ISSUE BRIEF JANUARY 2021 Closing Gaps in Maternal Health Coverage: Assessing the Potential of a Postpartum Medicaid/CHIP Extension Jennifer Haley Emily M. Johnston Research Associate Senior Research Associate Health Policy Center Health Policy Center Urban Institute Urban Institute HIGHLIGHTS TOPLINES Our current system of publicly supported coverage The postpartum period a options for pregnant and postpartum women is a complex growing focus of efforts to address the U.S. maternal patchwork that varies tremendously by income, immigration mortality crisis. status, and state, leaving many new mothers uninsured. Extending Medicaid and CHIP Approximately 123,000 of the nation’s estimated 440,000 coverage related to pregnancy women uninsured during the first year postpartum would for 12 months postpartum would likely be newly eligible for Medicaid or the Children’s Health expand access to needed health Insurance Program (CHIP) if pregnancy-related coverage care during a critical period. were extended for 12 months. Together with existing Medicaid and marketplace coverage, such an extension would mean that 70 percent of uninsured women would likely be eligible for some type of publicly subsidized coverage during the postpartum period. Extending pregnancy-related Medicaid/CHIP coverage for 12 months postpartum could increase the number of Americans with insurance during the postpartum period while expanding access to needed health care. Closing Gaps in Maternal Health Coverage: Assessing the Potential of a Postpartum Medicaid/CHIP Extension2 INTRODUCTION access to care, especially during periods without The United States is in the midst of a maternal morbidity insurance. and mortality crisis. An estimated 700 women* in the The Affordable Care Act’s major coverage provisions, United States die each year from pregnancy-related including Medicaid expansion and premium tax credits causes, and many more experience severe maternal for marketplace coverage available since 2014, expanded morbidity.1 Moreover, there are wide racial and ethnic coverage options for women, including those losing disparities in maternal outcomes, with Black and pregnancy-related Medicaid/CHIP coverage postpartum. American Indian/Alaska Native women experiencing These coverage provisions were associated with lower much higher rates of pregnancy-related mortality and uninsured rates and improved access to care for women of morbidity than other groups.2 reproductive age.7 Medicaid expansion, specifically, was The postpartum period is a growing focus of efforts associated with coverage gains among new mothers that to address this crisis. Sometimes referred to as the would be expected to improve their health care access and “fourth trimester,” it is a time of extensive physical and contribute to health gains.8 These increases in coverage emotional change for mothers as they recover from also reduced coverage disparities for Black and Hispanic delivery and adjust to life with a newborn — and it can new mothers.9 be a precarious time for mothers’ health. 3 More than Despite the coverage gains the ACA achieved, an estimated half of pregnancy-related deaths occur after delivery: 40 11.5 percent of new mothers remained uninsured during the percent occur 1 to 42 days postpartum and 11.7 percent 2015–18 period, with rates even higher in some states.10 from 43 to 365 days postpartum nationally, with even higher rates in some states.4 This issue brief assesses the current coverage landscape for pregnant and postpartum women and shows how The good news is that more than half of pregnancy-related a postpartum Medicaid/CHIP extension could benefit mortality overall and during the postpartum period is uninsured new mothers. We: considered preventable.5 This suggests that improvements to health coverage and care — including services that • provide an overview of existing publicly subsidized address physical, mental, reproductive, and behavioral coverage options for pregnancy and the postpartum health needs — can help reduce mortality rates. Meeting period, including covered benefits and cost-sharing these needs has become even more critical during the requirements COVID-19 pandemic and economic crisis. • review recent state and federal legislative proposals There is substantial evidence pointing to the importance to extend postpartum coverage options and examine of insurance coverage during the postpartum period.6 how such reforms could expand the coverage Although nearly all new mothers are covered by health landscape for new mothers insurance at the time of delivery, pregnancy-related coverage through Medicaid and the Children’s Health • estimate how many postpartum individuals would Insurance Program (CHIP) expires just 60 days after the likely benefit from a 12-month postpartum Medicaid/ end of pregnancy. Research indicates that more than half CHIP extension, based on analysis of 2016–18 of women who had Medicaid or CHIP coverage at delivery American Community Survey (ACS) data using the experienced “churn” — moving in and out of coverage — Urban Institute Health Policy Center’s Medicaid/CHIP in the following six months, which would likely reduce Eligibility Simulation Model. * In this analysis, we use “women” and “mothers” to describe people who