By: Kay Johnson, MEd, MPH and Laurie Zephyrin, M.D., M.P.H., M.B.A.
Maternal health and maternal mortality are the subject of more than three dozen bills introduced in the first six months of the 117th Congress, and many of their provisions were included in the House reconciliation package currently under consideration. Building on proposals in the 116th Congress, these pending bills mark the most recent attempts to respond to the United States’ persistently high maternal mortality compared to other nations, particularly the disparate rates of pregnancy-related deaths and severe morbidity among Black, Indigenous, and other people of color (BIPOC).
The Black Maternal Health Momnibus Act is the most comprehensive proposal to improve maternal health, encompassing 12 component bills introduced by members of the House Black Maternal Health Caucus. Championed by Caucus co-chairs Representative Alma Adams and Representative Lauren Underwood, the Momnibus Act aims to improve health outcomes through a multi-pronged approach to care quality (e.g., workforce, payment, data) and new ways to counteract social risk factors that can impact health outcomes (e.g., housing and nutrition, funding for community-based organizations). It also addresses maternal health issues related to COVID-19.
Most provisions of the Momnibus Act are included in the recent health reconciliation language passed by House committees, summarized in the table below.
| 12 components of the Momnibus Act (see fact sheet) |
House reconciliation language in the Build Back Better Act (Subtitle J) |
|---|---|
| 1. Make critical investments in social determinants of health that influence maternal health outcomes, like housing, transportation, and nutrition. | ✔ $175 million in funding for local entities to address social determinants of maternal health like housing, nutrition, and environmental conditions.
— Does not include the federal interagency task force proposed in the Momnibus Act. |
| 2. Provide funding to community-based organizations that are working to improve maternal health outcomes and promote equity. | ✔ Social Determinants of Health provisions call for a minimum of $75 million exclusively for community-based organizations working to promote maternal health equity. |
| 3. Comprehensively study the unique maternal health risks facing pregnant and postpartum veterans and support VA maternity care coordination programs. | — Does not include provisions related to veterans as proposed in H.R.958/S.796 |
| 4. Grow and diversify the perinatal workforce to ensure that every mom in America receives culturally congruent maternity care and support. | ✔ $275 million to grow and diversify the perinatal health workforce, including nurses, midwives, physicians, doulas, and maternal mental and behavioral health professionals. $50 million dedicated specifically for doulas.
✔ $25 million for anti-bias trainings among health care professionals. |
| 5. Improve data collection processes and quality measures to better understand the causes of the maternal health crisis in the United States and inform solutions to address it. | ✔ $160 million to strengthen federal maternal health programs like the CDC’s Surveillance for Emerging Threats to Mothers and Babies program, Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM), Pregnancy Risk Assessment Monitoring System (PRAMS), and the National Institute of Child Health and Human Development (NICHD).
✔ $50 million to advance maternal health research at Minority-Serving Institutions (MSIs) like Historically Black Colleges and Universities, Tribal Colleges and Universities, Hispanic-Serving Institutions, and AAPISIs. |
| 6. Support moms with maternal mental health conditions and substance use disorders. | ✔ $100 million for maternal mental health equity grant programs. |
| 7. Improve maternal health care and support for incarcerated moms. | — Does not include provisions related to incarcerated mothers as proposed in H.R.948/S.341. |
| 8. Invest in digital tools like telehealth to improve maternal health outcomes in underserved areas. | ✔ $60 million to expand access to digital tools and technologies that promote maternal health equity. |
| 9. Promote innovative payment models to incentivize high-quality maternity care and continuity of insurance coverage from pregnancy through labor and delivery and up to 1 year postpartum. | — Does not include innovative payment models as proposed in H.R. 950/S.334 or S.1675;
— Does not include “health home” type initiatives or demonstration projects to incentivize improved care linkages, as proposed in H.R. 2556/S.1234 or S.1622. ✔ Mandatory, permanent 12 months of postpartum eligibility in Medicaid and CHIP, passed as a state option in the ARPA. (Not in the Momnibus Act itself, but supports the objective). |
| 10. Invest in federal programs to address the unique risks for and effects of COVID-19 during and after pregnancy and to advance respectful maternity care in future public health emergencies. | ✔ Provisions to strengthen federal maternal health surveillance, data collection, and emergency preparedness programs at CDC. Also, see #5 above. |
| 11. Invest in community-based initiatives to reduce levels of and exposure to climate change-related risks for moms and babies. | ✔ $85 million to address the impacts of climate change-related maternal and infant health risks through health professional schools. |
| 12. Promote maternal vaccinations to protect the health and safety of moms and babies. | — Provisions as in H.R. 951/S.345 or S.1117 not included specifically in Build Back Better Act. Immunizations would be covered under Medicaid and other laws related to COVID vaccinations. |
What Remains to Be Done
Not all priorities of pending maternal health legislation on maternal health issues are included in the Build Back Better Act. Some of these can be addressed through executive branch action by the Biden-Harris Administration. Others will require additional funding.
