The number of women who die in the U.S. because of complications related to pregnancy is shockingly high — nearly 30 deaths for every 100,000 births each year. But some women die at higher rates than others: the maternal mortality rate for black women is three to four times higher than it is for white women.
On this episode of The Dose, the Commonwealth Fund’s Laurie Zephyrin, M.D., and Akeiisa Coleman talk about one way to address this crisis: Medicaid, which pays for nearly half the 4 million births in the U.S. each year. States have a real opportunity, they say, to take innovative steps to improve the care pregnant women and new mothers receive through their Medicaid programs.
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LAURIE ZEPHYRIN: The number of women dying in the United States as a result of pregnancy is on the rise and where we see international trends overall are decreasing, in the United States they’re increasing.
And when we look at the 4 million births that we’re seeing in the United States, this is a really significant issue. Maternal mortality in the United States has increased to a shocking rate of nearly 30 deaths for every 100,000 live births.
SHANOOR SEERVAI: Hi everyone. Welcome to The Dose. You just heard from Laurie Zephyrin, who’s on the delivery system reform team at the Commonwealth Fund. Laurie is on the show with me today along with Akeiisa Coleman, who is on our federal and state health policy team.
So Laurie just laid out what is a really serious problem in the U.S.: Women are dying and at alarmingly high rate for reasons related to pregnancy. And there’s no way to justify that this is happening in the richest country in the world. So a lot of people are trying to think of how to address this problem and we’re going to talk about one way that policymakers think they could help: Medicaid. But before we get into that — Laurie, tell me, does maternal mortality impact all women in the same way?
LAURIE ZEPHYRIN: When we look at maternal mortality, we see significant differences in outcomes, and those outcomes vary based on race. And so black women and other women of color are more likely to die as a result of pregnancy or have severe complications as a result of pregnancy when compared to white women. And so recent data shows black women almost three to four times that of white women.
SHANOOR SEERVAI: And what about other social and economic differences? Akeiisa, what do you think?
AKEIISA COLEMAN: We often see that income is a factor in whether or not people are able to access health care services when they’re early in their pregnancy, so that prenatal care which can be really critical.
But some of the things that we see are when the research is controlling for socioeconomic status, we continue to see some of those disparities for women of color, particularly among black and Native American women.
SHANOOR SEERVAI: So you’re saying that the maternal mortality rates are higher for lower income women, but when you map that onto race and you control for income, rates are still significantly higher for black and Native American women.
AKEIISA COLEMAN: That’s correct.
LAURIE ZEPHYRIN: Exactly. And typically, income and education typically would be protective, but when we break down the data by race, we see that for black women it’s actually not protective and those disparities we see persist.
SHANOOR SEERVAI: And we’ve talked a little bit about this on two recent episodes of The Dose. We talked about race and maternal mortality with Kennetha Gaines and she talked about her own experience being a black woman, a highly educated black woman, but still feeling like she wasn’t getting the same care as white women. And we also talked about implicit bias and the way that race plays into the medical care that people receive.
But as I mentioned when we got started, we have this huge problem with maternal mortality in the U.S. and there is a mechanism through which we can address the problem and that’s Medicaid. So Akeiisa, talk to me — tell me what the Medicaid program is.
AKEIISA COLEMAN: So Medicaid is a public health insurance program that varies from state to state but typically covers people with very low incomes.
So income less than $12,500 a year — and oftentimes the income levels can be set significantly lower than that for parents. Medicaid expansion, which was part of the Affordable Care Act, increased the threshold for covering people with Medicaid so higher — slightly higher incomes — but this is really important when we’re talking about maternal mortality, because Medicaid covers almost half of all births in the U.S.
So Laurie mentioned about 4 million births in the U.S., about half — a little less than half of those are covered by Medicaid, and that rate can vary state to state. So, for example, in Arkansas almost 70 percent of births are covered by Medicaid versus Vermont where only 20 percent of births are covered by Medicaid.
SHANOOR SEERVAI: So you’re saying that Medicaid sort of has a huge role to play in how safe it is for women to have a child.
AKEIISA COLEMAN: Exactly.
LAURIE ZEPHYRIN: Medicaid is really an important opportunity. It’s an important safety net for the neediest in society. Many of the women that I’ve seen in my career as an obstetrician in the past have been on Medicaid or uninsured. And these are women that may not have been able to get care otherwise but for Medicaid. And you know, this could be a student getting her college degree who needs health coverage or moms that I’ve seen working two low-paying jobs to make ends meet who didn’t have access to health insurance.
