Maternal health access and care were already in crisis before COVID-19, and the pandemic has further laid bare the racial and geographic disparities experienced by pregnant women and new mothers across the country. Last month we submitted comments in response to CMS’s request for information on improving access and quality of maternal health in rural communities, and recommended a range of Medicaid-focused actions CMS should take. Medicaid covers 50 percent of rural births nationally. Given the program’s outsized role in paying for prenatal, birth, and postpartum care for mothers  and their children, it’s good to see CMS focus on the ways the program could better serve these families.

For pregnant women and new moms in rural areas, higher uninsured rates, rural hospital closures, maternity care provider shortages and pre-existing unmet health needs all contribute to greater rates of maternal morbidity and mortality compared to their urban peers. Between 2007 and 2015, the higher rural maternal mortality and morbidity rate nationally, “represents an excess of approximately 4,378 cases of severe maternal morbidity and mortality among rural residents who would not have experienced morbidity or mortality had they been living in urban areas,” researchers found.

And while geography is clearly a key factor for maternal mortality and morbidity, focused attention is needed to address the endemic racism harming Black women and their families, as well as other women of color. For example, Black Americans are systematically undertreated for pain relative to white Americans, which research suggests can be traced in part to false beliefs about biological differences between black and white patients that can contribute to judgements about pain assessment and treatment.

In a recent survey of African American adults, 32 percent said they had personally experienced racial discrimination while going to a doctor or health clinic. Without systemically acknowledging and addressing the documented racial discrimination faced by women of color, and Black women specifically, any interventions to end maternal mortality will be limited in their ability to successfully improve health equity.

States have begun to document the higher rates of maternal mortality and morbidity for women of color who live in rural communities, including in Illinois and Texas. While morbidity and mortality are the most extreme and devastating results of racial inequity, the disparities persist in pre and postnatal care too, specifically around critically important depression screenings and referrals for women needing support.

Though postpartum depression screening is recommended universally, a new analysis by the Centers for Disease Control (CDC) found a missed opportunity to address mental health early: one in five women reported that their health care provider did not ask about depression during prenatal visits. One in eight women reported they were not asked about depression during postpartum visits. About 13 percent of women reported depressive symptoms when asked, with a low of 9.7 percent in Illinois to a high of 23.5 percent of women surveyed in Mississippi. American Indian/Alaska Native women, Asian women and Black non-Hispanic women reported the highest rates of depressive symptoms of any racial groups, and women under age 24 reported higher rates of symptoms than older women.

All of this points to opportunities to extend Medicaid’s comprehensive coverage to more women through Medicaid –the evidence is overwhelming. We’ve highlighted before the ways ACA Medicaid expansion has nearly closed the rural/urban gap in the uninsured rate for adult Americans. States that expanded Medicaid through the ACA have also made more progress lowering maternal and infant mortality rates. A more recent study links Medicaid expansion with lower maternal mortality. The effects were greatest for non-Hispanic black women, the racial group with the highest rates of maternal mortality and for the period beginning 60 days after birth, when Medicaid pregnancy coverage ends.

While CMS alone cannot solve the rural maternal health crisis, we recommended that the agency consider the following steps to assist states in their efforts to improve rural maternal health:

• Promote Medicaid expansion without added red tape
• Approve proposed state Medicaid demonstrations testing the postpartum coverage extensions beyond 60 days and propose 12 months of postpartum coverage for all pregnant women in Medicaid as part of the Trump Administration’s budget and legislative proposals – not just for women with substance use disorders as currently
• Encourage state adoption of eligibility and enrollment options for pregnant women in Medicaid and CHIP.
• Reinstate rules that monitor adequacy of payments and access to care.
• Issue additional guidance or tools on evidence-based or promising new ways to reach rural pregnant women and their families, including shared guidance with partner agencies where possible.
• Strengthen Medicaid data reporting and monitoring at the state and MCO plan levels, especially by race and ethnicity where possible.

As immediate treatment of the COVID-19 pandemic is the highest priority, the added social and economic stress on families makes comprehensive health care—including mental health supports— during the consequential period before and after childbirth even more critical. If things continue as they are, it is women in communities of color, low-income communities and areas with limited access to health care that will continue to bear the brunt of the crisis. It doesn’t have to be this way. CMS asked for input, we hope they heed the advice they receive and take prompt action to address the maternal health crisis.