How expanding postpartum Medicaid coverage could affect providers and health plans

Amid ongoing debate over Congressional Democrats’ roughly $ 2 trillion social spending bill, newly available data suggests a policy proposal is under the radar could have a big impact on U.S. medical costs, health care providers, insurers and others providing services to a particular group of patients: new mothers.

The measure would extend pregnancy-related Medicaid coverage to a full year after childbirth, up from the 60-day window currently required at the federal level, and estimate 123,000 women newly eligible for insurance. Advocates have long billed 12 months of postpartum coverage as the key to improving maternal outcomes, reducing racial disparities, helping women transition from pregnancy care to primary care, and ensuring they receive specialist support in when needed, such as mental health problems or chronic illnesses.

Two recent analyzes indicate how the policy change could affect health care: In 2020, women receiving charitable care, which usually means they are uninsured, experienced a rate of severe maternal morbidity or complications. serious, 73% higher than those with private insurance, according to data from Premier Inc., a hospital supplies purchasing company.

Meanwhile, maternal complications cost the U.S. healthcare system an estimated $ 18.7 billion in medical bills in 2019, The Commonwealth Fund valued. Mental health issues were the costliest issue under that umbrella of maternal morbidity that year, with medical bills estimated at nearly $ 7 billion.

Uninsured women have the highest rate of serious pregnancy complications

Severe maternal morbidity rate per 10,000 deliveries, by payer status

Earlier this year, Congress gave states the temporary option to extend their postpartum Medicaid coverage up to 12 months, and some states have already decided to do so, including just Virginia Last week. A federally mandated policy, however, would cost around $ 1,500 per person in 2022, and increase direct Medicaid spending by $ 6.1 billion through 2030, according to the Congressional Budget Office.

Despite this, senior health officials in the Biden administration are backing the policy, with Chiquita Brooks-LaSure, head of the Centers for Medicare and Medicaid Services, saying Virginia’s decision “will expand access to coverage and life-saving postpartum care.”

With more coverage, providers will offer less unpaid care

The policy change would also bring both opportunities and challenges for those working to address maternal health issues before they reach a crisis level. Accept payment: Medicaid pays providers less than private insurance, and in February, the Kaiser Family Foundation found that 90% of obstetricians-gynecologists said Medicaid’s lower reimbursement rates were a challenge for their practices.

Even so, “there is a portion of providers who provided care to uninsured new mothers,” said Emily Johnston, senior research associate at the Urban Institute focusing on maternal health and insurance. “There is a sizable group of providers who will benefit because they will be able to bill Medicaid. “

This could be particularly significant in the 12 states that have chosen not to extend Medicaid coverage to more low-income adults through the Affordable Care Act. While the Build Back Better plan would close the alleged coverage gap in states without expansion, these provisions would expire. in 2025.

Louisiana, which expanded Medicaid in 2016, offers clues as to how increased coverage for low-income patients, including new mothers, is affecting the performance of safety net providers.

Dr Gary Wiltz, executive director of the Teche Action Clinic, a network of community health centers in rural Louisiana, said that before the expansion, clinicians frequently provided discounted services to pregnant women and postpartum uninsured, an “unsustainable model”. Now, with more women covered by insurance, clinics are being paid for this care, which helps them keep running and allows staff to follow up patients more regularly over time.

“Many of these women are not just pregnant; they need to have their cholesterol or blood pressure monitored, ”said Wiltz. “They are in excellent condition to have long-term continuity of comprehensive care. “

A timely example: Getting new mothers vaccinated against COVID-19, given that many pregnant women have hesitated and vaccination rates are “woefully low,” Wiltz said.

Connection with specialists, awareness are challenges

Meanwhile, Rachel Gandell Tetlow, director of federal affairs at the American College of Obstetricians and Gynecologists, stressed that OBGYNs and other primary care physicians should not be the only clinicians involved in continuing postpartum care. Instead, she said, there are “a number of healthcare professionals who can take responsibility for patient care within 12 months of childbirth and beyond.”

Yet coordinating postpartum care can be easier said than done. In the KFF survey, about 3 in 4 OBGYNs said they had difficulty finding specialists to accept referrals from Medicaid patients.

“I am concerned about access to specialist care,” said Johnston. “Accessing mental health services can be very difficult in general, and especially for people covered by Medicaid. “

Maternal morbidity linked to more than $ 18 billion in medical costs in 2019

Estimates of medical costs related to maternal morbidity in 2019 in millions of dollars, from conception to the child’s fifth birthday

If postpartum coverage extensions go into effect, health plans that contract with state Medicaid programs may also need to step up outreach efforts to ensure women know they will not lose coverage. 60 days after childbirth.

“Because we have such an engagement with new moms, we hope there will be many more opportunities to educate, educate and keep them enrolled,” said Craig Kennedy, President and CEO of Medicaid. Health Plans of America, which represents care managed by Medicaid. industry.

At least one insurer, CVS Health Corp.’s Aetna, is already considering how the policy would affect its efforts. Dr Heidi Schwarzwald, deputy chief medical officer of Aetna’s Medicaid program, said the insurer was already caring for limbs during pregnancy and childbirth, and more stable postpartum coverage “would support our work. to stay in touch with our members, ”including through an initiative that helps them access mental health, breastfeeding, diabetes and hypertension services.

Meanwhile, health tech startups like Cityblock Health Inc., which provides primary care to Medicaid patients, are showing that it is possible to quickly increase awareness and connect people to services. At the start of the COVID-19 pandemic, the group used claims data to reach members in New York who were pregnant or who had recently given birth, identify gaps in their care and develop telehealth-focused offerings for childbirth preparation, behavioral health, breastfeeding support and more Again.

28% of uninsured new mothers may be eligible for Medicaid as part of the postpartum coverage plan

There are approximately 440,000 uninsured new mothers in the United States

The share of uninsured new mothers who may be eligible for coverage currently and under a proposed 12-month postpartum Medicaid extension

Coverage isn’t the only obstacle to better results

Yet even if Congress mandates 12 months of coverage for low-income mothers, it will not resolve all barriers to postpartum care. Premier data shows that the rate of severe maternal morbidity was still 35% higher among women on Medicaid than among those with private coverage in 2020.

This is not true everywhere. Among black women’s deliveries, the rate of severe maternal morbidity is the same for those covered by Medicaid and commercial insurance, according to a 2020 study cited by the Aspen Institute.

Racial disparities and the role of systemic racism in maternal health outcomes have been well documented, with black women being much more likely than white women to die from pregnancy-related problems. Those gaps persist according to age and level of education.

Johnston notes that factors unrelated to coverage play a role in maternal outcomes, including whether pregnant women and new mothers take time off work, childcare or transportation to see a doctor.

She said it was essential to “move the conversation beyond coverage of the postpartum period, to really start thinking about access and use.”

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