inequities that it currently exacerbates, and has implications for women and birthing people in particular. Of the roughly 800,000 women of reproductive age in the Medicaid coverage gap, two-thirds are women of color. Unsurprisingly, women in the coverage gap also experience a health care gap, and face worse outcomes than insured women. This commentary will discuss the implications of the Medicaid coverage gap as it relates to maternal and reproductive health, and how Congress can—and must—end the coverage gap once and for all.
Medicaid and Maternal Health
The United States has the worst maternal mortality rate among industrialized countries, with a rate of 17.4 per 100,000 pregnancies. Black women are disproportionately impacted, dying of pregnancy-related causes at approximately three times the rate of their white counterparts. According to the Centers for Disease Control and Prevention (CDC), the majority of these deaths are preventable. And while causes vary, hemmorhage, heart disease, substance use, and suicide are cited as some of the most common. It must be noted that structural inequality and racism exacerbate the likelihood of Black mothers experiencing poor maternal health outcomes, including death and severe maternal morbidity.
Black women are disproportionately impacted, dying of pregnancy-related causes at approximately three times the rate of their white counterparts.
Medicaid is a critical source of health insurance coverage for maternity care. In 2019, the program covered approximately 42 percent of all births nationwide. It covered over 65 percent of Black births. For people who enroll in pregnancy-only Medicaid, coverage is generally limited to women with incomes under 133 percent of the FPL. Prenatal care, labor, and delivery services are offered under this pathway, yet coverage ends for mothers just sixty days after giving birth.
In states that have expanded Medicaid, pregnant and postpartum people receive continuous coverage and their options for care are much more comprehensive. For example, Medicaid expansion states must cover preventive services as outlined by the United States Preventive Services Task Force (USPSTF) and mandated by the ACA. Many states cover breastfeeding and lactation support, comprehensive health screenings, counseling services, prevention interventions for perinatal anxiety and depression, and more. A handful of states cover doula care under the Medicaid program. All pregnancy-related care must be covered without cost sharing.
Medicaid expansion not only ensures better coverage options and comprehensive care for pregnant and postpartum people: it also helps ensure better maternal and infant health outcomes. The Georgetown University Health Policy Institute’s Center for Children and Families presented a detailed overview of research that affirms the link between implementation of Medicaid expansion and lower rates of maternal and infant mortality. Medicaid expansion was associated with 1.6 fewer maternal deaths per 100,000 women, while the decline in infant mortality was more than 50 percent greater in expansion states versus non-expansion states. While reproductive-age women of color make up a disproportionate share of current Medicaid enrollees, they are also more likely to fall within the coverage gap. Indeed, two-thirds of reproductive-age women in the coverage gap are women of color—29 percent of whom are Black and 33 percent are Latina. Closing the coverage gap is one of several important tools needed to help advance maternal health equity and improve poor maternal health outcomes.
Medicaid and Reproductive Health
In addition to maternal health and pregnancy care, Medicaid plays a crucial role in other reproductive health needs, particularly among individuals with low incomes. Family planning is a mandatory benefit within Medicaid, meaning that it must be covered without cost sharing, but states have discretion over which family planning services are covered. Twenty-six states offer family planning coverage to a population beyond traditional Medicaid enrollees; this is provided through a mix of Section 1115 waivers, time-limited demonstration projects that have to be approved by the Centers for Medicare and Medicaid Services (CMS), and state plan amendments (SPAs). These options allow uninsured and underinsured women to access contraceptive benefits and a limited set of preventive services, with coverage varying by state. Medicaid expansion is necessary to make family planning services available to low-income individuals in every state, and to ensure that coverage does not end at contraceptive services.
Medicaid expansion is necessary to make family planning services available to low-income individuals in every state, and to ensure that coverage does not end at contraceptive services.
Research has demonstrated an association between Medicaid expansion and increased use of long-acting reversible contraception (LARC). This increase was particularly pronounced among women seeking care in non-expansion states outside of Title X clinics. Title X plays a key role in providing contraceptive care and related services to low-income folks, especially young people. But expanding Medicaid has the potential to provide services to individuals in search of family planning care who do not find their way to a Title X clinic. Not all people of reproductive age desire contraceptive methods, and not all people seeking contraception desire LARC. Medicaid expansion, however, could help increase access to the range of contraceptive options so that individuals have access to the methods that they choose.
When it comes to abortion services, coverage is already heavily restricted under the Hyde Amendment and related riders—although the House’s recent passage of spending bills without those restrictions is an encouraging sign that Medicaid enrollees may not be discriminated against in this area forever. Despite limitations on federal funding for abortion care, states may use their state Medicaid funds to pay for abortion coverage, and sixteen states currently do so. Recent research suggests that Medicaid expansion may increase access to timely, Medicaid-covered abortion care in those states, reducing expensive out-of-pocket costs for patients.
