Tanesha Mondestin: Welcome, everyone. Thank you so much for taking the time to join us for this very timely conversation. We have a lot to cover during our time together.
Tanesha Mondestin: So, I'm going to get us started at the top of the hour. My name is Tanesha Mondestin, and I'm a research associate at Georgetown University's Center for Children and Families. And today for this webinar, Medicaid Connections.
Tanesha Mondestin: maternal and Infant Health and Justice. This is the first in a series and collaboration among ONCA Consulting.
Tanesha Mondestin: Georgetown CCF, and Johnson Policy Consulting.
Tanesha Mondestin: Next slide, please.
Tanesha Mondestin: The Medicaid Connections Webinar Series will be held every third Tuesday through January 2027. Next slide, please.
Tanesha Mondestin: We encourage those new to Medicaid advocacy, those seasoned, and even those confused about what's going on at this current time, to join these discussions on how the changes to the health system and Medicaid may impact your community, patients, clients, friends, and families.
Tanesha Mondestin: Medicaid is the invisible backbone of health advocacy, covering births for moms and babies, comprehensive care for kids, coverage for low-income adults, and keeping many hospitals financially afloat.
Tanesha Mondestin: Deep cuts could significantly affect people's lives, as we have already begun to see.
Tanesha Mondestin: We're kicking the series off with maternal and infant health and justice, but future CUT sessions will cover children and youth with special healthcare needs, substance use, immigration, mental health, and family preservation. I believe that when you registered, it was for the full series, so you should receive reminder emails
Tanesha Mondestin: Feel free to join us for future webinars that are of interest. Next slide, please.
Tanesha Mondestin: Today, I have the honor of
Tanesha Mondestin: Welcoming our speakers for today. We have Kay Johnson, the President of Johnson Policy Consulting, Madeline Morcelle, Senior Attorney at the National Health Law Program, Dr. Jamila Perritt, President and CEO for Physicians for Reproductive Health, and Lourdes Rivera, President
Tanesha Mondestin: of pregnancy justice. Next slide, please.
Tanesha Mondestin: A quick note before we dive in. While the Medicaid statute specifically uses the term women, we recognize that not all birthing people identify as women. Therefore, our discussion will use gender-inclusive terms alongside statutory language.
Tanesha Mondestin: To encompass all mothers and birthing parents.
Tanesha Mondestin: So the roadmap for the webinar today will start off with a brief history of Medicaid and women's health with Kay Johnson. I'll continue on the conversation briefly on Medicaid's role in the health of women and mothers, talk a little bit about Medicaid financing, the major threats ahead for the program, and then we'll dive into our panel discussion and audience Q&A as time permits.
Tanesha Mondestin: myths.
Tanesha Mondestin: So now, I will pass it off to Kay Johnson to talk about the history.
Kay Johnson: Thanks so much, Tanesha. I'm delighted to join this panel today. It's just going to be a wonderful discussion, and I know Tanesha's going to provide a lot of information. One of my roles in this series is to talk a little bit about the history of Medicaid as it relates to maternal and child health. I have two slides to talk about the milestones, and really going back to the beginnings.
Kay Johnson: when Medicare and Medicaid were created in 1965. And despite the fact that there was a proposal called the Children's Health Access Program, or CHAP, the White House did not… LBJ did not approve, and Congress did not approve, for us to have universal health coverage for pregnant women and young children.
Kay Johnson: Only the poorest children and mothers ended up who would qualify for AFTC cash assistance actually got Medicaid coverage. It was our first universal opportunity for this population, and it was lost.
Kay Johnson: And from 1967 to 1983, the early periodic screening, diagnostic, and Treatment benefit was created in Medicaid. It is, in essence, the child health benefit of the program. It also… family planning was required, beginning in the Nixon administration, and then by 1977, we had the Hyde Amendment, which limited the use of federal funds for abortion and put severe restrictions on what Medicaid
Kay Johnson: could actually finance. We'll talk more about that later.
Kay Johnson: Beginning in 1984 and ending up in 1990, there were 6 incremental expansions of Medicaid for maternal and infant health, and ultimately for all poor children. But the children phased in.
Kay Johnson: And the incremental expansions were both a testimony to the concern about maternal and infant health at that time, but they also… there was a curious politics that what failed in the Johnson administration, what failed in the Carter administration ended up being incrementally signed into law by President Reagan.
Kay Johnson: and President George Herbert Walker Bush.
Kay Johnson: I'm going to talk more about IMTALA in a moment, but it dates back to 1986, so there is a long history that we'll be talking about briefly. And by 1989, the EPSDT benefit was amended, really to expand so that
Kay Johnson: That there was a rich set of intervention and treatment benefits.
Kay Johnson: By 1991, we were having the Gingrich Revolution, the proposals for the Medicaid Block Grant, which President Clinton vetoed at the last minute in the final hour. Many were not sure that he would veto it, having signed welfare reform into law at that time.
Kay Johnson: The Family Planning Waivers approach was created, largely through the efforts of the Alan Guttmacher Institute, but many other lobbyists, making an effort to give states permission to extend family planning to people who were not otherwise covered.
Kay Johnson: The Children's Health Insurance Program, CHIP, was enacted in 1997, and by 2009, CHIPRA reauthorized that program and set out another whole set of changes, including changes to the automatic newborn and continuous infant coverage.
Kay Johnson: Next slide, please.
Kay Johnson: By 2010, we had the enactment of the Affordable Care Act, and obviously what the biggest thing that this did was to expand adult coverage.
Kay Johnson: that we worked on, you know, women if they were pregnant, if there was a disability, if they were seniors, they had other coverage. But this created much more coverage for women of reproductive age, and Tanesha's going to talk about that.
Kay Johnson: The Medicaid 133% of poverty mandate became an expansion option, and we're going to talk more about which states expanded and what the impact of that was. And through the efforts of a wide array of people, so far I was included in everything from 1984 till this point of actively working on a women's preventive services package.
Kay Johnson: So that we had an array of services covered for women across the lifespan. Barbara Mikulski, former Senator Barbara Mikulski, who was my senator at the time, has great credit for this, but also those who led an Institute of Medicine committee and other professionals who really led on getting a solid list of things that had been left out of the U.S. Preventive Service Task Force.
Kay Johnson: By 2017 and 19, the Trump administration and Congress pushed for a Medicaid block grant and for the repeal of the Affordable Care Act, but failed. By 2020, we had COVID public health
Kay Johnson: Arab protections.
Kay Johnson: and place on Medicaid coverage. Every state took that opportunity. We also had the postpartum extension option under Medicaid, which… the fastest adoption of an option, really, in the history of the program. And then there was an incentive for states to adopt the ACA Medicaid expansion, which did accelerate action there somewhat.
Kay Johnson: In 2023 to 24, then the unwinding of those protections from the COVID era, and really a lot of people losing coverage unnecessarily, concerns and lessons we're learning now.
Kay Johnson: But nearly all states extended postpartum coverage, and Tanesha will talk about that more, and also about how more states are paying for doulas and community health workers.
Kay Johnson: Between 2025 and 26, this current Congress, the One Big Beautiful Bill Act, or H.R. 1, added Medicaid work requirements, limitations on provider taxes and other payments, and a lot more hurdles for eligibility and enrollment.
Kay Johnson: Next slide, please.
Kay Johnson: I'm going to talk about EMTALA as a particular point of history here, and how it relates to this topic. Nancy has put in the chat a longer, about an 8-page document that gives you a brief history of EMTALA. So, the Emergency Medical Treatment and Active Labor Act
Kay Johnson: was created in 1986 on, links to Medicare.
Kay Johnson: And it imposes an obligation on Medicare-participating hospitals that offer emergency services or have emergency departments.
Kay Johnson: And it concerns those who came to the hospital emergency department. They requested services, they requested an exam or treatment for something that was going on with them.
Kay Johnson: And it applies to all of those individuals, regardless of whether or not they're beneficiaries of any program, they're enrolled in Medicaid or Medicare, and regardless of their ability to pay. The momentum for EMTALA
Kay Johnson: Started in the mid-1980s.
Kay Johnson: when there was a big problem about hospitals turning away uninsured people, and it gained a lot of visibility. And as a reminder, this was, you know, really around the time that the series of expansions had just begun so that only 15% of births were covered by Medicaid, and many, many births were to uninsured women. I'm going to use this
Kay Johnson: opportunity to talk about my own experience, it was my surprise that, in a small way, my work contributed to the momentum to pass EMTALA, and this is the kind of what-one-can-do idea.
Kay Johnson: A 50-state survey I conducted when I was right out of public health school and I began to work at the Children's Defense Fund documented multiple instances of mothers in labor being turned away from the hospital.
Kay Johnson: The most egregious examples were from Texas, including people giving birth in the parking lot and others losing the baby or dying themselves. The results of that survey were used by my supervisor, Sarah Rosenbaum, to inform Congress and other advocates.