are pregnant or recently gave birth. We use these terms to align with the language in the Social Security Act, which defines Medicaid eligibility for pregnant and postpartum women. However, we acknowledge that not all people who become pregnant or give birth identify as women. commonwealthfund.org Issue Brief, January 2021 Closing Gaps in Maternal Health Coverage: Assessing the Potential of a Postpartum Medicaid/CHIP Extension3 OVERVIEW OF PUBLIC COVERAGE OPTIONS FPL in Idaho, Louisiana, Oklahoma, and South Dakota to FOR PREGNANT AND POSTPARTUM WOMEN 380 percent in Iowa (Exhibit 1). Federal rules require states to offer Medicaid to pregnant Pregnancy-related coverage is federally required to cover women with incomes up to at least 138 percent of the only broadly defined services. Most states, however, include federal poverty level (FPL).11 States can set income comprehensive benefits in pregnancy-related Medicaid/ thresholds above this minimum, and many extend CHIP coverage, including the full range of nonpregnancy- eligibility to higher levels through Medicaid or CHIP.12 related health care services, with minimal cost-sharing. In most states, Medicaid/CHIP eligibility during pregnancy is more generous than it is for nonpregnant The 60-Day Cutoff and Postpartum Coverage Gaps women. The median state income threshold to qualify Pregnancy-related Medicaid/CHIP coverage, however, expires for pregnancy-related Medicaid/CHIP coverage in 2020 is about 60 days following the end of pregnancy. At that 205 percent of the federal poverty level (FPL) nationwide, point, new mothers are subject to their state’s regular well above the median Medicaid income threshold for Medicaid income eligibility thresholds for parents or nonpregnant adults (138% of FPL). Pregnancy-related adults, which are typically lower than pregnancy-related eligibility ranges widely across states, from 138 percent of thresholds. Exhibit 1 Pregnancy-Related Exhibit Medicaid/CHIP 1. Pregnancy-Related Income Medicaid/CHIP Eligibility Income Thresholds, Eligibility Thresholds, as as aa Share Shareof ofthe theFederal FederalLevel, Poverty Poverty Level,2020 by State, by State, 2020 150% 200% 250% 300% Notes: CHIP Notes: CHIP= Children’s Health Insurance = Children’s HealthProgram; InsuranceFPL = federal povertyFPL Program; level. = Thresholds federalreflect poverty income eligibility level. limits for pregnant Thresholds women reflect who meet income Medicaid/CHIP eligibility limitsimmigration status requirements. for pregnant women who Coverage meet is comprehensive in all states except Arkansas, New Mexico, North Carolina, and South Dakota, where benefits are limited to pregnancy-related services. Medicaid/CHIP immigration status requirements. Coverage is comprehensive in all states except Arkansas, New Mexico, North Carolina, Data: Tricia Brooks et al., Medicaid and CHIP Eligibility, Enrollment, and Cost Sharing Policies as of January 2020: Findings from a 50-State Survey (Henry J. Kaiser Family Foundation, Mar. 2020). and South Dakota, where benefits are limited to pregnancy-related services. Data: Tricia Brooks et al., Medicaid and Source: CHIP Haley Jennifer Eligibility, Enrollment, and Emily M. Johnston,and Cost-Sharing Closing Policies Gaps in Maternal asCoverage: Health of January 2020: the Assessing Findings from Potential of a a 50-StateMedicaid/CHIP Postpartum Survey (Henry J. Kaiser Family Foundation, Mar. 2020).Extension (Commonwealth Fund, Jan. 2021). commonwealthfund.org Issue Brief, January 2021 Closing Gaps in Maternal Health Coverage: Assessing the Potential of a Postpartum Medicaid/CHIP Extension4 Exhibit 2 summarizes Medicaid eligibility thresholds for to subsidize the purchase of insurance on the federal or parents after pregnancy-related eligibility expires in 2020. state-based marketplaces. Marketplace plans must cover (These apply to citizens and lawfully residing immigrant essential health benefits, including delivery, comprehensive postpartum women with more than five years’ residency perinatal and postpartum care, and family planning. But after pregnancy-related eligibility expires; for more detail these plans generally have higher cost-sharing and offer on variation in eligibility according to immigration less financial protection than Medicaid or CHIP, which status, see here). The exhibit illustrates how low income may pose a barrier to enrollment among women eligible eligibility thresholds are for traditional Medicaid relative for marketplace coverage. In most states, pregnancy is not to pregnancy-related Medicaid in most states: 138 percent a qualification for a special enrollment period outside of of FPL in states adopting the ACA’s Medicaid expansion, annual open enrollment, but the birth of a child or the and below 100 percent of FPL (and most often below 50 loss of pregnancy-related coverage are qualifications. Most notably, new mothers in all nonexpansion states except percent of FPL) in nonexpansion states. Wisconsin who have incomes higher than their parental Some postpartum women who have family incomes Medicaid thresholds, but below 100 percent of FPL, are in between 100 percent and 400 percent of FPL and are not a “coverage gap” and ineligible for marketplace subsidies, eligible for Medicaid may qualify