It is crucial that, in efforts to close the Medicaid expansion gap, restrictions on coverage for abortion are not also expanded.
It is crucial that, in efforts to close the Medicaid expansion gap, restrictions on coverage for abortion are not also expanded. These harmful restrictions already limit access to abortion care disproportionately for people of color and women working to make ends meet. Proposals to close the gap must be analyzed for their implications on abortion coverage and we must do away with all abortion coverage restrictions. Options abound in this current moment at the federal level to close the coverage gap and ensure access to comprehensive care for Medicaid enrollees.
Opportunities to Close the Coverage Gap
Closing the coverage gap is essential to ensuring better access to reproductive and maternal health care, as well as better health outcomes for women and birthing people. Years of political football on the issue of Medicaid expansion has led to a patchwork of coverage options across states, largely based on a person’s zip code. It is past time we cover everyone who falls within the coverage gap. Failure to take up Medicaid expansion has left many low-income people and people of color residing in the South (where the majority of states that have refused expansion are concentrated) uninsured or underinsured. However, there is renewed interest in ending this gap in coverage.
Several proposals are currently under consideration within the 117th Congress. Democrats are considering inclusion of Medicaid expansion in their $3.5 trillion reconciliation bill. The reconciliation path is an attractive one, as it would allow Democrats to get the measure across the finish line with a simple majority vote in the Senate. As of publication of this article, the details of the Medicaid expansion provisions in the reconciliation bill have yet to be determined. If Democrats wanted to take the simple route and incorporate legislation introduced by colleagues, they have a few options. Senators Tammy Baldwin (D-WI), Jon Ossoff (D-GA), and Raphael Warnock (D-GA) introduced the Medicaid Saves Lives Act on July 12. This bill would create a program that resembles Medicaid, but is administered by the federal government instead of states. Under the legislation, CMS would offer a Medicaid-like plan option to people residing in states that have yet to expand Medicaid. Another bill, the Cover Outstanding Vulnerable Expansion-Eligible Residents Now or COVER Now Act, was introduced by Representative Lloyd Doggett (D-TX) on June 17, 2021. This legislation builds off of a TCF Medicaid expansion proposal by authorizing CMS to work directly with counties, cities, and other localities to expand coverage under Medicaid for those in need. Additional proposals aimed at closing the coverage gap could be offered by congressional members in the coming weeks, including those that aim to address affordability of health care coverage, institute a public option, or others with the goal of getting the U.S. closer to universal coverage.
In order to ensure the most comprehensive approach to offering Medicaid-eligible populations continuous coverage and equitable access to maternal and reproductive health care, Medicaid expansion must go hand-in-hand with guaranteed postpartum Medicaid coverage for a full year. Some gains have been made across states on the postpartum coverage extension in recent months—while three states’ Section 1115 waivers have been approved by CMS, sixteen other states either have pending waivers or enacted legislation seeking federal approval through a SPA or Section 1115 waiver. And at the federal level, the American Rescue Plan Act gives states the option to extend postpartum Medicaid coverage to a full year for a limit of five years. Still, mandatory postpartum coverage has yet to be enacted. There have been several proposals introduced in Congress led by members of the Black Maternal Health Caucus to achieve this, including the Maximizing Outcomes for Moms through Medicaid Improvement and Enhancement of Services (MOMMIES) Act, which was reintroduced by Senator Cory Booker (D-NJ) and Representative Ayanna Pressley (MA-07) in May. The MOMMIES Act would extend Medicaid coverage to a year postpartum making it mandatory for states to take up, while also ensuring those benefits are comprehensive and not limited to pregnancy-related services.
In order to ensure the most comprehensive approach to offering Medicaid-eligible populations continuous coverage and equitable access to maternal and reproductive health care, Medicaid expansion must go hand-in-hand with guaranteed postpartum Medicaid coverage for a full year.
Congress faces an exceptional opportunity to end the Medicaid coverage gap, a move that would change the lives of millions of Americans—particularly those in need of maternal and reproductive health care. Simply expanding coverage alone is not enough, though. Closing this gap equitably requires maintaining the integrity of Medicaid’s comprehensive benefits and protections. Doing so—along with an extension of postpartum Medicaid coverage—will allow individuals to better control their reproductive lives and birthing people to have healthy and safe pregnancies. With both the coverage gap and U.S. maternal health crisis disproportionately impacting women and birthing people of color, expanding coverage is necessary to increasing health equity and must be passed by Congress.