Extending postpartum coverage continues to be a hot topic in state legislatures, in Congress, and in the Biden Administration. As my colleagues shared in a blog last week, CMS recently approved Section 1115 demonstration waivers in Georgia and Missouri that extend postpartum benefits to at least some pregnant people. While a step forward, the approvals reflect political compromises in states where legislative majorities have been resistant to Medicaid expansion, which would ultimately cover more people at a lower cost.

At the same time, several states, both Republican and Democrat-led, have already committed to adopting the new state plan amendment (SPA) option available through the American Rescue Plan to extend 12 months of postpartum coverage. For a running tally of the states pursuing the SPA option, see this tracker on state actions on postpartum extensions.

Both Georgia and Missouri’s Medicaid section 1115 demonstration approvals will undoubtedly result in more postpartum people gaining access to extended coverage. But looking at the approvals more closely, it’s clear that the demonstrations will not go as far as in states that take up the state option that extends coverage to 12 months.

As our recent letter to CMS noted, any 1115 waiver approvals for postpartum coverage extensions should be as expansive as the federally authorized option – a standard which Georgia and Missouri’s approvals do not meet. In both states, maternal mortality review committees recommended 12 months of postpartum coverage for everyone eligible for pregnancy coverage to reduce mortality and address the racial disparities in maternal death, which call out for a comprehensive coverage approach that lowers barriers to care.

Georgia

Starting with Georgia’s approval, the state will begin receiving federal matching funds for an additional four months of coverage for all people who are covered in Medicaid for pregnancy, offering a total of six months postpartum coverage, with continuous eligibility for the entire period. And, in support of the demonstration’s goal of reducing maternal mortality, the state will pair each postpartum person with its “Resource Mother Outreach services,” which include peer services in coordination with a nurse case manager.

Resource Mother services are already available in the state, but only for new mothers with very low birthweight babies. Medicaid managed care organizations (MCOs) in the state will employ these outreach workers, who will help new mothers make appointments for themselves and their newborns, arrange for transportation, and sign up for other services such as WIC and SNAP. It’s an innovative idea, and we look forward to seeing it tested and evaluated to meet the state’s goal of lowering maternal mortality and morbidity. To further spread the findings, the state should work with MCOs to develop reporting and transparency requirements for showing the program’s outcomes.

However, the state’s step forward for postpartum people is obscured by the fact that Georgia continues to reject Medicaid expansion for all adults. In addition to being uninsured before they get pregnant, under this plan many new mothers will still lose access to coverage at six months postpartum even though they have ongoing needs. State maternal mortality data shows that the largest number of deaths among postpartum people occur during the period of 180-365 days after the end of pregnancy, and Black non-Hispanic mothers were 2.7 times more likely to die from pregnancy-related causes than were White non-Hispanic mothers between 2012 and 2016.

The limited waiver also reflects the state’s history of creating workarounds to avoid expanding Medicaid by providing limited benefits to adults with low incomes, such as the “Pathways to Coverage” 1115 demonstration which provides Medicaid coverage to adults at or below 100% FPL if they meet a number of complicated requirements. My colleagues have previously blogged about the harmful waiver and its particularly harsh treatment of parents.

Missouri

Missouri’s approval is even more restrictive than Georgia’s. Submitted in early 2020, Missouri was among the first states to apply to CMS to extend the postpartum period. Rather than full state plan benefits, the state asked that they be allowed to receive matching funds to cover postpartum people diagnosed with substance use disorders (SUD) for a more limited set of services, such as case management, SUD counseling and treatment, and non-emergency medical transportation.

Setting aside the state’s ongoing uncertainty about implementing the successful constitutional amendment to expand Medicaid that Missouri’s voters passed last year through ballot initiative, the subdivided postpartum Medicaid program will create administrative burden for the state. The approved structure means that the state will now operate two postpartum coverage programs: one for postpartum people with extremely low incomes who can transfer to parent coverage, and a second for new mothers in the coverage gap whose incomes make them ineligible for a full set of parent benefits *and* who have been diagnosed with a SUD.

This bifurcated structure adds red tape for new mothers in crisis, requiring them to receive a specific diagnosis from a physician, licensed medical provider, qualified addiction profession, or licensed mental health professional, to access a skimpier set of services. The state estimated that 684 postpartum people would be eligible in the first year, just two percent of the people who give birth while covered by Medicaid in Missouri each year.

The diagnosis requirement could be especially harmful for Black pregnant and postpartum people, who, in Missouri in 2017, experienced pregnancy-related death at more than four times the rate of White pregnant people. According to a recent report from the Substance Abuse and Mental Health Services Administration, only 10 percent of people with a substance use disorder in the general population seek treatment, and “this is magnified in the Black/African American community where there is significant historical mistrust of the health care, social services, and the justice system.”

Limiting the 12-month postpartum coverage just to women with a specific diagnosis is a missed opportunity to address the root causes and persistent racial disparities in pregnancy-related death, and better support mothers and babies in the first year of life. Missouri’s maternal mortality review commission recommended in 2020 that the state extend Medicaid to one year postpartum to all pregnant people regardless of condition.

Looking ahead, the landscape of postpartum Medicaid and CHIP coverage is changing rapidly. The maternal mortality crisis demands our collective effort and attention, and research shows that consistent coverage before, during, and after pregnancy can reduce maternal and infant mortality. These latest approvals show forward motion, but fall short of addressing the many crises at the doorstep: maternal and infant mortality, racial inequities, mental health stresses, and substance addiction, to name only a few.  With federal matching funds on the table, it’s time for bigger, bolder action to ensure that every mother and baby, no matter where they live, has the best chance to thrive.