for premium tax credits with no affordable coverage options. Exhibit 2 Income Eligibility Thresholds for Publicly Subsidized Coverage Options for Citizen and Certain Exhibit 2.Lawfully Residing Income Eligibility Noncitizen Thresholds New Mothers for Publicly Under Subsidized Current Coverage Rules, Options by State, for Citizen and2020 Certain Lawfully Residing Noncitizen New Mothers Under Current Rules, by State, 2020 Share of FPL ACA-Expansion Medicaid Traditional Medicaid Basic Health Program 400% 350% 300% 250% 200% 150% 100% 50% 0% Alaska Arkansas Tennessee Arizona Illinois Maine Massachusetts Pennsylvania Washington Vermont South Dakota Florida Mississippi Alabama District of Columbia Minnesota Colorado Delaware Nebraska Iowa Montana New Mexico Wisconsin North Carolina Texas New York Indiana Idaho Kentucky Maryland New Jersey North Dakota Oregon Virginia West Virginia Connecticut Kansas California Hawaii Michigan Ohio Louisiana Nevada New Hampshire Rhode Island Utah South Carolina Wyoming Oklahoma Georgia Missouri Notes: ACA = Affordable Care Act; FPL = federal poverty level. Certain lawfully residing noncitizens are those with five or more years’ residency. New mothers gave birth 2 to 12 months ago. The exhibit shows parental Medicaid thresholds under 2020 rules. Thresholds do not include higher income limits available for pregnancy-related Medicaid eligibility within the first 60 days after the end of pregnancy. The shaded area indicates income range for subsidized Notes: ACA marketplace coverage.Care = Affordable Families in the Act; income FPL range forpoverty = federal both Medicaid andCertain level. marketplace coverageresiding lawfully are ineligible for marketplace noncitizens coverage. are thoseSomewithnew mothers five may qualify or more years’forresidency. limited family-planning benefits, but New mothers because this is not comprehensive coverage, it is not included here. Medicaid expansion states also offer traditional Medicaid at lower income levels than their ACA expansion levels (not shown). In Texas, most immigrants gave birth 2 to 12 months ago. The exhibit shows parental Medicaid thresholds under 2020 rules. Thresholds do not include higher income limits available legally present for more than five years are ineligible for Medicaid. The Basic Health Program reduces premiums and out-of-pocket cost-sharing for those eligible for marketplace coverage with incomes below 200 percent for of pregnancy-related Medicaid eligibility within the first 60 days after the end of pregnancy. The shaded area indicates income range for subsidized marketplace FPL. coverage. Data: Families Tricia Brooks in theand et al., Medicaid income rangeEnrollment, CHIP Eligibility, for bothand Medicaid and Cost Sharing marketplace Policies coverage as of January 2020: Findingsare fromineligible for marketplace a 50-State Survey coverage. (Henry J. Kaiser Family Some Foundation, Mar. new 2020).mothers may qualify for limited family-planning benefits, but because this is not comprehensive coverage, it is not included here. Medicaid expansion states also offer traditional Medicaid at lower income levels thanJennifer Source: their ACA expansion Haley levels and Emily M. (notClosing Johnston, shown). IninTexas, Gaps most Maternal immigrants Health legally present Coverage: Assessing for more the Potential than five Medicaid/CHIP of a Postpartum years are ineligible for Medicaid. The Basic HealthExtension Program(Commonwealth reduces premiums and Fund, Jan. out-of-pocket cost-sharing for those eligible for marketplace coverage with incomes below 200 2021). percent of FPL. Data: Tricia Brooks et al., Medicaid and CHIP Eligibility, Enrollment, and Cost-Sharing Policies as of January 2020: Findings from a 50-State Survey (Henry J. Kaiser Family Foundation, Mar. 2020). commonwealthfund.org Issue Brief, January 2021 Closing Gaps in Maternal Health Coverage: Assessing the Potential of a Postpartum Medicaid/CHIP Extension5 BENEFITS OF EXTENDING MEDICAID/CHIP COVERAGE FOR 12 MONTHS POSTPARTUM FEDERAL AND STATE EFFORTS TO Policymakers at both the federal and state levels have EXTEND POSTPARTUM MEDICAID/ proposed extending pregnancy-related Medicaid/CHIP CHIP COVERAGE coverage from 60 days to 12 months postpartum as an In 2019 and 2020, five federal bills were proposed efficient, targeted way to give many postpartum women to extend Medicaid/CHIP coverage for 12 months a new coverage option (see box for a summary of these continuously following the end of pregnancy, proposals). Such an extension would allow for continuous reflecting various approaches to financing and coverage during the first year after delivery and could required state actions. The Helping Medicaid Offer foster greater continuity of care. Maternity Services (Helping MOMS) Act of 2019 (H.R. 4996), which would allow states to adopt an Exhibit 3 illustrates how much new mothers’ eligibility extension without requiring a federal waiver, was for Medicaid/CHIP could change if states extended approved by the U.S. House of Representatives in pregnancy-related Medicaid/CHIP from 60 days to 12 September 2020 but was not considered by the months postpartum. Senate. The effects of a 12-month postpartum extension such as Meanwhile, nearly half of states have explored