States extend Medicaid for new mothers — even as they reject broader expansion

Until last year, Georgia's Medicaid coverage for new moms with low incomes lasted 60 days.

That meant the Medicaid benefits of many women expired before they could be referred to other medical providers for help with serious health problems, said Dr. Keila Brown, an OB-GYN in Atlanta. "If they needed other postpartum issues followed up, it was rather difficult to get them in within that finite period of time," said Brown, who works at the Family Health Centers of Georgia, a group of community health centers.

Georgia lawmakers, recognizing the state's high rate of pregnancy-related deaths, have taken action. In 2021, Georgia extended the Medicaid coverage window to six months postpartum. And, now, the state plans to broaden that benefits period to a year.

Georgia is one of a dozen states that have opted not to fully expand Medicaid — the federal-state health insurance program for people with low incomes or disabilities — under the Affordable Care Act. But nine of those states, mostly in the South, have sought or plan to seek an extension of postpartum Medicaid coverage, in many cases to a full year after a birth.

Some took advantage of a provision of the American Rescue Plan Act that allows states to extend coverage using a Medicaid state plan amendment, an easier path than applying for a federal waiver. The option is currently available to states only until March 31, 2027.

The extensions have political overtones. Some maternal health advocates say the new postpartum benefits could open the door to Medicaid expansion in some states. But other advocates say the extensions provide cover to lawmakers who don't want to fully expand Medicaid, which would give longer-lasting insurance coverage to these low-income women and others.

Lawmakers, physicians, and patient advocates point to high rates of maternal mortality as a reason to extend maternity coverage — as well as the positive impacts it could have on women's health generally.

Maternal health is on the mind of policy analysts, doctors, and advocates because the U.S. Supreme Court seems poised to upend abortion policy nationwide. States across the country, many of them in the South, have plans to restrict access to abortion if the court overturns its 1973 Roe v. Wade decision, which established the right to an abortion. New limits on abortion access could mean an increase in the number of women who continue their pregnancies and need postpartum care.

Nearly 2 in 3 pregnancy-related deaths are preventable, and 1 in 3 happen one week to one year after delivery, according to the Centers for Disease Control and Prevention. Many of these deaths are associated with chronic health conditions, and Black and Indigenous women are more likely to die than white women.

Medicaid pays for an estimated 42% of U.S. births, so health advocates suggest that expanding the insurance program to reach more mothers for longer would improve maternal health and save more lives.

A recent report on maternal mortality from Tennessee's health department linked many maternal deaths to substance use disorder, mental health conditions, and heart disease. A year of continuous Medicaid coverage could help mothers address those problems, said Dr. Nikki Zite, an OB-GYN in Knoxville.

The state's extension of coverage from 60 days to one year officially started April 1.

"You can't solve all problems in a year, but I think you can get a much better grasp of control on some of these problems in a year than you could in six to eight weeks — especially when that six to eight weeks was pretty much dominated by new infant care," Zite said.

Policy experts say the move to a year of postpartum Medicaid coverage, while important, solves only one part of the maternal health puzzle.

"A lot of these are conditions — for example, hypertension, cardiovascular conditions — which need to be addressed before a woman gets pregnant," said Joan Alker, a research professor at the Georgetown University McCourt School of Public Policy.

And women, whether they're pregnant or new mothers, can more easily get treatment for those conditions in Medicaid expansion states, Alker said. A 2020 study found that mothers in the states that had expanded Medicaid coverage had better health outcomes than those in non-expansion states.

Dr. Bonzo Reddick, a family practice doctor in Savannah, Georgia, said Medicaid expansion also reduces demand for abortion. "How you can prevent a lot of abortions is by having contraception available to people," he said.

For now, states must continue Medicaid coverage until the covid-related public health emergency ends, so women currently enrolled aren't falling through the cracks.

In a 2021 issue brief, federal health researchers said about 20% of people with pregnancy-related Medicaid become uninsured within six months of giving birth, including in states that have fully expanded Medicaid. The percentage is nearly double in non-expansion states.

That drop-off in coverage is why states as politically diverse as California, Oregon, Kentucky, Ohio, and Louisiana — all states that have expanded Medicaid — have instituted the 12-month maternal coverage extension. As many as 720,000 women across the country would qualify if all states adopted the longer coverage, according to a federal estimate.

There's some talk that the postpartum extensions might lead non-expansion states to take the next step. "In states that have taken up the extension, you’re building the political will and the momentum to get to a Medicaid expansion point," said Taylor Platt, a health policy researcher with the American College of Obstetricians and Gynecologists.

But some health care officials are wary of reading too much into the popularity of the benefits extension.

"Postpartum moms are a group that politicians of any stripe are going to have an interest in supporting," said Christian Soura, executive vice president of the South Carolina Hospital Association. Extending postpartum coverage might complicate efforts to get South Carolina lawmakers to fully expand Medicaid, Soura said. Peeling away a small, uncontroversial group for a coverage extension leaves what he called the "least politically sympathetic" groups uncovered.

Republican state lawmakers who pushed for the postpartum extension in other states say they encountered considerable resistance from some members of their party.

"There are those that absolutely do not want to expand Medicaid in any form or fashion in the state," said Republican state Rep. Debbie Wood of Alabama. Wood said she supported legislation that would have permanently extended postpartum coverage in Alabama from 60 days to a full year. The bill didn't pass, but lawmakers ended up putting $4 million in the state budget for a pilot program instead.

In Georgia, extending postpartum coverage took years of work and behind-the-scenes lobbying of fellow Republicans, said state Rep. Sharon Cooper, who pushed for the change. "In a perfect world, everybody would have some form of health insurance one way or the other. But this is not a perfect world," said Cooper, who chairs a House health care committee. "And if a year is what I’ve got, I’ll take a year."

Some states that haven't expanded Medicaid — such as Wyoming, South Dakota, and Mississippi — don't have the political will to extend postpartum care. "We've been very clear we're just not for Medicaid expansion," Mississippi House Speaker Philip Gunn recently told Mississippi Public Broadcasting. "This is arguably Medicaid expansion, certainly expanding coverage."

More work needs to be done to buttress coverage during the postpartum period, maternal health advocates said. They would like to see the fast-track extension option made available beyond 2027 and one year of coverage for new moms become a permanent requirement for all states.