Kay Johnson: In Texas, Mike Hudson was the director of the Children's Defense Fund and was a highly prominent and active and effective advocate who helped to shape this so-called anti-dumping policy in Texas, which was the first in the nation. So my first project as a new health professional gave me the insight that it was the first moment that I truly understood how my research, data, and voice
Kay Johnson: Could support policy change at the macro level for women, children, and families.
Kay Johnson: And as I said, IMTALA has… sets out these requirements. The person has to be assessed, the condition has to be stabilized, or there has to be an appropriate transfer.
Kay Johnson: To another facility equipped to handle that.
Kay Johnson: problem. In the case of a pregnancy, or something that endangers the health of the woman or her unburned child, that might be an obstetric emergency, like an ectopic pregnancy. It might be a non-obstetric emergency. Maybe she had appendicitis, or maybe there was trauma from a motor vehicle accident.
Kay Johnson: Since the Supreme Court Dobbs decision, there have been, battles and confusion about EMTALA. It raised major questions about whether the federal MTALA law or the state
Kay Johnson: abortion ban laws were really the ruling. We've had a couple of decisions. You can find all the details and citations in the document that was posted in the chat and on the website. But the current legal context creates confusion, it creates fear, and delay in care that puts both mothers and babies at heightened risk for death. More advocacy is obviously going to be needed to protect
Kay Johnson: I did make sure that HMTALA protections are there for pregnant people.
Kay Johnson: EMTALA violations were widespread when many people were uninsured, and as the ACA coverage expansion number is reduced, more adults are going to become uninsured, and we can expect more failure to comply with EMTALA at hospitals all over the country. And in addition, obviously, as state abortion laws continue to evolve, and courts make future decisions.
Kay Johnson: Access to birthing and abortion services will be affected and putting, as I said, mothers and infants at heightened risk for death.
Kay Johnson: We all can learn, and we've got a cycle of change going on here where we're all pitching together to try to make conditions better. Back to you, Tanesha.
Tanesha Mondestin: Thank you so much, Kaye, for grounding us in this history. Now, let's turn to Medicaid's role in maternal and infant health specifically. Next slide, please.
Tanesha Mondestin: So, I know that there's a lot going on in this slide, and at CCF, we like to say that this slide is intentionally busy because Medicaid is busy. Medicaid touches nearly every system that families rely on from birth to death. Next slide, please.
Tanesha Mondestin: Now, shifting our gears to focus more on Medicaid and maternal and infant health, Medicaid is the largest payer of births in the U.S, covering over 40% of births nationally. Investing in maternal health through Medicaid not only saves lives, it also lowers healthcare costs.
Tanesha Mondestin: Strong maternal health systems strengthen communities and improves intergenerational health. In honor of Black Maternal Mental Health Week this week, I also want to highlight that Medicaid is also the single largest payer of behavioral health care, including mental health and substance use disorder services.
Tanesha Mondestin: This is important because mental health and substance use disorders
Tanesha Mondestin: and unintentional overdose are leading causes of maternal death across all races, though leading causes vary by race and ethnicity. Next slide, please.
Tanesha Mondestin: Medicaid is not only important during the perinatal space before, during, and after pregnancy, but it is important along the continuum of reproductive and pregnancy health.
Tanesha Mondestin: Medicaid is critical for preconception health, because the health of a person prior to becoming pregnant has a big impact on the health of the pregnancy and postpartum period. Ensuring that people enrolled in Medicaid know about their coverage and that they have access to care is imperative.
Tanesha Mondestin: Coverage is just the first step. The implementation where people actually begin to use their healthcare coverage is also just as important. Next slide, please.
Tanesha Mondestin: In 2023, a brief by the National Partnerships for Women and Families found, through their analysis, that 13.3 million women ages… between the ages of 19 to 49 had Medicaid coverage. That's about 1 in 5
Tanesha Mondestin: women of reproductive age nationally. Now, there's a common misconception that there are more Black people covered, but by sheer number, as we can see here, people who identify as white, there were over 5.5 million women that were enrolled in Medicaid. Next slide, please.
Tanesha Mondestin: So here we see that 41%
Tanesha Mondestin: of births are covered by Medicaid nationally.
Tanesha Mondestin: But if you look at the number of states.
Tanesha Mondestin: Generally, it is over 50% in a few states.
Tanesha Mondestin: We see that in 2023, 64% of births in Louisiana, 57% of births in Mississippi, 55% averse in New Mexico, and 52% of births in Oklahoma were financed by Medicaid. So this is clear… a clear example of how Medicaid is a backbone in the healthcare system.
Tanesha Mondestin: Next slide, please.
Tanesha Mondestin: While there is a higher percentage of Medicaid enrollees who identify as white, people who identify as Black, Hispanic, and American Indian, Alaska Native are disproportionately more likely to be covered by Medicaid and CHIP.
Tanesha Mondestin: Among Black mothers giving birth, more than two-thirds of the births are financed by Medicaid.
Tanesha Mondestin: And key factors for this are Black women are more likely to have lower incomes, and they're also less likely to have jobs that offer employer-based private insurance. Next slide, please.
Tanesha Mondestin: So here we see the median Medicaid income eligibility as of April 2026. You can start to see how much higher the eligibility levels are, both for pregnant women and for those covered under expansion.
Tanesha Mondestin: Though, as we'll discuss, that expansion population is now facing new risk. Next slide, please.
Tanesha Mondestin: Medicaid expansion through the Affordable Care Act has increased coverage rates for both women of childbearing age and children, leading to better outcomes and overall health for families. The uninsured rate is much lower for individuals in the expansion category. Next slide, please.
Tanesha Mondestin: Now, this slide shows the trend in coverage among new mothers, that is, people who gave birth in the last year. This analysis from the Urban Institute shows that about 30% had Medicaid coverage. But if you focus on the blue bar at the bottom, uninsured rates fell for new mothers from 11.7 in 2019 to a low of 9.8%.
Tanesha Mondestin: 0% in 2020.
Tanesha Mondestin: And that was largely thanks to the pandemic-era continuous coverage requirement. But in 2024, that progress stalled at 9.2%, and this is important because uninsurance is important.
Tanesha Mondestin: Healthcare costs in the United States are rising, and it is expensive. Coverage is the difference between a new mother getting screened or treated, or falling through the cracks.
Tanesha Mondestin: Next slide, please.
Tanesha Mondestin: So on the right, we have this map that shows the uptake of the postpartum extension from 2022 to present day.
Tanesha Mondestin: We see that we only have one state left to pass the legislation, Arkansas.
Tanesha Mondestin: So we've seen real wins, not only in postpartum extension, but when we're looking at doula Medicaid reimbursement, maternal mental health improvements with bills passed at the federal and state levels, non-nurse midwife reimbursement, and home visiting reimbursement.
Tanesha Mondestin: There has been some improvement, but it is not enough. While more provide… there are more providers of maternity care that qualify for Medicaid reimbursement, there is still a lack of diversity among providers such as midwives and obstetricians. Next slide, please.
Tanesha Mondestin: Now, let's talk briefly about how Medicaid is financed. Next slide, please.
Tanesha Mondestin: So, under the current law, Medicaid financing is open-ended and is not subject to the annual appropriations process.
Tanesha Mondestin: The federal-state partnership requires state matching contributions. The exact matching rate is generally determined by the Federal Medical Assistant Percentage, or FMAP, which is a statutory formula based on relative per capita income. Next slide, please.
Tanesha Mondestin: So, here you can see how the regular FMAP rate varies from state to state. States with higher per capita income are matched at 50%, the statutory minimum, while states with lower relative per capita income can be matched up to 83%. So, we have Mississippi that has the highest rate of
Tanesha Mondestin: at 76.9%. And we have 10 states that are at the federal minimum of 50%. Next slide, please.
Tanesha Mondestin: So, Medicaid, by far, is the largest source of federal funds that flows into states.
Tanesha Mondestin: On average, 56% of all federal dollars that states receive go towards the Medicaid program. But note that in state budgets, education is often the largest category, so education will be the larger piece of the pie when we're looking at state budgets. Next slide, please.
Tanesha Mondestin: Now, with that financing picture in mind, let's turn to the threats currently facing…
Tanesha Mondestin: The U.S. has one of the highest maternal mortality rates among high-income countries, so we are hearing about the maternal mortality crisis a lot. 80% of deaths are preventable. In 2023, every race and ethnicity saw a decline in maternal mortality.
Tanesha Mondestin: Black mothers were the only group to rise from 49.5 to 50.3 births per 100,000 live births.
Tanesha Mondestin: The maternal mortality crisis is because of racism, not race.
Tanesha Mondestin: Looking at the maternal mortality rates from 2022 to 2024, even if we look before 2022, we see that there is a pattern that has been upheld for years.
Tanesha Mondestin: And this shows that Black mothers are dying at a disproportionately higher rate. It's not a one-time spike. It's a persistent structural gap with racism as the main culprit. Next slide, please.
Tanesha Mondestin: And this doesn't change when we look at morbidity. Now, morbidity is far more common than mortality, with about 50,000 to 60,000 individuals experiencing a severe maternal morbidity event annually in the U.S.