that proposed in the Helping MOMS Act, which was under postpartum Medicaid/CHIP extensions in 2019 and consideration by the 116th Congress, assuming adoption 2020. Most proposals would use Section 1115 waiver of the extension option in every state can be summarized authority under the Social Security Act to obtain joint as follows: federal and state funding for coverage extensions, requiring review and approval of waiver applications • Medicaid/CHIP eligibility for new mothers would by the Centers for Medicare and Medicaid Services continue at the higher pregnancy-related level for (CMS). Others would be financed using only state funds 10 additional months, effectively increasing upper and would not need CMS approval. And although most income limits as a share of FPL in nearly every state. proposals would extend Medicaid/CHIP coverage Thresholds would rise from 97 percentage points to for a full year postpartum for all new mothers with 206 percentage points in nonexpansion states and by pregnancy-related Medicaid/CHIP (similar to the 6 to 242 percentage points in 34 of the 36 expansion federal proposals), some states have considered shorter states. (As currently proposed, eligibility for new extensions of six months or limited proposed extensions mothers would not change in Idaho and Louisiana, to targeted groups. which cover pregnant women at the same income Very few states have yet implemented postpartum level as nonpregnant women.) extensions. California’s 12-month postpartum extension • New mothers who already meet the requirements for women with maternal mental health conditions for Medicaid coverage as parents would likely have was briefly delayed because of the pandemic and greater consistency in their providers and continuity implemented in August 2020, and Texas implemented in their care. That is because they would qualify for a limited extension in September 2020, by adding one year of selected postpartum services for Healthy Texas 12-month continuous coverage even if their income Women enrollees. Though several states have Section fluctuates throughout the year. 1115 waivers to extend Medicaid/CHIP for some or all • In states that have not expanded Medicaid under postpartum women currently under review by CMS, or the ACA, a 12-month postpartum extension have considered or passed legislation to apply for such would temporarily eliminate the coverage gap for waivers, it is unclear whether and under what conditions postpartum women with incomes above the parental CMS will approve state efforts to extend Medicaid/CHIP. Medicaid threshold and below 100 percent of FPL. commonwealthfund.org Issue Brief, January 2021 Closing Gaps in Maternal Health Coverage: Assessing the Potential of a Postpartum Medicaid/CHIP Extension6 Exhibit 3 Exhibit 3.Eligibility Income Income Eligibility Thresholds Thresholds for Publicly for Publicly SubsidizedCoverage Subsidized Coverage Options Optionsforfor New Mothers New Mothers Under Postpartum Medicaid/CHIP Extension, by State and Program Type, Under Postpartum Medicaid/CHIP Extension, by State and Program Type, 2020 2020 Increase in Medicaid/CHIP eligibility under 12-month postpartum extension Basic Health Program Share of FPL Traditional Medicaid ACA-Expansion Medicaid 400% 350% 300% 250% 200% 150% 100% 50% 0% Wisconsin* Tennessee Alaska Arizona California* Hawaii* Illinois South Carolina* South Dakota Florida Mississippi Alabama New York* Connecticut* Maine* Montana Pennsylvania* Texas District of Columbia* Iowa New Jersey* New Mexico* Nebraska* Minnesota* Indiana Delaware* Colorado* Idaho Kentucky North Dakota Oregon Washington* North Carolina* Kansas Maryland* Michigan Arkansas* Rhode Island Utah Vermont* Virginia* West Virginia* Louisiana Massachusetts* Nevada New Hampshire Ohio* Wyoming* Oklahoma Georgia Missouri Notes: ACA = Affordable Care Act; CHIP = Children’s Health Insurance Program; FPL = federal poverty level. These coverage options are available to citizen and lawfully residing noncitizen (more than five years’ residency) new Notes:(2ACA mothers to 12=months Affordableafter theCare end ofAct; CHIPunder pregnancy) = Children’s Health current rules Insurance and proposed 12-month Program; postpartumFPL = federalextension. Medicaid/CHIP povertyThe level. These shaded coverage area indicates options the income rangeare for available to citizencoverage. subsidized marketplace and lawfully Families residing in the noncitizen income range (more and for both Medicaid than five years’ marketplace residency) coverage new are ineligible formothers marketplace(2coverage. to 12 months afterparental All states extend the end of pregnancy) coverage to citizens andunder current legally present rules and noncitizens withproposed 12-month more than five years’ residency. Expansion states are shown on the left side of the figure, and nonexpansion states are shown on the right, using state expansion status as of January 2020. The Basic Health Program reduces premiums and out-of- postpartum Medicaid/CHIP extension. The shaded area indicates the income range for subsidized marketplace coverage. Families in the income pocket cost-sharing for those eligible for marketplace coverage with incomes below 200 percent of FPL. Some new mothers may qualify for limited family