Federal and state leaders have prioritized maternal health in Medicaid in recent years with welcome (if overdue) attention. As Say Ahhh! readers know, the new state option to extend postpartum coverage to 12 months for all pregnant women in Medicaid has been adopted or is in progress in all but two states (AR and WI) since the federal match became available in April 2022.

Idaho and Iowa are the latest of the remaining states to extend postpartum coverage—that’s generally good news. But unfortunately, Iowa’s extension comes with a dramatic tradeoff: a rollback of Medicaid eligibility for pregnant women from 375% to 215% of the federal poverty level (FPL). While current pregnant beneficiaries will receive postpartum coverage, no affordable coverage will be available in future years for uninsured Iowans who become pregnant with monthly incomes of $4700 or more for a family of three—an estimated 1,300 pregnant women or more in any given month. And adding insult to injury, 400 of their infants (or “deemed newborns”) will also lose out on coverage in their first year. So pregnant people who want to take on a few more work shifts or hours to save more money before a new baby is born could find themselves unable to enroll in affordable coverage and get needed prenatal care. This could lead to more Iowans unnecessarily facing significant medical debt.

But wait– can’t pregnant women above 215% FPL in Iowa get subsidies for affordable marketplace coverage? As it turns out, NO! Iowa leaders decided not to administer a state-based ACA marketplace and instead joined the federal marketplace. Pregnancy is not a qualifying condition to enroll in the federal marketplace outside of the open enrollment period, usually November 1 to December 31 of each year. (Medicaid and CHIP allow enrollment at any time.) This means any working, uninsured person who makes more than $4700 a month should hope they find out they’re pregnant in the late fall during open enrollment. Otherwise, they have to wait until the child is born to get marketplace coverage. Iowa lawmakers could have created a parallel state CHIP option for pregnant women at the higher income levels losing Medicaid coverage to fill the gap, but did not choose to do so.

So, to be clear: A policy designed to help more pregnant women access postpartum care will only happen because Iowa lawmakers removed access to any affordable coverage for pregnant women and newborns in working families. Not only will fewer pregnant women benefit from a full year of postpartum coverage but fewer will qualify to get Medicaid coverage in the first place, missing out on critical prenatal care. All signs point to a swift signature from Iowa Governor Kim Reynolds.

But even without eligibility cuts undermining the benefits of extended postpartum coverage, we know that postpartum extension won’t address the maternal health crisis alone. Coverage itself is a necessary but insufficient step to help address the abysmal maternal health crisis that disproportionately impacts Black and Brown women. And while it’s encouraging to see more states move to reimburse new services for pregnant and postpartum women in Medicaid, such as doula care, no one intervention or service can undo years of health system inaction, including and unwillingness to truly listen to the needs of pregnant women and their families. As we noted in our recent report, state Medicaid leaders need to assess the full continuum of health services for pregnant women, from promotion to treatment, and use policy and systems changes to address gaps. This could mean improved primary care, access to community-based health workers or doulas, mental health, nutritional support, connections to health-related social needs, and others. And even with the best policies in place, as Medicaid agencies make changes to reimburse more provider types or services, how can states best to ensure pregnant women get the care they need when they need it?

This leads us to a second state – California – where state leaders have allowed a long-standing comprehensive benefit for pregnant women to lapse despite strong early evidence of its value in helping to lower the incidence of low-birth weight infants. There may be other positive outcomes to share, but they stopped paying attention long ago. A February state auditor’s report summarized:

“The Legislature established the Comprehensive Perinatal Services Program (perinatal program) in 1984, which provides enhanced medical services to pregnant and post‑partum Medi‑Cal members. These services include health education, nutrition education, and mental health assessments and interventions. The program’s purpose is to reduce maternal and infant illness and death. State law vests authority for the perinatal program with the Department of Public Health (Public Health). However, a different state department—the California Department of Health Care Services (Health Care Services)—is responsible for Medi‑Cal and contracts with managed care plans, requiring them to provide perinatal services comparable to the perinatal program’s care. Public Health administers the perinatal program as offered through fee‑for‑service plans. Neither department provides sufficient oversight to ensure that Medi‑Cal members receive program services or that providers and Medi‑Cal members are educated about the program.”

So even though two state agencies had responsibilities to ensure the comprehensive perinatal services program worked effectively for pregnant women both in fee-for-service (public health) and managed care arrangements (Medi-Cal’s agency), lack of agency oversight and managed care organization (MCO) plan accountability has meant fewer pregnant women know about or take advantage of services. This may reflect the concerning decline in public investments in state agency capacity, but nevertheless state lawmakers – directly or indirectly – started a comprehensive benefit for pregnant women and then failed to monitor its value and opportunities for improvements beyond its initial years. The lack of managed care oversight is not surprising, given the severe lack of publicly available information as reported in my colleagues’ recent scan of 12 states’ Medicaid managed care plan performance on maternal health. But it’s still gravely concerning.

Making sure Medicaid coverage achieves its full potential serving the needs of pregnant women, children, and their families requires intentional, sustained effort to engage with families themselves. It also requires oversight that most states are challenged to provide with ever-competing demands and shrinking resources and staff. Promising solutions to the maternal health crisis require leadership and a commitment to ongoing quality improvement. Leaders at all levels should keep in mind the fact that Medicaid is a central payer of births and stay focused on the quiet, necessary work needed to ensure it is fully leveraged to ensure high quality health care that can help meaningfully improve maternal health.