Or I’ve taken care of moms with disabilities who were starting their families and relied on Medicaid for care, and so as the largest public health insurance program, Medicaid has an opportunity to lead the way and in many states is leading the way. And it’s just a real opportunity to really transform this crisis we’re seeing, particularly for low-income women.
SHANOOR SEERVAI: So when we talk about Medicaid leading the way, it sounds like if you’re a pregnant woman you’re likely to be covered at a higher income level than the very low threshold for Medicaid in some states. Is that correct?
LAURIE ZEPHYRIN: Right, right, and so as Akeiisa was mentioning, I mean it’s a large public health insurance program and there are key requirements to being eligible for Medicaid and so if you’re pregnant that’s one of the eligibility criteria: you’re pregnant and low income.
And so when we’re talking about almost half of the 4 million births in the United States, those women that are low income — if and when they become pregnant, they can qualify for Medicaid.
SHANOOR SEERVAI: So how does Medicaid work differently in different states when it comes to — because each state has a different Medicaid program — so how does it work when it comes to covering pregnancy and pregnant women?
AKEIISA COLEMAN: So each state is allowed to kind of set their own threshold levels for who’s covered under what category in Medicaid. So most states are pretty generous when it comes to pregnant women. So for example, in Oklahoma, a single woman who’s pregnant for the first time can have income up to about $17,000 a year and qualify for Medicaid.
But once she’s had that child, she’s most likely not eligible for Medicaid coverage after 60 days and would only be eligible as a parent with income around $5,000 a year. So that’s about 42 percent of the federal poverty level. And so you see some variation there, so in a state that’s a little bit more generous like Iowa, they’ll actually cover that same single mom having a first child with income up to about $47,000 a year.
And then because that state has expanded Medicaid, that woman would be able to continue Medicaid coverage with income at the $17,000 level beyond that 60 days after delivery. So there’s a lot of variation there, which has impacts and implications for continuity of care after delivery for women.
SHANOOR SEERVAI: Wow. Those are some really stunning numbers in there. And I guess when we talk about continuity of care, we should talk about how likely it is that a woman would experience pregnancy-related complications more than 60 days after birth, right? Because having a child isn’t as simple as here’s your health care for 60 days and now you’re out the door. It’s more than that, right?
LAURIE ZEPHYRIN: Exactly, exactly. Being a mom, having had a child and being an obstetrician, your health care continues after birth and sometimes it increases. But if we look at the data around causes of maternal mortality or rates of maternal mortality and maternal morbidity or near-misses, we see that more than half of those happen after birth.
And so if we’re talking about Medicaid and in states where Medicaid — your Medicaid coverage ends 60 days after birth, you’re leaving a lot of moms uncovered with nowhere to go. And so that’s a huge challenge, and so when we think about solutions, thinking about that piece after birth, that episode of care after birth is critical and really thinking through extending that.
I don’t know who exactly came up with 60 days or what the modeling was around that, but definitely more is needed.
SHANOOR SEERVAI: Yeah, I feel like you read my mind. I was just going to ask you that like, who said that 60 days is where your need for maternal care ends?
LAURIE ZEPHYRIN: Right, exactly. I have no idea but we know it’s not enough. And there are a lot of efforts out there around restructuring and rethinking how we deliver care for women, particularly around when they’re pregnant.
And there’s this new concept of this fourth trimester of pregnancy where after birth there’s another long period of time where women need support — whether it’s social support, behavioral health support, whether it’s health, general physical health support — that’s critical. And there’s an opportunity for Medicaid to lead in that. And Akeiisa talked a little bit about Medicaid expansion — one of the key provisions of the Affordable Care Act was Medicaid expansion.
And essentially for states it was initially required or the federal government would withhold provision of federal funds for Medicaid. And so that essentially was declared unconstitutional and so it became an optional provision to expand Medicaid.
But what that has allowed researchers to do is compare outcomes for states that have expanded Medicaid and states that have not expanded Medicaid. And there’s a couple of interesting studies that have come out that are focused on maternity care or outcomes around infant mortality. And what we’ve seen in at least in one study is showing that in Medicaid expansion states, there was a decrease — a shrink — a decrease in maternal mortality and in disparities relating to maternal mortality.
SHANOOR SEERVAI: What was that difference in Medicaid expansion states versus nonexpansion states? Akeiisa?
AKEIISA COLEMAN: For that particular study that Laurie mentioned, it was a decrease of like 1.6 fewer maternal deaths per 100,000 in the states that expanded Medicaid and also an improvement around infant mortality as well.