planning benefits, but because this is not comprehensive coverage,range for both it Medicaid is not included andhere.marketplace coverage are ineligible for marketplace coverage. All states extend parental coverage to citizens and legally present noncitizens with *more than Indicates statefive also years’ residency. covers legally Expansion present noncitizen states pregnant arewith women shown fewer on thanthe left side five years’ of the residency figure, and nonexpansion in pregnancy-related Medicaid/CHIP. states are shown on the right, using state expansion Data: Tricia status asBrooks et al., Medicaid of January 2020.and CHIP The Eligibility, Basic HealthEnrollment, Programand Cost Sharing Policies reduces premiums as of January and 2020: Findings fromcost-sharing out-of-pocket a 50-State Surveyfor (Henry thoseJ. Kaiser Family Foundation, eligible Mar. 2020).coverage with incomes for marketplace below 200 percent of FPL. Some new mothers may qualify for limited family planning benefits, but because this is not comprehensive coverage, it is not included here. Source: Jennifer Haley and Emily M. Johnston, Closing Gaps in Maternal Health Coverage: Assessing the Potential of a Postpartum Medicaid/CHIP Extension (Commonwealth Fund, Jan. 2021). * Indicates state also covers legally present noncitizen pregnant women with fewer than five years’ residency in pregnancy-related Medicaid/CHIP. Data: Tricia Brooks et al., Medicaid and CHIP Eligibility, Enrollment, and Cost-Sharing Policies as of January 2020: Findings from a 50-State Survey (Henry J. Kaiser Family Foundation, Mar. 2020). Medicaid/CHIP eligibility increases in these states HOW MANY PEOPLE WOULD BENEFIT FROM A are also larger, on average. But pregnant women in 12-MONTH POSTPARTUM EXTENSION? many expansion states also would experience large We assessed the extent to which new mothers who were increases in eligibility. uninsured in 2016–2018 could benefit from an extension of pregnancy-related Medicaid/CHIP eligibility for 12 • Some women who currently may qualify for months postpartum as well as from other subsidized marketplace coverage would gain Medicaid/ coverage options. To do so, we analyzed data from the CHIP eligibility. Because coverage provided under American Community Survey (ACS) from 2016–18, using Medicaid/CHIP would require lower cost-sharing, the Urban Institute Health Policy Center’s Medicaid/CHIP it would offer more financial protection than a Eligibility Simulation Model and 2020 eligibility policies.13 marketplace plan. (For complete study methods, see the Urban Institute brief, Closing Postpartum Coverage Gaps and Improving Continuity and Affordability of Care Through a Postpartum Medicaid/CHIP Extension.) commonwealthfund.org Issue Brief, January 2021 Closing Gaps in Maternal Health Coverage: Assessing the Potential of a Postpartum Medicaid/CHIP Extension7 According to the findings of our analysis, if pregnancy- Among the remaining 30 percent of uninsured new related Medicaid/CHIP were extended for 12 months mothers who would not be eligible for publicly postpartum: subsidized coverage with a postpartum Medicaid/ CHIP extension, 88 percent are noncitizens who • Approximately 70 percent of the nation’s estimated are barred from federally subsidized coverage. The 440,000 uninsured new mothers would likely be remaining small share are primarily citizen new eligible for some type of publicly subsidized coverage mothers with incomes above eligibility thresholds for (Exhibit 4). This includes an estimated: either extended postpartum Medicaid/CHIP coverage – 28 percent who would become newly eligible for or marketplace subsidies. Medicaid/CHIP through a postpartum extension • Gains in eligibility under a postpartum Medicaid/ (approximately 123,000 new mothers) CHIP extension would vary across subgroups of – 27 percent who are eligible for Medicaid under uninsured new mothers. For instance, 38 percent current policy but not enrolled of uninsured new mothers in states not expanding – 15 percent who would not be eligible for Medicaid/ Medicaid would likely gain eligibility, compared with CHIP under current policy or an extension just 13 percent in expansion states. And 39 percent of but could qualify for subsidized marketplace uninsured citizen new mothers would become newly coverage if they lack access to affordable employer- eligible, compared with just 8 percent who were not sponsored insurance. citizens. More than four in 10 uninsured new mothers Exhibit 4 Share and Number of New Mothers Uninsured Postpartum and Estimated to Be Eligible Exhibit for 4. Share and Subsidized NumberUnder Coverage of NewCurrent Mothers Uninsured EligibilityPostpartum Rules and and EstimatedPostpartum a 12-Month to Be Eligible for Subsidized Coverage Under Current Eligibility Rules and a 12-Month Postpartum Medicaid/CHIP Medicaid/CHIP Extension, 2016–18 Extension, 2016–18 Among 440,000 uninsured new mothers 30.3% 41.3% (182,000) (133,000) Not eligible for subsidized coverage 15.1% (67,000) Eligible for marketplace subsidies 32.1% (142,000) 27.9% (123,000) Potentially Medicaid/CHIP-eligible under postpartum extension Medicaid-eligible under current policy 26.6% (117,000) 26.6% (117,000) Without proposed postpartum extension With proposed postpartum extension Uninsured Notes: FPL = federal poverty level. CHIP = Children’s Health Insurance Program. New mothers are women who reported giving birth in the past 12 months. Notes: FPL = federal The sample poverty level. is limited CHIP = Children’s to mothers agesHealth 19 toInsurance Program. 