Medicaid Unwinding Risks Maternal Health Coverage Gains During Pandemic

The pandemic’s continuous coverage protection had a profound effect on health coverage for pregnant women and new mothers, who for the first time experienced pregnancy-related coverage that did not end just 60 days after the end of pregnancy. Before the pandemic, about half of all people covered by Medicaid for pregnancy lost coverage after the 60 days postpartum period. Data show that about one-third of pregnancy related deaths occur between 43-365 days postpartum, after many have lost Medicaid coverage.

During the pandemic, however, the federal government increased its contribution to state Medicaid programs on the condition that states maintain coverage for all Medicaid beneficiaries, including pregnant women, for the duration of the COVID-19 public health emergency. Across the two-plus years of uninterrupted coverage, the pregnancy eligibility category saw the greatest percentage increase (75%) of any group from February 2020 to July 2022– adding roughly 761,000 beneficiaries– according to CMS-reported enrollment data.

Research shows that the pandemic’s protections led to substantial reductions in postpartum coverage loss and greater insurance continuity through the postpartum year. An early study of a Texas community found that women covered after the disenrollment freeze took effect in March 2020 accessed more mental health and substance use disorder services, contraception care, and experienced fewer short-interval pregnancies than women who gave birth in the year before the pandemic.

The continuous coverage protection was one bright spot in response to the pandemic, which caused additional upheaval and hardship for young families. Maternal mortality increased during the COVID-19 pandemic for all women, and Black women remain nearly three times as likely to die from complications related to pregnancy and childbirth than their white peers. COVID-19 contributed to about a quarter of the maternal deaths in 2020 and 2021, and the virus continues to cause more severe illness in pregnant women than for people who are not pregnant.

One story of a Texas mom helped by the continuous coverage period stands out: Tiayana Hardy gave birth to her daughter in November 2022 while covered by Medicaid, and said in a recent news story that the continuous care gives her peace of mind knowing she can make an appointment if something comes up. Now four months postpartum, the Garland, Tex., mom who works in retail, said she’s gotten help managing anemia, postpartum bleeding and cramping, and anxiety.

“Those are just a few things that I just want to get checked on, especially I’m more concerned with like, I don’t want to be here today and gone tomorrow, especially because I have her now,” Hardy said.

As states begin redetermining eligibility for millions of people enrolled in Medicaid, coverage and access gains are at risk, including for thousands of new mothers who became parents during the pandemic. The earliest disenrollments will happen as early as April 1, depending on state policy choices.

The unwinding will also begin states’ implementation of the optional 12-month postpartum period, which the majority of states elected during the pandemic. The tally is up to 36 states and Washington, D.C., with more states actively debating it in ongoing state legislative sessions. In states with pending legislation on electing the 12-months postpartum coverage option, Medicaid agencies have flexibility to delay eligibility determinations for people in the pregnancy coverage category until their legislature makes a decision. However, in states that do not act, they will revert back to a shorter, 60-day postpartum period.

States recently reported their renewal plans to CMS to define how they plan to distribute renewals through the unwinding period, and CMS will use this information to identify states at greatest risk of inappropriate coverage losses and will follow up with states as needed to ensure that proper mitigations are in place to reduce risk of inappropriate terminations and that states’ plans will establish a sustainable workload in future years.

As my CCF colleagues have emphasized, it will be important for states to take the full amount of time available, work with trusted messengers to get the word out to families, and be willing to pause redeterminations if too many people are losing coverage for procedural reasons. The Consolidated Appropriations Act of 2022 also provided additional tools to mitigate coverage losses and provide transparency and accountability as states begin eligibility redeterminations.

To be sure, there will be many mothers who had their pregnancy coverage extended through the pandemic who are no longer eligible for Medicaid. These are the very beneficiaries who will need support in ensuring they successfully transition to other available coverage. For those eligible for Marketplace plans, CMS recently announced a temporary “unwinding” special enrollment period (SEP) for people losing Medicaid/CHIP coverage due to the unwinding of the Medicaid continuous coverage requirement, in states with a federal Marketplace (or in states that use the federal Marketplace platform for their eligibility and enrollment). See my colleague Kelly Whitener’s blog here for more details.

This special enrollment period will be particularly important for new mothers with incomes too high for Medicaid or without access to affordable employer-sponsored insurance. The number of postpartum people eligible for the special enrollment period would likely be especially high in non-expansion states, where eligibility outside of pregnancy is limited to extremely low-income parents (roughly an average of $10,00 per year for a family of three in 2023).

Medicaid has filled a critical gap for new mothers during the pandemic, and the end of the disenrollment protections will put in sharp relief the contrast between states that have elected the 12 months postpartum option and those that have not. With rising rates of maternal mortality and morbidity and ongoing racial disparities in maternal health outcomes, state policymakers must take great care to avoid large coverage losses for new mothers and children. States have an important opportunity to learn from the pandemic to build a new foundation for maternal health coverage.

Maggie Clark is a Program Director at the Georgetown University McCourt School of Public Policy’s Center for Children and Families.