The biggest thing that we see in the Medicaid expansion states is that you have that continuous coverage postpartum which has a number of different benefits. So not only are you more likely to catch some of those health complications that can arise in that first year after giving birth, but then you also have the opportunity to have conversations and really — and be intentional around spacing out births and getting prenatal care before getting pregnant.
As well as having that — that continuous care during pregnancy and then following afterwards. There is some evidence that that continuous coverage makes a huge difference across the board for those who are qualifying for Medicaid.
In nonexpansion states, that drop-off has some serious concerns and states are looking at ways to address that. One particular area is around substance use and so how can you make sure that while mom is getting treatment for that substance-use condition while covered under Medicaid — so while pregnant that’s being managed — but if that coverage ends 60 days after giving birth, the ability to maintain sobriety and continue with treatment is significantly impacted.
And so states are looking at continuing that coverage beyond the 60 days to a full 12 months, as well as how do you make that substance-use treatment consistently available to not only pregnant women but those women who’ve just given birth so that they can maintain their sobriety and their treatment and be there for their child.
SHANOOR SEERVAI: One quick note: A few days after we recorded this episode, the House Energy and Commerce committee in Congress introduced a bipartisan bill to give states the option to extend Medicaid coverage for a full year after birth. The bill, called the Helping MOMS Act of 2019, hasn’t passed yet, but stay tuned. Now, back to the show.
SHANOOR SEERVAI: So obviously Medicaid matters because it covers such a large number of births — we said almost half of the 4 million births in the country, it’s the largest public health program — but what are other ways in which Medicaid can really be a leader when it comes to the way that pregnant women actually get health care?
AKEIISA COLEMAN: Sure, so one of the mechanisms that we’re seeing used more and more often in Medicaid is a bundled payment, and so that’s a fixed payment for a set of services that are specific to an episode of care.
SHANOOR SEERVAI: So basically what you’re saying is that every single ultrasound you need to go in for isn’t treated as a discrete thing and it’s all regarded as being under one episode of care and that’s being pregnant.
AKEIISA COLEMAN: Right.
SHANOOR SEERVAI: Okay, got it.
AKEIISA COLEMAN: So, within that bundled payment in Medicaid you can say — we want to see a specific set of services included within that bundle and that should be screening for and catching some of those conditions that can lead to complications during pregnancy and at birth.
And helping to catch some of those things on the front end as well as reducing some of the unnecessary and elective procedures that we know can be a little bit riskier like Caesarean sections or early deliveries that can have some — that can potentially have negative consequences.
So Medicaid setting that standard helps push some of the commercial insurers to look at and see, “Wait, is that cost effective, is that driving down cost, is it improving health outcomes? Maybe we should also be doing the same thing.” And so you see commercial insurers also adopting that same payment model as well.
SHANOOR SEERVAI: That’s really interesting. Do you have thoughts, Laurie?
LAURIE ZEPHYRIN: If we think of just state Medicaid programs as they’re thinking through ways to increase value and — meaning like, have better outcomes and maximize or minimize their costs — there’s a huge opportunity. If you can influence the payer, if you can influence how the care is delivered from how it’s being paid for, that hopefully ultimately will help drive how care is delivered on the ground and ultimately will help improve outcomes, right?
And so that’s why thinking through Medicaid as an influencer is definitely critical and there are states that are thinking through this and so, can innovative payment models help incentivize improvements in quality of care, specific for maternity?
There’s definitely a lot of opportunity to do that. And so, for example, if you look at group prenatal care, which is a model of providing maternity care where women receive this care during pregnancy as part of a group — and these are like hour-plus-long visits where there’s education involved, and then they may go out and see the provider and come back, and they have a peer group and peer support group that they’re going through pregnancy with.
And there are some studies that have shown that that decreases rates of preterm delivery and preterm births and potentially shrinks disparities, and so there’s some insurers like in South Carolina, for example, where they’ve decided to reimburse for that and pay for that as a way of helping to improve outcomes and decrease costs, right?
And so if you can decrease preterm births then you decrease neonatal ICU stays and you could potentially save millions of dollars, for example, and those cost savings can be redirected into other valuable aspects of care. So there’s a lot of opportunity to think through payment strategies that can help incentivize how care is delivered on the ground.
SHANOOR SEERVAI: Because as Akeiisa pointed out, if more and more states start doing innovative things in their Medicaid programs and they’re able to show that there’s actually value to what they’re doing, then commercial insurers might also want to adopt those models.
LAURIE ZEPHYRIN: Absolutely, absolutely. And also states learn from each other, so if one state does it then another state can look and say, “Hey, I can figure out how to do it as well.”