Tanesha Mondestin: The severe maternal mortality rate shows the same consistent trend in the racial disparity pattern, and studies have shown that a person who experiences a severe maternal morbidity event in a first pregnancy is generally 3 to 6 times more likely to experience a severe maternal morbidity event and subsequent deliveries. Next slide, please.
Tanesha Mondestin: Morbidity?
Tanesha Mondestin: Thanks to Kay Johnson for this slide. Back in 1988, the Institute of Medicine identified four categories of barriers to timely prenatal care. A more recent systemic review of 34 studies
Tanesha Mondestin: found that the most common barriers today are still very much structural. We have enrollment delays, difficulty finding providers who accept Medicaid, lack of provider continuity, and transportation and childcare hurdles.
Tanesha Mondestin: In the study, it was common for those who accessed care to face racism, discrimination, and disrespect, all tied to things such as race, insurance status, age, substance use, and language. All of these factors which may contribute to maternal mortality and morbidity rates. Next slide, please.
Tanesha Mondestin: So where were we before the One Big Beautiful Bill Act, OBBBA, or H.R.1?
Tanesha Mondestin: So, there has been unprecedented progress in maternal health coverage that helped to mitigate some disparities that we see in the healthcare system, but it is nowhere near perfect. Before the One Big Beautiful Bill Act, we were already facing persistent maternal and child mental health crises, state budget shortfalls.
Tanesha Mondestin: Leading to Medicaid cuts, rural hospital and OB unit closures, provider burnout, discrimination, and bias in the healthcare system. Next slide, please.
Tanesha Mondestin: Medicaid remains an entitlement program, so anyone who is legally eligible can enroll and be guaranteed coverage. So Medicaid was not block-granted, so there was no cap, meaning that the federal government must still pay a set open-ended percentage of a state's Medicaid cost.
Tanesha Mondestin: And the federal government cannot limit the total amount it spends on the program, no matter how much enrollment or healthcare costs may increase.
Tanesha Mondestin: The federal matching rate for Medicaid expansion still remains at 90%, and there still remains a strong public support for Medicaid. Next slide, please.
Tanesha Mondestin: So, major Medicaid provisions with the One Big Beautiful Bill Act.
Tanesha Mondestin: Nearly a trillion dollars from Medicaid will be cut over the next decade, and these cuts target the Affordable Care Act, or ACA, Medicaid expansion population directly, especially through the new work reporting requirements.
Tanesha Mondestin: in restricting how states use provider taxes to finance their share, adding red tape to enrollment and renewal, and rolling back immigrant eligibility. Next slide, please.
Tanesha Mondestin: So why does Medicaid work reporting requirements matter? All states are mandated, they're required to start by January 1st, 2027. We have a few states adopting early, as well.
Tanesha Mondestin: So the policy targets ACA expansion directly, so this means that an estimated 5 million people will become uninsured as a result of the new Medicaid work reporting requirements.
Tanesha Mondestin: Next slide, please.
Tanesha Mondestin: So, on the right, there is a diagram of people who will be
Tanesha Mondestin: exempt from these categories. And despite these exemptions, people will lose coverage due to administrative barriers.
Tanesha Mondestin: Everyone has the right to verify work or exemption status at application or renewal of eligibility. Reporting will be required every 6 months, or perhaps monthly, depending on the state. Documentation will be required for most.
Tanesha Mondestin: And states will need to set up some sort of system and technology for efficient processes. Parents, pregnant and postpartum people, and others will be affected. Next slide, please.
Tanesha Mondestin: The work reporting requirements are alarming, particularly for pregnant enrollees, because pregnant people can be covered in many different categories within Medicaid. A report by the Urban Institute found that nearly 16% of pregnant women across the 36 expansion states
Tanesha Mondestin: that were reviewed were enrolled in the Medicaid expansion category during the month of delivery, and even more were enrolled 6 months prior to the delivery.
Tanesha Mondestin: 35.5% were in the pregnancy category, and others were already covered as low-income parents, or in other categories like disability, former foster care youth.
Tanesha Mondestin: Or child under 19.
Tanesha Mondestin: Next slide, please.
Tanesha Mondestin: H.R. 1 and interim federal regulations are clear that pregnant and postpartum enrollees are excluded from work requirements throughout pregnancy in the 12-month postpartum period in 49 states
Tanesha Mondestin: and DC. That part is straightforward for people in pregnancy-related coverage categories. The harder question becomes in how states will identify and protect people in other categories who then become pregnant.
Tanesha Mondestin: Next slide, please.
Tanesha Mondestin: So, what can you do? After hearing this information, here are a few action steps that you can engage in. And I love this quote that's on the left by Maya Angelou, that do the best you can until you know better, then when you know better, do better.
Tanesha Mondestin: First step can be to educate your policymakers and key decision makers about the value of Medicaid, the full value of Medicaid, and how it affects more than just healthcare. It goes beyond healthcare, because health can affect child welfare prevention, jail and prison diversion, employment access.
Tanesha Mondestin: in retention, the ability to stay in school. Health is the backbone of all of these things.
Tanesha Mondestin: And it has larger impacts than just the individual.
Tanesha Mondestin: Employment is important for communities and families and their well-being. If a person cannot work because of their poor health and they're unable to go to work, this can impact their income, this can impact their ability to get their education, and so on and so forth. You can highlight the harmful impact of Medicaid cuts.
Tanesha Mondestin: On individuals, families, state budgets, communities, providers, and more.
Tanesha Mondestin: Leverage the tables that you currently sit at. Leverage coalition partners to raise awareness, echo what national advocacy groups are already working on.
Tanesha Mondestin: to help keep eligible people enrolled and partner with people across the full spectrum of Medicaid beneficiaries.
Tanesha Mondestin: Because these cuts don't just hurt one group of people, they hurt everyone covered by the program and beyond. So with the Medicaid cuts, everyone, the society at large, will feel the ripple effects of Medicaid cuts.
Tanesha Mondestin: Next slide, please.
Tanesha Mondestin: Now, let's hear from our panel with this context.
Tanesha Mondestin: So, as a reminder, we have with us Madeline Morcelle, Dr. Jamila Perritt, and Lourdes Rivera, so thank you for joining us for this discussion. And to get us started, we're in a moment of active rollback, so before we get into
Tanesha Mondestin: specifics, how would each of you describe the current threats to maternal and infant health equity in one, two sentences? Madeline, we're going to start with you.
Madeline Morcelle: It's hard to sum up the current landscape in one to two sentences, but I would say that the threats are intersectional. It's the cuts to Medicaid and other health insurance coverage, long-standing
Madeline Morcelle: Discrimination in healthcare and other sectors that impact people's health.
Madeline Morcelle: the attacks on civil rights, DEI, and immigrants, the criminalization of pregnant people, a rapidly changing and complex landscape that providers are trying their best to keep up with, to keep
Madeline Morcelle: delivering care, and so much more that intersects, that is fueling our Black and Indigenous maternal health crisis.
Tanesha Mondestin: Thank you. Now, Dr. Perritt, if you would like to add on.
Dr. Jamila Perritt (she/her) | PRH: Sure, I agree a thousand percent. I think the challenge when we think about the threats is that it can feel really overwhelming, because you think, well, I'm working in this space, I'm working on…
Dr. Jamila Perritt (she/her) | PRH: maternal health, or I'm working on infant health, or I'm working on immigration… immigrant rights, or I'm working on pregnancy criminalization, and the inability for us to both see those things as deeply connected, but also to fund them in a way that is deeply connected. These issues are not separate in the lives of the folks that we care for, and so they cannot be separated, and our advocacy, they cannot be separated, and our strategy
Dr. Jamila Perritt (she/her) | PRH: as we seek solutions. When we look at folks who are seeking to undermine, to decimate the social safety net, to strip us of our human rights, we see that their organizing is intersectional. The same folks that are advocating against access to expanding Medicaid are the same folks that are rallying their communities to kidnap our community members and our neighbors.
Dr. Jamila Perritt (she/her) | PRH: Because of their immigration status, are the same people that are fighting and assaulting
Dr. Jamila Perritt (she/her) | PRH: folks who were seeking abortion access are the same people that are pushing back access to gender-confirming care for young people and anyone who needs it. So, you know, I agree a thousand percent with Madeline. It is the lack of ability to see this work as intersectional and to understand that our organizing and our fight must be intersectional as well. I think that wasn't two sentences, but…
Tanesha Mondestin: Yes, that is totally fine. It is hard to sum up in one to two sentences, for sure. Lourdes, would you like to add on, please?
Tanesha Mondestin: You're on mute.
Lourdes Rivera: Because my co-panelists were so comprehensive, I can just be very brief by saying racism, sexism, callous disregard, deprivation, and punishment being prioritized over access, care, compassion, and respect for human rights.
Tanesha Mondestin: Thank you for summarizing that. Very important points as we continue on this discussion. So, Madeline, I want to turn to you specifically for this question. I briefly described how the One Big Beautiful Bill Act will include Medicaid work reporting requirements, and how
Tanesha Mondestin: they… it is likely to affect pregnant and postpartum people, so can you tell us more about how states and communities, what they can do to minimize the disruption in coverage for pregnant and postpartum people?
