Many people in the United States can’t access needed maternal health services, and the consequences can be lethal. Among high-income countries, the U.S. has the highest rate of maternal deaths, most of which are considered preventable. For every maternal death in the U.S., there are also an estimated 70 to 80 cases of severe illness related to pregnancy, which can lead to months or years of health complications. Decades of research have made clear that this crisis in U.S. maternal health disproportionately impacts people of color and people living in rural areas. These disparities have worsened during the COVID-19 pandemic.
Consistent and equitable access to health care following childbirth is vital for preventing maternal deaths, addressing pregnancy-related health complications, and promoting overall well-being for parents and children. As the payer for more than 40 percent of births nationwide and an even greater share of births for people of color and people in rural areas, Medicaid plays a major role in ensuring access to care during and after pregnancy. Federal law requires that all states provide continuous Medicaid coverage from pregnancy through 60 days postpartum for people with incomes up to 138 percent of the federal poverty level (about $25,300 for a family of two). Most states now provide coverage above that income threshold either through Medicaid or the Children’s Health Insurance Program.
The American Rescue Plan Act (ARPA) gave states the option to extend postpartum Medicaid coverage from the federal minimum of 60 days to a full 12 months by submitting a state plan amendment, a less rigorous and time-consuming process than the section 1115 demonstration waivers states have previously used to extend postpartum coverage. The state plan amendment option is currently available through March 2027. As of November, 26 states and the District of Columbia have implemented 12-month extensions of Medicaid postpartum coverage, mostly through state plan amendments. Seven additional states have announced plans to implement 12-month extensions — most received legal authority to move ahead. Texas and Wisconsin have proposed more limited postpartum coverage through 1115 waivers.
If all states took up the ARPA option, an estimated 720,000 people each year who would have otherwise lost their Medicaid coverage at 60 days postpartum could maintain access for a full year. Before the ARPA option took effect, losing or experiencing disruptions in coverage after giving birth was the norm for many low-income people. While some people maintain Medicaid coverage through other eligibility categories (e.g., as a low-income parent) or enroll in employer-based or marketplace coverage, many become uninsured during the first six months after giving birth. Preventing these coverage losses during the first postpartum year is a necessary step for improving outcomes and mitigating stark racial and geographic maternal health disparities.
Recent research has confirmed that continued eligibility for Medicaid after 60 days postpartum improves the stability of coverage for low-income birthing people, which likely translates to increased access to care and improved maternal health outcomes. Postpartum coverage offers opportunities to address a range of health issues that impact birthing people after 60 days postpartum. These include hypertensive disorders, diabetes, and other chronic conditions, all of which tend to be more prevalent among people covered by Medicaid than those with private insurance. The postpartum year is also an important time to monitor for and treat behavioral health conditions, which by some estimates are among the leading causes of maternal deaths.
A year of postpartum coverage would be especially impactful for the approximately 350,000 birthing people in states that have not yet expanded Medicaid eligibility as allowed under the Affordable Care Act. As of 2018, birthing people in nonexpansion states lost Medicaid coverage within the first postpartum year at twice the rate of people in expansion states.
Conclusion
The broad take up of the ARPA postpartum option within its first year is an encouraging sign that state leaders across the political spectrum are serious about improving maternal and child health for low-income people. However, because states may choose to forgo the option, wide state-by-state variation in postpartum coverage persists, and many birthing people continue to face challenges with coverage and access to care. As Congress weighs priorities for a year-end spending package, federal policymakers have an opportunity to address these gaps and improve maternal health nationwide by making 12 months of postpartum coverage a mandatory, permanent benefit across state Medicaid programs.