SHANOOR SEERVAI: I want to come back to something that we talked about a little bit in the beginning, which is the issue of disparities, particularly when it comes to race and income. And obviously there isn’t a single prototype for the kind of pregnant woman who gets her coverage from Medicaid.
But in as far as it’s possible, what could Medicaid do to bring down this disparity between black and Native American women dying at rates of three to four times higher than white women when it comes to pregnancy-related causes?
AKEIISA COLEMAN: So one of the unique features of Medicaid is that each state is allowed to try and test different things and see what works, and when they find things that work they can adopt those more broadly and other states will look to see how they can replicate some of those same things.
So for example, Wisconsin has an obstetric medical home program that is really trying to reduce racial disparities in maternal and child health. And so that model provides incentive payments to providers who meet particular care and quality measures.
And so for example, bonuses for prenatal care and screenings and positive birth outcomes. And so when those Medicaid beneficiaries are identified early and enrolled in the program early on — they’ve seen some really positives outcome from that — that model which I believe has been adopted in other states or similar models are being adopted in other states.
There are things about Medicaid that are particularly unique. And just looking at some of the characteristics of pregnant women who are covered under Medicaid — looking at 2014 tells us that just under half of the pregnant women on Medicaid are white, about 21 percent are black, 22 percent are Hispanic, and about 8.5 percent are another race or ethnicity.
So there’s a significant amount of variation within that Medicaid population and it varies state to state, and so those solutions in each state need to be tailored to the population that they’re seeing there. One of the things Medicaid can do is say, “Here are the standards that we want to be seeing across the board, here are the outcomes that we’re seeking.”
And putting it on the delivery system and providers to say, “Here’s how we’re going to do that in culturally competent ways to meet those needs of these particular populations that we’re serving.”
LAURIE ZEPHYRIN: And I think it’s also important to incorporate measurement as well.
And so as new innovations are being tested, whether it’s a maternity medical home or whether it’s integrating mental health or whether it’s group prenatal care — being able to stratify that data by race is going to be critical and can there be incentive payments around shrinking disparities specific to a particular population.
Another piece I’d like to get at to your question, Shanoor is — is that Medicaid and thinking through innovations through Medicaid is a start and a beginning, and definitely important to do and it’s also important — if we’re going to think about shrinking the disparities in maternal mortality and maternal morbidity — it’s going to have to also go beyond Medicaid as well.
SHANOOR SEERVAI: Right, of course. It can’t be that the public program that covers the poorest people in the country is expected to be the only trailblazer when it comes to this issue. We really need innovation coming from every single piece of our health care system.
So I guess as we’re wrapping up, there’s a lot of things that our health care system could do differently when it comes to thinking about moms and their newborn children. But if you had to pick one thing, one broad change that could be adopted across the country, what would that be?
LAURIE ZEPHYRIN: I have a few things, but I guess since I’m limited to one. In the work that we’re doing around health care delivery systems reform, there’s a lot of lessons that we can learn around other sectors.
Like we think of women’s health as very siloed and there are all these new things that need to be developed, but as we’re having conversations around social determinants of health and health-related social needs and integrating behavioral health into primary care — those are similar types of discussions that we need to have specific to women’s health, specific to maternity care. And so as states are thinking through innovative models to address this crisis that we’re experiencing, I think it’s important to look at innovations that they’re moving forward in primary health care and behavioral health.
Because we’re talking about a lot of the same things here but specific for maternity care and for pregnant women. And it’s a defined population. I think we can lead the way in maternity care, states can lead the way in maternity care and really make significant changes.
AKEIISA COLEMAN: I would go with making the federal change to Medicaid coverage for pregnant women and extending that coverage for 12 months postpartum.
SHANOOR SEERVAI: Like I said earlier, after we recorded this episode, a bill to do just that — the Helping MOMS Act of 2019 — was introduced in Congress. Akeiisa explains why it helps for mothers to have coverage for a full 12 months after giving birth.
AKEIISA COLEMAN: So that way you’ve got a better chance of having continuity of care across the prenatal and postnatal period. And then also catching some of those serious health complications that can arise after delivery for all pregnant women who are covered by Medicaid — not just those who have lower incomes and continue to be covered in expansion states, but across the board.
SHANOOR SEERVAI: Well, that’s a hopeful note to end on. So I just want to thank both of you for joining me on the show today.
LAURIE ZEPHYRIN: Thank you.
AKEIISA COLEMAN: Thank you.
Illustration by Rose Wong