Madeline Morcelle: Yeah, absolutely, and thank you so much, Tanesha. You did such a great job of sort of breaking down why work requirements are really a bad idea, and why they're going to hurt pregnant people.
Madeline Morcelle: I think about this in a few different buckets. Number one, trying to maximize the number of people who can maintain their coverage under Medicaid expansion and under the requirements.
Madeline Morcelle: Until we can hopefully repeal the requirements.
Madeline Morcelle: Because work should not be a requirement for healthcare, which is a human right.
Madeline Morcelle: One of the exemptions is the exemption for people who are pregnant or who were recently pregnant. Keeping verification
Madeline Morcelle: basically proving that you are… should… should, qualify as simple as possible for people.
Madeline Morcelle: there should be, something called self-attestation available. This basically means allowing people to provide… make,
Madeline Morcelle: for people to make a statement on the fact that they're currently pregnant, or they were pregnant within… in most states, it's within the last year, in order to serve as proof of them qualifying for an exemption, and thus not having to meet the requirement.
Madeline Morcelle: This can be filling out a form.
Madeline Morcelle: by the individual. This could be providing a verbal statement, but keeping it really simple and not requiring additional paperwork, things like
Madeline Morcelle: a form that their provider has to fill out, that just puts burden on both the individuals and providers who are already really burdened, so that's not good, so keeping it really simple.
Madeline Morcelle: looking out for arbitrary restrictions on this exemption. Things like restricting who's eligible based on how their pregnancy ends. We see a lot of this kind of discrimination. The way the law is written
Madeline Morcelle: these restrictions are… are not permissible. So, anyone who is pregnant or was recently pregnant, depending on the rules in their state, should be… should not have to meet the work requirements.
Madeline Morcelle: Also, making sure that the communications to communities from the state are clear, accessible, and culturally and linguistically appropriate, so that people understand the changes that are coming.
Madeline Morcelle: And how to comply with the requirements, or access an exemption if they aren't going to have to comply. How to prove that they shouldn't have to comply.
Madeline Morcelle: And then for those of you who are, working at the community level, partnering with legal services providers in your state, really important to help
Madeline Morcelle: With outreach to help ensure that people understand their rights under the requirements.
Madeline Morcelle: And what to do when they're violated.
Tanesha Mondestin: Thank you, Madeline. That is so important, and I love the part that you brought up about self-attestation. That is an easy thing that can… that states can do to ensure and promote maternal health equity. And with that, I'm going to transition
Tanesha Mondestin: slightly to Dr. Perritt. Now, many of us have heard of statistics in different categories, with infants
Tanesha Mondestin: With maternal health, looking at stark disparities among racial and ethnic lines.
Tanesha Mondestin: So while access to care is important, access is not enough if people are being treated poorly when they get said access.
Tanesha Mondestin: So how can we get health and other systems to not solely focus on improving access, but actually tackling racism so people truly have equitable access? And how might we move the health system forward despite the current climate that we live in?
Dr. Jamila Perritt (she/her) | PRH: So, the easy question for me, then, right, how does this country actually grapple with the legacies of racism, genocide, enslavement.
Dr. Jamila Perritt (she/her) | PRH: In a way that we have been unwilling to do so before. I think, you know, part of the thing that's really important to understand is that it begins with naming the thing.
Dr. Jamila Perritt (she/her) | PRH: Right? Calling a thing a thing, and really being honest about what it is that we're facing. We have been unwilling to do that, and we… and in the ways… in the times that we have, in the cases where we have seen it take a foothold, we are experiencing a similar backlash around that. A refusal to grapple with this country's history and the legacy is what has
Dr. Jamila Perritt (she/her) | PRH: put us in this situation in the first place. You said it in your presentation. It is racism, not race, that creates this disparities. I would offer a couple of things. Like, one is to be really, truly honest. Race-bound conditions cannot be addressed with race-blind policies.
Dr. Jamila Perritt (she/her) | PRH: And so we have to be really upfront about what is at the root of the inequities. And I say inequities intentionally, and not disparities. Disparities are simply differences, right? You know, one person has one thing, someone else experiences something else. Inequities are rooted in injustice, and they are things that can and must be addressed. When I look at the history of medicine in this
Dr. Jamila Perritt (she/her) | PRH: country, we can see really clearly that, my profession, I'm a board-certified OBGYN,
Dr. Jamila Perritt (she/her) | PRH: And, obstetrics and gynecology in particular has been built on the backs and the wounds of enslaved Black people in this country through experimentation, through torture, through abuse. And we see the legacy of those things play out in medical care today, in medical decision-making today, and certainly in health inequities.
Dr. Jamila Perritt (she/her) | PRH: So the way to address
Dr. Jamila Perritt (she/her) | PRH: racial inequities and models of care and experiences of care and places where we give and receive care is to meet it head on, to grapple with this history as it has impacted every single part of what we do. And this is true whether you are a Black OBGYN or not. As a Black OBGYN, I was also trained in the very same system that
Dr. Jamila Perritt (she/her) | PRH: has that legacy as part and parcel of its model of care. And so the work of undoing that… those legacies, the work of unpacking the impact that racism has on every single part of care is really critical. I think medicine is really unique in that, or we think we are unique in that we like to pretend
Dr. Jamila Perritt (she/her) | PRH: that these legacies, are something that don't impact us, that we are uniquely absolved from this history, right? It is… racism has impacted every other part of our lives. We can say, yes, we can point to it in educational systems, yes, we can point to it in housing, yes, we can point to it in the legal system. But medicine, we're objective.
Dr. Jamila Perritt (she/her) | PRH: Right? We are… we are above board, we are… we don't let those things impact, and that is simply untrue, and it bears out in all of the ways that folks are… are experiencing care in their communities and beyond.
Dr. Jamila Perritt (she/her) | PRH: When I think about what solutions look like, I think about the work that we do at Physicians for Reproductive Health in particular. We are a network of physicians really working to organize
Dr. Jamila Perritt (she/her) | PRH: and mobilize medical providers around the country to advance access to comprehensive reproductive health care for the communities we serve. We recognize that as physicians, we hold a unique space of power and of privilege. And it is our obligation, not just an opportunity, but our obligation and our responsibility to leverage that power and to leverage that privilege to make sure that we are really
Dr. Jamila Perritt (she/her) | PRH: doing the work that serves the folks that we take care of. And so, the way that I think about what it means to dismantle these systems, because this is not about finding that racist doctor, or that racist nurse, or this racist legislator, but instead to really grapple with the systems that allow this to continue for centuries, that allowed us to turn an eye away from
Dr. Jamila Perritt (she/her) | PRH: these abysmal maternal and infant mortality rates, to radicalize as many doctors in the work as possible, whether or not the system is ready to confront it. We are part of the system. We uphold it, we participate in it, and so it is our obligation to work to undo those legacies as well.
Tanesha Mondestin: Thank you, Dr. Perritt, and one thing, that stuck out to me is really naming the thing, because if you can't
Tanesha Mondestin: Name it, you can't address it, and also how you said that race-related issues can't be solved with race-blind policies, and that is so critical, especially when we are talking about cuts and everything going on with maternal and infant health.
Tanesha Mondestin: And Lourdes, I will turn to you next, to continue on this conversation on…
Tanesha Mondestin: criminalization when it comes to pregnancy. So you lead a powerful organization, Pregnancy Justice, and part of your work focuses on pregnancy criminalization.
Tanesha Mondestin: So, which is rife with racism and other isms leading to disproportionate outcomes. Ideally, pregnant parents would not be criminalized, but receive equitable access to and outcomes from all the services, healthcare and otherwise, that they need to thrive.
Tanesha Mondestin: So how can access to health and healthcare help forestall entry into these punitive systems? And how might we change Medicaid and other public programs to be more of support?
Lourdes Rivera: So I want to start answering this question. Well, first of all, I agree with everything that Dr. Perritt and what Madeline have said.
Lourdes Rivera: I mean, we live in a country in which the carceral system has substituted for the lack of access to medical care, to mental health care, you know, for meeting people's needs, like housing, right? And so…
Lourdes Rivera: And I just want to interject here. I grew up in Bedford-Stuyvesant, Brooklyn, and if folks are not familiar with Bed-Stuy, the motto growing up was Bed-Stuy, Do or Die, right? Because
Lourdes Rivera: You know, I had a front seat to the carceral system substituting for deprivation, because that was what was impacting my community, along with sterilization abuse and all these other things, right?
Lourdes Rivera: So, while health insurance coverage is necessary, it's, it's a… it's a really important pillar
Lourdes Rivera: It's also not sufficient. As Dr. Perritt said, we also have to look more broadly at the systems that impact people and set them up to fail.
Lourdes Rivera: And one of the things that I want to talk about is, you know, what's… what is driving… one of the things that's driving, in particular, pregnancy criminalization. That's also about racism and sexism, but also very intertwined with the anti-abortion agenda.
