Extending Medicaid Coverage One Year Postpartum

Extending Postpartum Medicaid to One Year

Breastfeeding has health benefits for both babies and mothers. Breast milk provides a baby with ideal nutrition and supports growth and development. Breastfeeding can also help protect baby and mom against certain illnesses and diseases. – U.S. Centers for Disease Control and Prevention, 2023

As the epigraph above makes clear, postpartum care is critically important for the health and wellbeing of both mothers and infants following childbirth. During this vulnerable period of transition and recovery, continued medical support helps detect and address potential complications or risks arising from delivery. The well-being of the mother is a crucial factor in the child's initial year of development. There has also been a rising trend in new mothers actively engaging in breastfeeding postpartum. Breastfeeding offers numerous health advantages, including passive immunity, a healthier digestive system, a reduced incidence of diabetes in breastfed children, and a myriad of other benefits. Continuing Medicaid coverage for mothers throughout the baby’s first year of life enables these individuals to address their health concerns, potentially mitigating issues that could affect milk production or transmit infections through breast milk. This extended coverage period aligns with the broader goal of promoting maternal and child health during the critical early stages of development.The purpose of this paper is to provide a review of the relevant literature to explain how extending Medicaid coverage for a full 12 months, instead of the current 60 days following childbirth, brings substantial multiple benefits for pregnant individuals meeting the financial need requirement. Following this review, the paper presents a summary of the literature review and important findings concerning the importance of extending postpartum Medicaid to one year in the conclusion.

Review and Discussion

With nearly 4 million births each year, the postpartum period is a time-sensitive opportunity to deliver comprehensive healthcare addressing issues arising from pregnancy and childbirth. Although the American College of Obstetricians and Gynecologists (ACOG) emphasizes a continuum of postpartum care, it recommends a “comprehensive” postpartum visit within 12 weeks postpartum (Attanasio et al., 2021). Current Medicaid policy, however, allows just 60 days of postpartum coverage following pregnancy, after which new mothers abruptly lose health benefits.

This dangerous coverage gap directly threatens maternal wellness and mortality during a pivotal yet vulnerable recovery stage. Losing access amid worsening national maternal death rates linked to preventable post-delivery complications makes the status quo unconscionable. Congress must act to universally extend pregnancy-related Medicaid to 12 months postpartum in light of states now resuming ineligibility redeterminations. In this regard, the American College of Obstetricians and Gynecologists (ACOG) emphasizes that, “Extending Medicaid coverage from 60 days to one year postpartum is especially critical because of the Medicaid unwinding, which began in April 2023 and allowed states restart the process of disenrolling ineligible members from Medicaid” (Extend Postpartum Medicaid Coverage, 2023, para. 4). Consequently, increasing numbers of American women are at risk of becoming ineligible for extended postpartum coverage.

With millions slated to be dropped from pandemic coverage waivers, continuing affordability protections would ensure care continuity for lower-income mothers during childbearing years. No new mom should be confronted with coverage denial notices because arbitrary time limits expired before her body or baby fully healed. It is a moral and economic imperative to nurture families by guaranteeing health security during maternity through consistent postpartum safety net access, not just shorter-term maternity alone (Extend Postpartum Medicaid Coverage, 2023).

Attendance rates for postpartum visits in the U.S. vary widely, however, ranging from 50% to nearly 90%. Research indicates that disparities exist, with women of color, uninsured individuals, younger women, those with lower socioeconomic status, and those with delayed prenatal care being less likely to attend (Attanasio et al., 2021). Although every individual case is unique, some of the more common barriers to postpartum care include perceptions of not needing further care, busy schedules with newborn care, and access challenges such as lack of insurance or transportation (Attanasio et al., 2021). Discrimination experiences within the healthcare system contribute to disengagement and avoidance of necessary care, especially among women from marginalized social groups. Notably, women who encountered discrimination during childbirth hospitalization demonstrated lower postpartum visit attendance in a national survey from 2011–2012 (Attanasio et al., 2021).