44 without New mothers Medicare, are women who reported Supplemental SecuritygivingIncome, birth in theor past 12 months. active The sample military duty.is limited to mothers Coverage is atages the19time to 44 of without Medicare, survey and Supplemental Security Income, or active military duty. Coverage is at the time of survey and adjusted for potential misreporting. Mothers eligible for marketplace subsidies have incomes between 100 percent and 400 adjusted percent forwepotential of FPL; do not accountmisreporting. Mothers for whether a mother eligible has access for marketplace to affordable subsidies employer-sponsored have insurance. incomes Eligibility between categories 100 are mutually percent exclusive and 400 in hierarchy, withpercent of FPL;preceding Medicaid eligibility we do marketplace not account for whether eligibility. Mothersaineligible motherforhas access subsidized to affordable coverage are ineligibleemployer-sponsored insurance. for Medicaid and do not qualify for subsidizedEligibility marketplacecategories are mutually coverage. Annualized counts areexclusive in hierarchy, noted in parentheses withtoMedicaid and rounded eligibility the nearest 1,000. Data: Urban Institute preceding analysis of 2016–18 marketplace American eligibility. Community Mothers Survey data ineligible forand 2020 Medicaid subsidized eligibility rules. coverage are ineligible for Medicaid and do not qualify for subsidized marketplace coverage. Annualized counts are noted in parentheses and rounded to the nearest 1,000. Source: Data: Urban Institute analysis of Jennifer 2016–18 Haley andCommunity American Emily M. Johnston, Closing Survey Gaps data andin 2020 Maternal Health Coverage: Medicaid Assessing eligibility rules. the Potential of a Postpartum Medicaid/CHIP Extension (Commonwealth Fund, Jan. 2021). commonwealthfund.org Issue Brief, January 2021 Closing Gaps in Maternal Health Coverage: Assessing the Potential of a Postpartum Medicaid/CHIP Extension8 with incomes between 100 percent and 249 percent of and those who would retain coverage in the postpartum FPL would become newly eligible for Medicaid/CHIP period but who otherwise shift between coverage types under an extension. Furthermore, over one-third of (such as Medicaid and marketplace coverage or employer- non-Hispanic Black (36.5%) and non-Hispanic white sponsored insurance), or coverage pathways (such as (35.6%) uninsured new mothers, as well as about a pregnancy-related Medicaid and parental Medicaid). quarter of Hispanic new mothers would likely gain It would reduce the burdens on new mothers needing eligibility under a postpartum extension. to apply to maintain or obtain coverage or to switch • The number and share of new mothers likely to coverage while recovering from delivery, dealing with benefit would vary by state. Nearly two-thirds of complications related to pregnancy, and caring for their uninsured new mothers who would likely gain infants. And even if family income fluctuated, coverage eligibility through a postpartum extension reside in would remain intact for a full year. just five southern states: Florida, Georgia, Missouri, Postpartum Medicaid/CHIP extension also could improve North Carolina, and Texas. continuity of care and health outcomes. And it could have • The COVID-19 pandemic and resulting recession positive spillover effects on children — for example, by have likely changed access, coverage, and income increasing continuous coverage for infants during their patterns among new mothers. Our estimates of likely first year, supporting the mental and physical health of eligibility for a postpartum Medicaid/CHIP extension, new mothers and their ability to care for their infants, and based on insurance status and income reported in improving family financial security.14 2016–18, likely understate the potential benefit to new mothers in 2021. Other Federal and State Actions That Could Help DISCUSSION In addition to passing legislation to implement The nation’s current system of publicly supported coverage postpartum extension, the federal government has other options for pregnant and postpartum individuals is options to improve postpartum coverage options. For a complex patchwork that varies tremendously by instance, swift approval of current Section 1115 waiver income, immigration status, and state. Extending applications to implement state-level Medicaid/CHIP pregnancy-related Medicaid/CHIP coverage for 12 months postpartum extensions would expand coverage options in postpartum would simplify and streamline one piece of several states while federal legislation is being considered. this patchwork. Doing so would expand coverage options Of course, adoption of the ACA’s Medicaid expansion for many. We estimate that 28 percent of new mothers by states that have not yet expanded would offer the who were uninsured during the postpartum period — or most sweeping and dramatic improvement of coverage about 123,000 annually — would become