Lourdes Rivera: Which, you know, the anti-abortion agenda from
Lourdes Rivera: Very early on, when states started,
Lourdes Rivera: decriminalizing abortion before Roe, and then in response to Roe.
Lourdes Rivera: We're working to make embryos and fetuses legal persons with rights, and now we're in an environment where it's like with corporations, you know, get to be legal persons with constitutional rights, but not Black voters.
Lourdes Rivera: not trans people, not babies born to immigrants, and certainly not pregnant people, right? And because of this.
Lourdes Rivera: And again, both pre- and post-overturning of Roe, pregnant people have been surveilled and investigated and criminalized, or have lost custody of their children.
Lourdes Rivera: who have been put in foster care, for having health conditions or engaging in conduct that would not be criminal except for the fact that somebody is pregnant. So, what am I talking about?
Lourdes Rivera: You know, being exposed to a substance, or using a substance that can test positive in a drug test, or having a substance use disorder.
Lourdes Rivera: Falling down the stairs, driving without a seatbelt, you know, any number of circumstances, any behavior, and if you talk about communities that are over-policed, whose behavior gets scrutinized, behaviors that are just like human behaviors that wealthy white people also do, but they don't get
Lourdes Rivera: Surveilled and, and, criminalized for.
Lourdes Rivera: If you're poor, if you're Black, and if you're, and I'm including poor white women, too, because now all of this has expanded to affect them, right? Indigenous, if you're in a healthcare setting and you're pregnant, you're being tested.
Lourdes Rivera: You know, for drug use without your informed consent.
Lourdes Rivera: And then, and then you're being reported to law enforcement, and you're being reported to Child Protective Services. So, you know, this is not just about
Lourdes Rivera: you know, health coverage, right? And then now we are seeing that, if you're pregnant, and again, this is pre- and post-Roe, but we're seeing this in a post-Dobbs environment where
Lourdes Rivera: you're getting denied necessary medical procedures, like miscarriage management. You're also being denied the ability to make medical decisions, like being forced to have a C-section against your will, or be kept on machines if you're brain dead, right?
Lourdes Rivera: And so at Pregnancy Justice, we're documenting more criminalization, also, of miscarriages and stillbirths, which… which are…
Lourdes Rivera: you know, it happens a lot. You know, 1 in 4 known pregnancies end in miscarriage, and stillbirths, it's about 1 in every 150 births, right? But…
Lourdes Rivera: Now we're in a situation where pregnancy loss is treated as a potential crime scene.
Lourdes Rivera: And sometimes allegations of not receiving prenatal care is used as evidence of criminal intent. So now, you know, all of these great expansions are being attacked. We're gonna see more and more people without health coverage.
Lourdes Rivera: not being able to get prenatal care, and then that potentially can be used as, you know, so-called evidence of criminal intent of killing a live baby.
Lourdes Rivera: So, in addition to expanding coverage and fighting for the expansions that Medicaid, has had, we also need to change the systems to make them patient-centered, evidence-based, confidential, and with informed consent.
Lourdes Rivera: So I'll leave it at that for now.
Tanesha Mondestin: Thank you, Lourdes, for this important perspective on pregnancy criminalization, how this is more than just health coverage, but how you're seeing criminalization, even when it comes to pregnancy laws, and with, you know, Medicaid expansion at risk.
Tanesha Mondestin: with, Medicaid work reporting requirements and other policies, we see all these changes, you know, that can happen and how criminalization can be increased. So with that, I have a question to pose.
Tanesha Mondestin: for all three of you, the One Big Beautiful Bill Act was a policy decision by Congress that will do harm, we've been seeing the harm, being done. So many policies of the past
Tanesha Mondestin: have been implicitly or explicitly racist in their design or impact. So how might federal and state governments improve Medicaid to shift toward equity?
Tanesha Mondestin: We'll start with Dr. Perritt.
Dr. Jamila Perritt (she/her) | PRH: You know, I think there are… there's some culture shift work that has to happen here.
Dr. Jamila Perritt (she/her) | PRH: and some real organizing that has to occur as well. One of the reasons why we do our work in the way that we do at Physicians for Reproductive Health is because we believe that… because we are organizers at heart, and we believe that organizing people is the way to effect change. And to that end, one of the things that I think is an important culture shift
Dr. Jamila Perritt (she/her) | PRH: That we need to really organize around is the belief that healthcare.
Dr. Jamila Perritt (she/her) | PRH: Access to community-grounded, culturally responsive, language and racially concordant healthcare is a human right.
Dr. Jamila Perritt (she/her) | PRH: If we don't believe that healthcare is a human right, then all… we will continue to see inequitable outcomes, we will continue to see inequitable policies. I want to be really clear, that is not the way that it's taught.
Dr. Jamila Perritt (she/her) | PRH: in…
Dr. Jamila Perritt (she/her) | PRH: in medical education and training, we're not taught about human rights frameworks, we're not taught about the work… taught about the work that we do from a human rights perspective. And so, when I think about what does it mean to advance access to Medicaid, it means beginning with…
Dr. Jamila Perritt (she/her) | PRH: an inherent understanding that healthcare is a human right, and everyone is deserving of that. The second thing that I would offer is really leaning on Black feminist organizing principles and organizing from the margins.
Dr. Jamila Perritt (she/her) | PRH: Right? So this idea that if we create systems and circumstances where those on the margins of care, on the margins of society, those least likely.
Dr. Jamila Perritt (she/her) | PRH: to receive access to healthcare, to have access to insurance, to be able to get care in their community from folks who look like them, who speak like them, who understand their lived experience. If we create systems of care that actually meet the needs of those folks on the margins, everybody else will benefit. I think we're in a time where this, the phrase equity has, you know, folks running scared. This idea
Dr. Jamila Perritt (she/her) | PRH: that people deserve, to be well is something that has, run afoul, I guess, of folks' understanding of the reality of the human condition. And I think allowing the opposition to
Dr. Jamila Perritt (she/her) | PRH: take control, to dominate, that side of the conversation is where we have gone wrong. Equity is not a bad word. The ability for people to get their needs met is not a bad word, and the reality is that our ability to be well is absolutely shaped by the conditions of our communities.
Dr. Jamila Perritt (she/her) | PRH: And so if we are not willing to invest in our communities, then the idea that people will magically be well, whether they have Medicaid or not.
Dr. Jamila Perritt (she/her) | PRH: Is, is a pipe dream at best.
Tanesha Mondestin: Thank you. Lourdes?
Lourdes Rivera: I, I would say I just want to, like, say two things, around learning from our past to stop repeating the same
Lourdes Rivera: mistakes, over and over again. And this… this also includes addressing the need to address racism and sexism in healthcare and in our legal frameworks. And, you know, one historic point of view that I want to share is
Lourdes Rivera: Digging down on how, like…
Lourdes Rivera: What gave the opening to the anti-abortion movement to establish, or to begin establishing in law this idea of that fertilized eggs were people, but pregnant women, pregnant people were not?
Lourdes Rivera: And, you know, this was done, on the backs of Black women,
Lourdes Rivera: during the war on drugs that started under Nixon, and then Reagan came along and added the disparaging trope of the welfare queen, which pathologized Black motherhood and created this whole myth of the crack baby.
Lourdes Rivera: And again, this gave the opening to embed in state laws this idea of embryos and fetuses as crime victims of their so-called unfit mothers.
Lourdes Rivera: And while the myth has been debunked, the approach has expanded and shifted, capturing more people, including now poor white and rural women.
Lourdes Rivera: And, you know, and we still see, of course, that Black women, get disproportionately tested because of racism, even though, you know, the actual results, of, of,
Lourdes Rivera: of the drug testing shows that, you know, there are no more drug-using than anybody else, and in fact, less so.
Lourdes Rivera: So, you know, and I share… and I share this history, right, because, you know, I think we need to understand and absorb that, one, there is no such thing, as Dr. Perritt was talking about, there's no such thing as colorblindness. There's no such thing as colorblindness in
Lourdes Rivera: Healthcare in our society.
Lourdes Rivera: And what we're left with is, a system where people go to the doctor for help.
Lourdes Rivera: And instead, they get tested and reported to law enforcement and to Child Protective Services, right?
Lourdes Rivera: That… is sabotage for Medicaid expansion, because who's gonna go to the doctor
Lourdes Rivera: Right? If they know that they're gonna get reported to the police.
Lourdes Rivera: And lose their children.
Lourdes Rivera: And we cannot continue to replicate these systems
Lourdes Rivera: Again, that are gonna set people up to fail, and that's going to result in worse outcomes. And, you know, every major medical association opposes the punitive treatment of pregnancy in this way.
Lourdes Rivera: Because it does drive people away from care and results in worse health outcomes for both, you know, the pregnant person and the resulting, infant. So,
Lourdes Rivera: And then the other thing I will say, and, you know, and share is the research and the scholarship of Professor Kira Bridges, who wrote a book. I really highly recommend it. It's called Expected Inequality, How the Maternal Health Crisis Affects Even the Wealthiest Black Americans.
Lourdes Rivera: And basically, it boils down to, you cannot buy your way out of racism.