The U.S. Centers for Disease Control and Prevention (CDC) reports a notable increase in breastfeeding rates among American mothers, with a rise of over four percentage points in the proportion of breastfeeding mothers from 2000 to 2008. This upward trend is observed across all demographic groups, indicating a positive shift in breastfeeding practices. The report highlights that in 2000, 35% of mothers were breastfeeding at 6 months, a figure that increased to nearly 45% by 2008 (Nordquist, 2013). These positive trends underscore the fact that growing numbers of American women are recognizing the health benefits that accrue to themselves and their babies through breastfeeding, but this uptake is not equally shared among all demographic groups.

While Caucasian women still exhibit higher breastfeeding rates compared to African-American mothers, the gap has reduced from 24 percentage points in 2000 to 16 in 2008 (Nordquist, 2013). As noted above, the CDC and scientific community all emphasize the health benefits of breastfeeding for both mothers and infants; despite these advancements and positive trends, however, challenges persist in providing necessary support to breastfeeding mothers, particularly in hospitals, healthcare settings, and workplaces. The CDC underscores the need for targeted strategies to offer enhanced support to African-American mothers, acknowledging the importance of continuous efforts to promote breastfeeding (Nordquist, 2013).

There are a number of good physical and mental health reasons for this enhanced support of breastfeeding by all American women. For instance, according to Malhi et al. (2023), “Breastfeeding and parental stimulation both confer positive benefits to the early cognitive functioning of toddlers, and these need to be emphasized during primary care visits” (p. 563). Likewise, the CDC emphasizes that the evidence is clear and breast milk is the optimal first food for infants. Moreover, breastmilk changes over time to adapt as babies grow to provide perfect customized nutrition (Breastfeeding Benefits Both Baby and Mom, 2023).

Beyond superior digestibility over substitutes, breastfeeding uniquely transfers antibodies from mothers to develop babies' immune systems, protecting against various illnesses. Studies confirm babies who breastfeed experience lower risks of asthma, obesity, type 1 diabetes, infections, and SIDS. Moreover, the practice benefits mothers long-term, correlating breast and ovarian cancer reductions with lactation (Breastfeeding Benefits Both Baby and Mom, 2023). In sum, mothers and their babies become healthier and enjoy multiple long-term benefits from breastfeeding.

Beyond the foregoing, the portability of feeding directly at the breast also promotes responsive bonding on-the-go without preparation hassles. Given this multifaceted nurturing for infant and maternal health, medical authorities strongly advise breastfeeding as extensively as possible wherever feasible for families in the earliest months, alongside introducing solids as age appropriate. When mothers have access to accommodating environments and support systems, breastfeeding remains nature’s most sophisticated way of fueling humans’ foundational growth (Breastfeeding Benefits Both Baby and Mom, 2023).

In response to the need, the ACOG has recently called on the Centers for Medicare & Medicaid Services (CMS) to encourage states in pursuing this policy and promptly approving relevant Section 1115 waiver and state plan amendment (SPA) requests. The extension of postpartum Medicaid coverage can be achieved through a combination of legislative, executive, or regulatory actions (Extend Postpartum Medicaid Coverage, 2023). For instance, the American Rescue Plan Act, enacted into law on March 11, 2021, introduces an additional pathway for states to extend their Medicaid coverage for pregnant women from the current 60 days to one full year postpartum through the provisions of SPA requests. The Center for Medicaid and CHIP Services has provided specific, step-by-step guidance to state Medicaid directors for the implementation of the postpartum SPA in their respective states (Extend Postpartum Medicaid Coverage, 2023). Currently, 40 states and the District of Columbia have implemented some form of SPA to extend postpartum Medicaid coverage to one year and several others are considering this implementation; two states have proposed a limited extension period (Medicaid Postpartum Coverage Extension Tracker, 2023).

The implementation guidance provided by the Center for Medicaid and CHIP Services emphasizes that Medicaid stands as the primary payer for pregnancy-related services, covering over 42 percent of births nationwide. The Children's Health Insurance Program (CHIP) also contributes by covering pregnant adolescents and, in select states, low-income pregnant individuals exceeding Medicaid income limits. Together, it is clear that Medicaid and CHIP play a pivotal role in ensuring access to care for pregnant and postpartum individuals, enhancing maternal health care quality, and addressing health outcome disparities (Extend Postpartum Medicaid Coverage, 2023).