Interagency Task Force to Address Social Determinants of Health: The Momnibus Act calls for multi-agency and inter-agency efforts to improve maternal health, particularly among BIPOC, veterans, and others. A task force to develop a strategy to address social determinants of health would include representation from eight departments, as well as the leaders of eight units of HHS. Representatives of patient experience, perinatal health workers, and community-based organizations also are required. The Biden-Harris Administration could convene such a task force without new legislative authority.
Payment Models and Innovations in Financing: Payment innovation is a focus of several pending bills. For example, some pending legislation describes the range of stakeholders a process to design payment innovation might include. Others define the array of providers to be engaged in the process and included in innovative payment methodologies.
Based on a decade of experience, the federal Center for Medicare and Medicaid Innovation within the Centers for Medicare and Medicaid Services (CMS Innovation Center) recently released a bold new strategy to achieve equitable outcomes by embedding equity in every aspect of the CMS Innovation Center’s work. CMS already has sufficient authority to develop demonstration projects to test and advance innovative maternity care payment models that seek to advance health equity.
New payment approaches could build on the IMPACT to Save Moms Act, which calls on the HHS Secretary to test alternative payment models in Medicaid and CHIP. To be considered, new payment models must be designed to improve outcomes for groups with disproportionate rates of adverse maternal health outcomes, include methods for stratifying by demographics and pregnancy risk level, set quality and equity metrics for payments, include non-hospital birth settings such as freestanding birth centers, include consideration of social determinants of health and other drivers of health segmented by race and ethnicity, and ensure payments for racial/ethnic and professionally diverse maternity care teams (e.g., OB-GYNs, family physicians, midwives, nurse practitioners, doulas, CHW, social workers, home visitors, etc.).
Health Care System Transformation and Dissemination of Best Practices: Many maternal health bills have provisions designed to accelerate health care system transformation and spread best practices – both of which are critical to advancing maternal health equity and eliminating disparities. Some proposals focus on Medicaid improvements, such as incentives to finance maternity health homes, better care coordination, or new payment models. Others would provide grants to states and community-based organizations to enhance supports in communities for pregnant and postpartum women and their families. Specific areas of need for pregnant and postpartum women include: seamless care transitions in and out of pregnancy; patient-centered linkages between maternal health providers and community-based social supports; expansion of high-quality postpartum care across delivery systems; opportunities to integrate equity meaningfully into perinatal quality efforts; and opportunities to address inequities in rural and urban maternity desserts. Immunizations would be covered under Medicaid and other laws related to COVID vaccinations.
To address the maternal health crisis in America, Congressional leaders have introduced dozens of bills that contain important policy proposals, which would address multiple dimensions of unmet need and root causes of inequities and disparities. Congress and the Administration have the tools to act for the birthing people who continue to face gaps in access, unequal treatment by race/ethnicity, and preventable deaths.
Additional Resources:
- https://www.commonwealthfund.org/maternal-health
- https://www.commonwealthfund.org/blog/2021/state-options-extending-medicaid-postpartum-coverage
Kay Johnson, M.Ed., M.P.H., has been a leader in health policy for women, children, and families for 35 years, active in Medicaid and children’s health policy at the federal and state levels since 1984 and has advised more than 40 state health and/or Medicaid agencies.
Laurie Zephyrin, M.D., M.P.H., M.B.A., is vice president for Advancing Health Equity at the Commonwealth Fund. Dr. Zephyrin has extensive experience leading the vision, design, and delivery of innovative health care models across national health systems.