Lourdes Rivera: Because her research shows that actually Medicaid is kind of a equalizer, you know, for… it narrows the disparities between Black women and white women.
Lourdes Rivera: doesn't eliminate it, but narrows. But for higher-income Black women with private health insurance, who have the ability to access fancy healthcare systems.
Lourdes Rivera: They have broader disparities.
Lourdes Rivera: than their count… than their lower-income counterparts. So, again, it's… it's… it boils down to the racism in the systems that we have to address. And unfortunately, this… this anti…
Lourdes Rivera: so-called anti-DEI agenda, this anti-wokeness, it actually has consequences. It's killing people, right? And so.
Lourdes Rivera: Going back to naming the thing.
Lourdes Rivera: The national agenda to eliminate our ability to grapple with racism and inequality is actually killing people, and that's what we have to address.
Tanesha Mondestin: Madeline?
Madeline Morcelle: He paid, appreciate it.
Tanesha Mondestin: We can't…
Kay Johnson: I'm really hearing you, Madeline.
Madeline Morcelle: What about that?
Madeline Morcelle: Can you hear me now?
Tanesha Mondestin: It's still a little low.
Madeline Morcelle: Is the Patti powder?
Madeline Morcelle: Sorry, y'all. I shared earlier, I'm in the process of getting a new laptop.
Madeline Morcelle: Got it, husband, and… And then, then…
Madeline Morcelle: Going off camera to answer the action better now.
Kay Johnson: Maybe Melody, try to mute Madeline and bring her back on?
Tanesha Mondestin: Okay, you can try to unmute. I think some people from the audience say they can hear you if they turn their volume up higher.
Madeline Morcelle: you know.
Madeline Morcelle: Any luck?
Madeline Morcelle: Let me try…
Kay Johnson: Let's let her work on it and come back.
Kay Johnson: It's… what she wants… what she has to say is important. Let's be sure we can hear it.
Madeline Morcelle: Yeah.
Dr. Jamila Perritt (she/her) | PRH: I think that's it, Madeline.
Tanesha Mondestin: about it.
Kay Johnson: Yeah, that's it.
Kay Johnson: Try speaking on your headset.
Lourdes Rivera: Seems like she can't hear us now.
Tanesha Mondestin: Yeah, so I'll let her work out, some difficulties, with the technology.
Tanesha Mondestin: So, so far, what I'm hearing from you guys is that, it's important to realize that healthcare is a human right, and this idea of deservingness of who deserves care, that it's important to look at our past.
Tanesha Mondestin: and learn from our history, and that there is a danger of a narrative, such as a welfare queen and crack baby, and those dangers can slip into policy, and how these things are turned into dangerous policies. Also, how racism in the system at large can be dangerous.
Tanesha Mondestin: and deadly, for across racial and ethnic lines. So, to kind of go on a more positive, light in the discussion, are there any bright spots that we can build on where Medicaid or other healthcare partners are evolving and advancing toward equity?
Tanesha Mondestin: So, for example, we see, points like Dr. Nathan.
Tanesha Mondestin: Jamila's report from Minnesota about Medicaid's role in building racial equity. NHELP also does a lot of work tracking with Medicaid
Tanesha Mondestin: reimbursement for doulas, and I have written about it as well. So, in… what are some of your favorite examples? I'll start with you, Lourdes.
Lourdes Rivera: Sure, so I, I wanna, I wanna, share a very local example,
Lourdes Rivera: just to show that some states and localities can actually change their policies and laws, you know, to have a big difference. So in 2020, the New York City Health and Hospitals Corporation
Lourdes Rivera: change their policy. You know, New York City Health and Hospitals Corporation is the public health system in the, you know, the public hospital system in New York City.
Lourdes Rivera: So it changed its policy from just automatically drug testing pregnant people, and newborns to requiring informed consent. And that was a really major shift, because you have, you know, you have to explain to the patient what it's about, and then get their… get their consent.
Lourdes Rivera: So, reporting to child welfare dropped 80% overall and 90% for Black mothers.
Lourdes Rivera: And, you know, this is from a report from Movement for Family Power, their data brief, and it showed
Lourdes Rivera: that, and this… this accompanied, there was no evidence that newborns and infants were any less safe because of the reduced child welfare system involvement.
Lourdes Rivera: So… and there's a law…
Lourdes Rivera: That's proposed in the New York legislature to make this policy statewide, that folks have been working on, so hopefully there'll… there'll be an opportunity to institute this policy on a statewide basis. So, given that, perhaps Medicaid,
Lourdes Rivera: you know, I know we need a different Congress and a, you know, a different administration to, you know, that would sign law,
Lourdes Rivera: But, you know, perhaps something can be done through 1115 waivers, you know, to address this, to expand, you know, to require informed consent, and to expand, substance, you know, substance use disorder treatment for… for people who are pregnant.
Lourdes Rivera: through the Medicaid program.
Tanesha Mondestin: Thank you, Lourdes. So, now that Madeline's back, I'm gonna try to see if we can hear her now.
Madeline Morcelle: How about Al?
Tanesha Mondestin: Yes.
Madeline Morcelle: Okay, great. Thank you so much for your patience. Are we talking about bright spots?
Tanesha Mondestin: Yes, but, I'm gonna pivot, a little…
Tanesha Mondestin: back so that we can get your response, because I think your perspective can also add on to this conversation, talking about how,
Tanesha Mondestin: policies that are going on, not one big beautiful bill, but other policies that have been enacted have implicitly or explicitly been racist by design. So how do you see, the federal and state governments improving Medicaid to shift toward Medica… toward equity?
Madeline Morcelle: Yeah, I mean, this is… I so appreciate this question, because for me, this question is foundational to any conversation about the future of Medicaid. From Medicaid's birth, white supremacist notions of worthiness.
Madeline Morcelle: Who's worthy of care, who isn't, have shaped requirements.
Madeline Morcelle: For who states have to provide coverage to, and who gets excluded.
Madeline Morcelle: As well as state decisions where they have options.
Madeline Morcelle: There is research out of Duke establishing a connection between white supremacy and state refusals to expand Medicaid. That's just one…
Madeline Morcelle: readily available example, cuts to immigrant eligibility in 1996, also driven by racism. This… there's a long history here, and OBA is just the latest hit.
Madeline Morcelle: We need states to close coverage gaps, adopting state options, and also using their own funds when possible to close gaps when federal funding is not possible.
Madeline Morcelle: We need… a lot of states, don't provide coverage to lawfully present immigrants who are pregnant or children until after a 5-year waiting period. We need the 10 holdout states to expand Medicaid, really important to closing maternal health equities.
Madeline Morcelle: inequities. We also need to strengthen the coverage provided to those who are eligible. So, this is Medicaid doula coverage, at a fair reimbursement rate, so that doulas can provide, services.
Madeline Morcelle: and participate in the program. This is state-funded abortion coverage, really important to maternal health.
Madeline Morcelle: This is strengthening non-emergency medical transportation delivery so that people can get to appointments.
Madeline Morcelle: And also strengthening civil rights protections, which really shape what is covered and how care is delivered. While we have strong federal civil rights laws that, are applicable in a healthcare context.
Madeline Morcelle: The implement… those… a lot of those laws are… are not, being enforced, or they're being weaponized against underserved communities, and so we really… now is the time for states to step up to…
Madeline Morcelle: create and expand civil rights protections on the state level. This is really crucial for addressing the mistreatment that
Madeline Morcelle: especially Black birthing people encounter in maternal care, for addressing disability discrimination, immigration, limited English proficiency, and intersecting discrimination in maternal healthcare, as well as the
Madeline Morcelle: Broader healthcare system that can shape maternal health outcomes.
Tanesha Mondestin: Thank you, Madeline, and I'm gonna, continue on with the Bright Spots, question with you on, ways that we can build on, you know, where Medicaid and other health, care partners are evolving. So, do you have any examples yourself?
Madeline Morcelle: Yeah, I mean, someone else may have mentioned this, while I, was troubleshooting, but in just the last few years, all but one state have either expanded or in the process of extending pregnancy-related Medicaid coverage through a full year after pregnancy ends, and that
Madeline Morcelle: Is tremendously important for improving maternal health outcomes and improving equity.
Madeline Morcelle: Doula coverage. My colleague Ami Chen coordinates our Medicaid doula project, which includes, among other things, monitoring and supporting
Madeline Morcelle: Medicaid doula coverage efforts, and 28 states and DC are now actively reimbursing for Medicaid coverage of doula care. 7 states and territories are in the process of implementing Medicaid doula coverage, and 13 states and territories
Madeline Morcelle: have, have adopted other… have taken other actions aimed at ultimately improv… Implementing Medicaid coverage of doula care. So, all of this, tremendously important to, improving maternal health outcomes for communities.
Tanesha Mondestin: And Dr. Perritt?
Dr. Jamila Perritt (she/her) | PRH: Thanks. I think all of those… all of those examples are… are fantastic, and
Dr. Jamila Perritt (she/her) | PRH: ones that we would love to see, continue to expand. I think maybe the one that I'll mention is, there are two that I'll mention. One is around Medicaid coverage for abortion access. And, you know, we often hear lots of conversation about the Hyde Amendment.