At present, Sections 9812 and 9822 of the American Rescue Plan Act of 2021 (ARP) empower states with a new option to extend postpartum coverage to 12 months for pregnant individuals enrolled in Medicaid and CHIP, effective April 1, 2022 (Extend Postpartum Medicaid Coverage, 2023). The extended postpartum coverage presents states with an opportunity to provide comprehensive care, potentially reducing pregnancy-related deaths and severe maternal morbidity. This opportunity also facilitates improved continuity of care for chronic conditions such as diabetes, hypertension, cardiac conditions, substance use disorder, and depression, all of which can adversely maternal and newborn health (Tsai, 2021). Given that over half of pregnancy-related deaths occur in the 12-month postpartum period, and significant disparities persist, especially affecting Black and American Indian/Alaska Native individuals, this option addresses a critical healthcare need (Tsai, 2021).

It is also important to note that Black and American Indian/Alaska Native individuals face higher risks of pregnancy-related complications and preventable deaths, emphasizing the urgency of addressing these disparities. Furthermore, lingering disparities in postpartum follow-up care rates for several conditions that are associated with morbidity and mortality underscore the importance of this extended postpartum coverage option in promoting equitable access to healthcare resources (Tsai, 2021). In other words, equity in healthcare demands the universal availability of a full year of postpartum Medicaid coverage.

At present, a number of pregnant individuals qualify for Medicaid based on their pregnancy, falling under the eligibility group outlined at 42 C.F.R. § 435.116. In the alternative, pregnant women may be eligible for a one-year extension based on different grounds, such as already being a parent or caretaker relative, or based on their disability status (Tsai, 2021). States also have the flexibility to extend coverage to lawfully residing pregnant women and children, provided they meet the eligibility criteria under the state’s program, typically known as the CHIPRA 214 option. Pursuant to current regulations, pregnant Medicaid beneficiaries maintain eligibility for pregnancy-related services under the state plan until the conclusion of the month in which the 60-day period, starting from the last day of pregnancy, concludes (this is referred to as the “60-day postpartum period”). This continuous eligibility persists throughout the entire 60-day postpartum period, unaffected by changes in income that would typically result in a loss of eligibility (Tsai, 2021).

This mish-mash of Medicaid coverage options, though, does ineligible women in Alabama, Florida, Georgia, Kansas, Mississippi, North Carolina, Tennessee, Texas, Wisconsin and Wyoming, a major disservice (Medicaid Postpartum Coverage Extension Tracker, 2023). For example, the findings that emerged from a study by Boundy et al. (2023) can help improve the understanding of public awareness in the U.S. regarding the maternal health benefits of breastfeeding. The findings of the Bondy et al. (2023) study can enhance public awareness in ways that may persuade political leaders of the need for universally extending Medicaid postpartum care to one full year. For example, data from the 2018 and 2021 surveys were analyzed to investigate American public beliefs regarding specific maternal benefits associated with breastfeeding.

Similar to the findings in 2018, the 2021 data revealed a relatively low percentage of respondents who believed that breastfeeding provides protection to the mother against breast cancer (23.9%), high blood pressure (15.5%), or type 2 diabetes (15.4%). The analysis further indicated that male, older, and unmarried respondents were less likely to believe in these protective effects. The study suggests that increasing public awareness of the maternal benefits of breastfeeding could potentially boost demand for programs and policies that support breastfeeding, including Medicaid postpartum coverage (Boundy et al., 2023).

Taken together, it is clear that extending Medicaid coverage for one full year postpartum is a highly cost-effective short- and long-term, evidence-based approach to improving maternal and infant health. Not only can new mothers impart critical nutrients and antibodies that are specific to babies’ needs, the breastfeeding experience establishes a lifelong bond during this formative period in young people’s lives. Although there are some avenues available for certain states to apply for a Medicaid extension for their constituents, the multiple benefits that accrue to breastfeeding strongly support making this extension universally available. In sum, breastfeeding is superior to all other forms of infant nutrition and the price is right.