eligible through options. Expanding Medicaid also would eliminate the a postpartum extension. Another 27 percent are likely coverage gap not only in the postpartum period but also already eligible for Medicaid but not enrolled. prepregnancy, which could improve mothers’ health Not only would many uninsured new mothers have a during pregnancy and beyond.15 Moreover, our finding new coverage option, but they could remain enrolled that many uninsured new mothers appear to already in the same coverage type they had during the prenatal qualify for Medicaid under current policy underscores and delivery period without a break or change in that that eligibility alone is insufficient to ensure continuous coverage. This continuity would benefit individuals who coverage, pointing to the importance of expanded would otherwise go uninsured after 60 days postpartum outreach and improved enrollment and retention systems. commonwealthfund.org Issue Brief, January 2021 Closing Gaps in Maternal Health Coverage: Assessing the Potential of a Postpartum Medicaid/CHIP Extension9 The large number of postpartum extension proposals in NOTES Congress and across states in recent years indicates strong 1.“Severe Maternal Morbidity in the United States,” interest in enacting postpartum Medicaid/CHIP coverage Centers for Disease Control and Prevention, updated extensions. Additional reforms that consider factors Jan. 31, 2020; and “Pregnancy Mortality Surveillance other than coverage that shape maternal health would System,” Centers for Disease Control and Prevention, also likely be needed to improve outcomes and address updated Nov. 25, 2020. Also see William M. Callaghan, inequities in the maternal health system more broadly. Andreea A. Creanga, and Elena V. Kuklina, “Severe For instance, the Black Maternal Health Momnibus Act Maternal Morbidity Among Delivery and Postpartum of 2020 was proposed to invest in social determinants of Hospitalizations in the United States,” Obstetrics and health, community-based organizations, data collection, Gynecology 120, no. 5 (Nov. 2012): 1029–36; Marian and maternal mental health care, as well as target specific F. MacDorman et al., “Is the United States Maternal groups of mothers, such as veterans and incarcerated Mortality Rate Increasing? Disentangling Trends from women.16 Measurement Issues,” Obstetrics and Gynecology 128, no. 3 (Sept. 2016): 447–55; and Emily E. Petersen et al., COVID-19 has impeded progress for some of these “Vital Signs: Pregnancy-Related Deaths, United States, initiatives and likely exacerbated racial inequities. At the 2011–2015, and Strategies for Prevention, 13 States, same time, however, the pandemic highlights the risks of 2013–2017,” Morbidity and Mortality Weekly Report inaction. To help address the nation’s maternal morbidity 68, no. 18 (May 10, 2019): 423–29. and mortality crisis, it is clear that, more than ever, we need policy solutions to ensure affordable, comprehensive, 2. Andreea A. Creanga et al., “Racial and Ethnic continuous coverage and access to care during the Disparities in Severe Maternal Morbidity: A Multistate postpartum period. Analysis, 2008–2010,” American Journal of Obstetrics and Gynecology 210, no. 5 (May 2014): 435 e1–e8; and Petersen et al., “Vital Signs,” 2019. 3.“The 4th Trimester Project,” University of North Carolina at Chapel Hill School of Social Work, Jordan Institute for Families, accessed Nov. 5, 2020. Also see ACOG (American College of Obstetricians and Gynecologists) Committee Opinion No. 736, “Optimizing Postpartum Care,” Obstetrics and Gynecology 131, no. 5 (May 2018): 949–51. 4. Petersen et al., “Vital Signs,” 2019; and Kristin P. Tully, Alison M. Stuebe, and Sarah B. Verbiest, “The Fourth Trimester: A Critical Transition Period with Unmet Maternal Health Needs,” American Journal of Obstetrics and Gynecology 217, no. 1 (July 2017): 37–41. 5. Petersen et al., “Vital Signs,” 2019; and CDC Foundation, Report from Nine Maternal Mortality Review Committees (CDC Foundation, 2018). commonwealthfund.org Issue Brief, January 2021 Closing Gaps in Maternal Health Coverage: Assessing the Potential of a Postpartum Medicaid/CHIP Extension10 6. Adam Searing and Donna Cohen Ross, Medicaid 11. The required minimum is 133 percent of FPL. Adding Expansion Fills Gaps in Maternal Health Coverage a standard 5-percentage-point income disregard, Leading to Healthier Mothers and Babies (Georgetown the effective minimum is 138 percent of FPL. Some University Health Policy Institute, Center for Children states’ mandated limits are higher, up to 185 percent and Families, May 2019). of FPL, based on their Aid to Families with Dependent Children income limits in 1988; see Amy Chen, 7. Jamie R. Daw and Benjamin D. Sommers, “The Pregnancy-Related Medicaid and Minimum Essential Affordable Care Act and Access to Care for Coverage (National Health Law Program, Jan. 2017). Reproductive-Aged and Pregnant Women in the Income eligibility is based on modified adjusted United States, 2010–2016,” American Journal of gross income for the family unit, which considers the Public Health 109, no. 4 (Apr. 2019): 565–71; Emily M. unborn child part of the unit size when determining Johnston et al., “Impacts of the Affordable Care Act’s income eligibility. Women applying for Medicaid/ Medicaid Expansion on Women of Reproductive CHIP who are pregnant at the time of application Age: Differences by Parental Status and State who fall below both the pregnancy-related income Policies,” Women’s Health Issues 28, no. 2 (Mar.