Dr. Jamila Perritt (she/her) | PRH: and its passage, just two years after Roe was decided that limited access, or coverage, insurance coverage, and ultimately access.
Dr. Jamila Perritt (she/her) | PRH: to abortion care for people who receive their insurance through the government-sponsored programs like Medicaid, but also folks who are in the military, who work internationally at NGOs, any relationship with the federal government.
Dr. Jamila Perritt (she/her) | PRH: But what we have seen in, in the wake of that is about 20 states
Dr. Jamila Perritt (she/her) | PRH: that do use their own state Medicaid funds to cover abortion for those who receive Medicaid or federally sponsored insurance. Now, some of those, only use that coverage for, you know, medically necessary abortions, which is defined in any number of ways, but it is a bright spot to, one, to acknowledge that it is possible, right? We heard in the presentation in the beginning
Dr. Jamila Perritt (she/her) | PRH: that Medicaid is jointly funded by the state and the federal government, and so while we work on one end to repeal the Hyde Amendment so that everyone has access to the same services, whether their insurance is private or government…
Dr. Jamila Perritt (she/her) | PRH: sponsored. In the meantime, some states have stepped in to say, we will cover this care for folks who receive Medicaid services, and I think that that is an important bright spot. I work and practice in the DC metropolitan area, and in D.C, Maryland, and Virginia, there are three different rules around Medicaid coverage for abortion care.
Dr. Jamila Perritt (she/her) | PRH: In Maryland, the federal funds,
Dr. Jamila Perritt (she/her) | PRH: State funds can be used under medical exceptions, right? But not the typical Hyde exceptions, but other more expanded exceptions. In Virginia, they do not use state funds for Medicaid coverage, and in DC, I won't get on my soapbox, but because we lack statehood.
Dr. Jamila Perritt (she/her) | PRH: than we experience and are at the whims of the federal government in terms of what we are able to use with our own tax funds. But what you see is really a patchwork of care for folks if they live in this area, and that is something that shows up across the states. But I think the bright spot here is to, one, to understand that it is universally supported.
Dr. Jamila Perritt (she/her) | PRH: people want, the majority of Americans want folks to be able to access abortion care and support the use of these funds, whether, regardless of insurance status. They don't want politicians making decisions about what their insurance should pay for.
Dr. Jamila Perritt (she/her) | PRH: And it absolutely improves outcomes for maternal and infant health. I think some people have the misconception that if there are these exceptions.
Dr. Jamila Perritt (she/her) | PRH: for rape, incest, and threat to maternal life, then that is good enough. And I want to say really clearly, they do not work.
Dr. Jamila Perritt (she/her) | PRH: Exceptions are no protections for people who need access to care. The number of hoops that you have to jump through to actually get that benefit when you have Medicaid or TRICARE or whatever kind of insurance makes it nearly impossible to utilize that. So, I want to lift up those 20 states
Dr. Jamila Perritt (she/her) | PRH: 20-ish states that actually are using their state funds to make sure that there is equitable access to the full range of reproductive healthcare services for their Medicaid enrollees.
Tanesha Mondestin: Thank you, Dr. Perritt, for this important perspective, for this bright spot.
Tanesha Mondestin: that you… you brought up, because I agree with what you said, that exceptions are not protections for people who truly need care.
Tanesha Mondestin: And from here, I want to ask you all, where do we go from here? What do we need to do to protect the most vulnerable pregnant folks and their kids during these times?
Tanesha Mondestin: What tools and strategies should advocates use to elevate mothers and babies in Medicaid amid the headwinds? Lourdes, I would like to start with you.
Lourdes Rivera: Thank you, Tanesha. I mean, I think, first of all, we have to, like.
Lourdes Rivera: Remember who's the person in this equation? And that is the…
Lourdes Rivera: you know, the person who's actually carrying the pregnancy, the living, breathing person, right? And that is the person
Lourdes Rivera: That needs to be centered in terms of, you know, healthcare access and rights, and so forth. And if you take care of that person, then other things get taken care of too, right? So, that's one thing. The other, you know, the other thing is we have to reprioritize where we're spending resources in this country.
Lourdes Rivera: So there is a report by the Nonpartisan Council on Criminal Justice that estimated that in 2025,
Lourdes Rivera: It costs between $87,000 and $122,000 per woman To imprison her.
Lourdes Rivera: Yet we have still the same kind of dearth of…
Lourdes Rivera: accessible drug treatment programs for pregnant and parenting people that we had when I first started doing this work in the early 1990s, right? So, where is it that we're prior… you know, and that also says something about, how our systems
Lourdes Rivera: think about…
Lourdes Rivera: The role of pregnant people, the role of women, who should be punished, you know, who should be given access to care, and so we need to have that big shift.
Lourdes Rivera: Like Dr. Perritt was saying, just in terms of, you know, what is the culture shift here, and then the money needs to follow, and the policy and the laws need to follow, too.
Lourdes Rivera: You know, we need to require informed consent for drug testing. Hard stop.
Lourdes Rivera: And then set high bars for reporting. And Dr. Perritt reminds us
Lourdes Rivera: that, you know, there's no medical necessity for testing, and people, you know, and the health… and the health providers need to remember that as well. Just don't do the test.
Lourdes Rivera: We need stronger protections for patient confidentiality. We need to strengthen HIPAA, both for those situations that we've been talking about, but, you know, also.
Lourdes Rivera: the fake clinics, that Cosplay being medical clinics, you know, for pregnant people, whose, you know, whose mission is to divert people away from, you know, getting abortion services, they can collect your data.
Lourdes Rivera: and share it with whomever, including law enforcement, you know, Child Protective Services, whomever.
Lourdes Rivera: Because HIPAA doesn't apply to them because they're not medical providers, right? So, we need to strengthen the laws.
Lourdes Rivera: to protect patient… and… and private health information.
Lourdes Rivera: Can we enforce the EMTALA Act? Because, like, we're back in the 80s where pregnant people are bleeding out in parking lots, because, you know, in these abortion ban states,
Lourdes Rivera: You know, a doomed pregnancy, Because there's a, cardiac pulse detected, Women have to…
Lourdes Rivera: You know, and pregnant people are being asked to, get really close to almost dying before they can get health treatment.
Lourdes Rivera: Right? That is not being treated as a person with dignity and respect.
Lourdes Rivera: Right? And then, you know, there's some federal law changes that can be made as well, like amending, some of the spending provisions, like the Child Abuse Prevention and Treatment Act, CAPTA,
Lourdes Rivera: Which, you know, just to make it clear that
Lourdes Rivera: It does not require individual reporting of positive drug testing to child welfare agencies. It actually requires aggregate reporting, but it gets interpreted
Lourdes Rivera: at the state level, as requiring, individual reporting, and that's really causing a lot of harm. So I think, you know, there's a lot that can be done at both the federal and state level.
Tanesha Mondestin: Thank you, Lourdes. Madeline?
Madeline Morcelle: you know, I think it's really important that we not get complacent.
Madeline Morcelle: While… while we work to reduce the damage of work requirements, immigrant eligibility cuts.
Madeline Morcelle: Medicaid cuts impacting reproductive health providers, including but not limited to abortion providers.
Madeline Morcelle: We can't lose sight of the need to repeal these cuts in the future.
Madeline Morcelle: We also can't lose sight of the healthcare system that we want to build for our families.
Madeline Morcelle: for… The people that we love,
Madeline Morcelle: again, like, going back again to that sort of ethics of care, as part of my role at NHELP, I am privileged to
Madeline Morcelle: Direct our reproductive justice movement lawyering initiatives, which mobilize our legal capacity to help reproductive justice advocates
Madeline Morcelle: protect Medicaid and transform the healthcare system toward their vision. And part of our work includes anchoring and providing legal support to our Medicaid and Reproductive Justice Collaborative, which is a collective of
Madeline Morcelle: 30 reproductive justice organizations across the country.
Madeline Morcelle: working on Medicaid-related issues. And in 2024, the collaborative put out reproductive Justice Principles for Federal Universal Healthcare Reform.
Madeline Morcelle: And the principles were for advocates and policymakers, but it was also really important to our advocates that we put out community-facing values available in 9 languages as well.
Madeline Morcelle: And these documents, this framework provides a policy framework, but also a procedural, a process-based framework.
Madeline Morcelle: For advancing a healthcare system in which affordable, comprehensive, non-discriminatory, and confidential healthcare access, including pregnancy-related care, including abortion without restrictions.
Madeline Morcelle: is delivered and protected as a human right. The framework talks about the importance of centering underserved and especially
Madeline Morcelle: Black, Indigenous, and other person of color communities' concerns, vision, and leadership at every stage of reform, because the people closest to the problems are so often closest to the solution. So.
Madeline Morcelle: I think it's, you know, in this moment, we have to walk and chew gum, because if we don't work on damage mitigation, a lot of people are going to be hurt.
Madeline Morcelle: But we also can't lose sight of the future.
Tanesha Mondestin: Thank you, Madeline. Dr. Perritt?
Dr. Jamila Perritt (she/her) | PRH: I'll try to keep it brief, so we have time for a couple of questions, but I'll offer a couple of things, and I love that Madeline talked about reproductive justice and…
Dr. Jamila Perritt (she/her) | PRH: and her answer, because it's such a critical part of the way that I think about what care should look like.
Dr. Jamila Perritt (she/her) | PRH: For those who aren't familiar with it, I know we're talking about maternal and infant health, but reproductive justice is really the right to have children, to not have children, and to parent the children that you have in communities that are safe and sustainable. And so that means if we're talking about access to maternal health care services, we also have to talk about access to abortion care. We also have to talk about environmental justice and violence in our communities.
Dr. Jamila Perritt (she/her) | PRH: and segregation and racial dislocation, right? All of those things are deeply connected. So for me, when I think about what a way forward looks like, it really encompasses all of those things. It means that we have to consider all of them as part of the way forward, and to understand that community care is, in fact.
Dr. Jamila Perritt (she/her) | PRH: maternal and infant health care. And so, in that vein, it's really critical that we look to models that already exist. I mentioned that I live in
Dr. Jamila Perritt (she/her) | PRH: and work here in the District of Columbia, and there are several models here in DC that are fantastic examples. I'd love to lift up the work that they're doing at the DC Birth Center, one of the only FQHC birth centers in the country, also led by Dr. Ebony Marcell. Also, the work done at Mamoto's Village, and Dr. Aza Nadari is leading that work, and those are community-based
Dr. Jamila Perritt (she/her) | PRH: place-based models of care. This isn't to suggest that this is a pack-and-play model, that you just sort of pick up the work that they're doing and move it to Ohio, or Nebraska or Florida. But instead, the reason why these programs are so successful, the reason why their maternal and infant mortality rates are so low, the reasons why their outcomes are so fantastic is because
Dr. Jamila Perritt (she/her) | PRH: they are in and of community. So often we see people that are… my grandmother used to call them the come-heres and the from-heres, right? And the come-heres who sort of pop in and determine what the from-heres need, and create all of these solutions. And this is really to echo what Madeline is saying about those who are closest to the problem are often closest to the solutions as well.
Dr. Jamila Perritt (she/her) | PRH: Community care is, in fact, maternal and infant care.
Dr. Jamila Perritt (she/her) | PRH: I would also like to echo what Lourdes has said about disengaging carceral systems from medical care. These things cannot coexist. We have,
Dr. Jamila Perritt (she/her) | PRH: A tremendous appetite in this country for punishment, and particularly the punishment of people with the capacity for pregnancy.
Dr. Jamila Perritt (she/her) | PRH: And so as long as we think it is okay to enter our hospital systems and see the police there, as long as we think that it is okay to have large contracts with sheriff's offices and prison systems within our hospital systems, then we will never see equitable care. We will continue to see black and brown and poor people being harmed by medical systems. So really disconnecting
Dr. Jamila Perritt (she/her) | PRH: This carceral logic and carceral thought from places of care, understanding that they have no place
Dr. Jamila Perritt (she/her) | PRH: and models of care. They are not keeping us safe, they are not keeping our community safe. And then the last thing that I would offer is really a reimagining of what this could be, and I think that that's so important.
Dr. Jamila Perritt (she/her) | PRH: We spend so much time thinking about all of the things that are wrong, and that is important. It is important to address the immediate needs of folks in this moment, particularly when harm is being played out. But what could it look like if we imagined and reimagine care as a liberatory model? I knew growing up that I wanted to be a doctor, I knew that I would be a doctor growing up, but I also knew that doctoring in its current iteration
Dr. Jamila Perritt (she/her) | PRH: was never going to keep us well. It was never going to keep us safe. And so imagining… imagine what it could be
Dr. Jamila Perritt (she/her) | PRH: if
Dr. Jamila Perritt (she/her) | PRH: healthcare and the models of care were actually the tools of liberation that they were designed to be. I stay in medicine because I believe it can be a tool of liberation. In this current iteration, it is not.
Dr. Jamila Perritt (she/her) | PRH: In most cases. But I believe that there is a possibility in that, and that is going to take collective energy, will, and work, and also a reformation
Dr. Jamila Perritt (she/her) | PRH: Of medical education as we currently know it.
Tanesha Mondestin: Thank you, Dr. Perritt, for that thoughtful response. We have a question up around your wheelhouse in DC. So, DC has Medicaid coverage for doula services, and I know that the transformation…
Tanesha Mondestin: the Transforming Maternal Health model is expected to strengthen implementation over time, but as implementation evolves, has there been any discussions about intentionally supporting community-led implementation models through partnerships
Tanesha Mondestin: Technical assistance are dedicated investments to help build the doula workforce and improve access amid the upcoming cuts.
Dr. Jamila Perritt (she/her) | PRH: I mean, I can't speak to what it looks like on a national level, but what I do know is that these models currently exist, as I've said, and so what it's going to take is really a demand from those of us who are on the ground to say, these are the things that we see as successful. And again, this is not an, sort of a… I can't even think of the…
Dr. Jamila Perritt (she/her) | PRH: what the word is, right? It's not like a sort of a pack-and-play model where you take it and you move it someplace else. It requires a deep investment in community. The reason why we are seeing these outcomes is because we have divested from community. And so these models, whether it's doula support, or perinatal health workers or whatever that may be, in order for them to be successful, whether that's here in DC, or in California.
Dr. Jamila Perritt (she/her) | PRH: or in Ohio, or wherever that may be, requires a reinvestment in community. I will offer, as well.
Dr. Jamila Perritt (she/her) | PRH: that we often see, sort of, these, low-hanging fruit solutions, and sometimes Medicaid coverage for doula services is seen as that. Well, we'll just throw some doulas in there, and that'll fix the problem. I want to be very clear, it requires a more expansive role. The reimbursement for doulas now, because of the bottles of pay that we see, are sometimes higher than they are for midwifery care in the city.
Dr. Jamila Perritt (she/her) | PRH: Right? So, it cannot be a trade, we cannot barter, it requires the entire care team in order to ensure that I survive my pregnancy, and that my children survive the life in this city, right? So, it requires all of the things in order for it to work. It is not just doulas, it is not just midwives, it is not just having more Black OBGYNs, it is all of the things
Dr. Jamila Perritt (she/her) | PRH: in order to make sure that our communities can be well, and that they have the ability to determine if, when, and how they build their families. That means if they want to see an OBGYN, they can.
Dr. Jamila Perritt (she/her) | PRH: If they want to see a midwife, they can. If they want a doula there, they can, right? And if they don't want those things, they are also supported to be able to make those decisions.
Tanesha Mondestin: Yes, thank you so much.
Tanesha Mondestin: We do have, some more questions, but we are running out of time, but we will get to your questions in an email. So, for closing, for in about 30 seconds from the three of you, do you guys have any final thoughts or words of wisdoms that you can impart in about one sentence?
Tanesha Mondestin: We'll start with Madeline.
Madeline Morcelle: Medicaid is complicated, but so important, and there are so many
Madeline Morcelle: Partners available to you to help you understand it, so that you can help communities on the ground navigate what's coming.
Madeline Morcelle: So please reach out if we can be helpful.
Tanesha Mondestin: Lourdes?
Lourdes Rivera: I'm gonna end my comment by answering one of the questions, which is the one on, do we anticipate worse outcomes for Latinas and immigrants?
Lourdes Rivera: I anticipate, yes, and we'll… and there's usually a lag in data collection and reporting, so we'll just have to see, but I do remember during COVID, the Latina maternal mortality rate did go up, because of lack of access.
Lourdes Rivera: And so, we'll just have to see, but I will close out by saying we have to fight for access, care, dignity, respect, and rights over stereotypes, stigma, surveillance, and punishment.
Tanesha Mondestin: Thank you, Dr. Perritt?
Dr. Jamila Perritt (she/her) | PRH: Thank you. I think that in… in terms of a closing sort of thoughts, it would just say that this is… this is not an exercise in futility.
Dr. Jamila Perritt (she/her) | PRH: This is a battle that can be won.
Dr. Jamila Perritt (she/her) | PRH: But it has to be done in a way that is strategic. Right now, we are faced with a game of whack-a-mole, where so many awful things are happening. And so, our, our energy is diffuse, our attention is diffused, but if we continue to reground ourselves in purpose and injustice, then all of the fights are the same. And so, if we continue to come back to that.
Dr. Jamila Perritt (she/her) | PRH: as our core value, our core principle, then all of the things matter, and all of the things are possible if we are starting from that point.
Tanesha Mondestin: Thank you so much, everyone, for taking the time to join us today. I want to thank our panelists as well. We have learned so much, and we hope that you have some takeaways to take back to your communities. As a reminder, this webinar, the recording and slides, will be made available, sent through email, and available on our website.
Tanesha Mondestin: And remember, this is just the start of the conversation, so we hope to see you in future sessions.
Tanesha Mondestin: Thank you.