-Apr. threshold and other eligibility thresholds would 2018): 122–29; Lois K. Lee et al., “Women’s Coverage, be enrolled in pregnancy-related Medicaid/CHIP; Utilization, Affordability, and Health after the ACA: A meanwhile, those already enrolled must be offered Review of the Literature,” Health Affairs 39, no. 3 (Mar. the option to either switch to pregnancy-related 2020): 387–94; and Claire E. Margerison et al., “Impacts Medicaid/CHIP or stay in that coverage. See Amy of Medicaid Expansion on Health Among Women of Chen and Emily Hayes, Q&A on Pregnant Women’s Reproductive Age,” American Journal of Preventive Coverage Under Medicaid and the ACA (National Medicine 58, no. 1 (Jan. 2020): 1–11. Health Law Program, Sept. 2018). 8. Daw and Sommers, “Affordable Care Act and Access,” 12. Tricia Brooks et al., Medicaid and CHIP Eligibility, 2018; Sarah H. Gordon et al., “Effects of Medicaid Enrollment, and Cost-Sharing Policies as of January Expansion on Postpartum Coverage and Outpatient 2020: Findings from a 50-State Survey (Henry J. Kaiser Utilization,” Health Affairs 39, no. 1 (Jan. 2020): 77–84; Family Foundation, Mar. 2020). Medicaid and CHIP Payment and Access Commission, Access in Brief: Pregnant Women and Medicaid 13. We applied January 2020 eligibility rules for (MACPAC, Nov. 2018); and Searing and Cohen Ross, pregnancy-related Medicaid/CHIP thresholds and Medicaid Expansion Fills, 2019. expansion Medicaid thresholds, including the four states that implemented the ACA’s Medicaid 9. Emily M. Johnston et al., Racial Disparities in expansion between 2018 and January 1, 2020: Idaho, Uninsurance among New Mothers Following the Maine, Utah, and Virginia. For nonexpansion states Affordable Care Act (Urban Institute, July 2019). and Connecticut (an expansion state with changing 10. Stacey McMorrow et al., Uninsured New Mothers’ eligibility thresholds), we applied 2016–2018 Health and Health Care Challenges Highlight the eligibility thresholds to the corresponding year. Benefits of Increasing Postpartum Medicaid Coverage Changes in the underlying coverage and income (Urban Institute, May 2020). distributions may have changed between 2016–2018 commonwealthfund.org Issue Brief, January 2021 Closing Gaps in Maternal Health Coverage: Assessing the Potential of a Postpartum Medicaid/CHIP Extension11 data and 2020 eligibility rules, especially in states ABOUT THE AUTHORS with large policy changes (e.g., adoption of the Jennifer Haley is a research associate in the Health Policy Medicaid expansion), and additional changes may Center at the Urban Institute, focusing on Medicaid, have occurred during the pandemic and associated the Children’s Health Insurance Program (CHIP), and recession. Both coverage and eligibility status are uninsurance among children and families. likely measured with error, such as error owing to misreporting of characteristics, disconnection across Emily M. Johnston is a senior research associate in time frames, and our inability to estimate eligibility the Health Policy Center. She studies health insurance for all available coverage pathways for adults under coverage, access to care, Medicaid policy, reproductive current law. Moreover, measurement error in health, and maternal and infant health with a focus on the estimating Medicaid eligibility under current law effects of state and federal policies on the health and well- appears larger in nonexpansion states, potentially being of women and their families. leading to overstating potential eligibility for 12-month postpartum Medicaid/CHIP among new ACKNOWLEDGMENTS mothers in nonexpansion states. See the appendix The authors thank the Urban Institute’s Ian Hill, of Closing Postpartum Coverage Gaps and Improving Genevieve M. Kenney, Stacey McMorrow, Clare Pan, Tyler Continuity and Affordability of Care Through a W. Thomas, and Robin Wang for their contributions to this Postpartum Medicaid/CHIP Extension for more detail issue brief, as well as the Commonwealth Fund’s Laurie on study data and methods. Zephyrin and Chris Hollander for helpful feedback and 14. Kay Johnson, Sara Rosenbaum, and and Morgan support. Handley, “The Next Steps to Advance Maternal and Child Health in Medicaid: Filling Gaps in Postpartum Editorial support was provided by Christopher Hollander. Coverage and Newborn Enrollment,” Health Affairs Blog, Jan. 9, 2020. Also see Elizabeth Wright Burak, Health Coverage for Parents and Caregivers Helps Children (Georgetown University Health Policy For more information about this brief, please contact: Institute, Center for Children and Families, Mar. 2017); Jennifer Haley and Benjamin D. Sommers et al., “Insurance Churning Research Associate, Health Policy Center Rates for Low-Income Adults Under Health Reform: Urban Institute Lower Than Expected but Still Harmful for Many,” jhaleyurban.org Health Affairs 35, no. 10 (Oct. 2016): 1816–24. 15. Searing and Cohen Ross, Medicaid Expansion Fills, 2019. 16.“About the Black Maternal Health Momnibus Act of 2020,” Black Maternal Health Caucus, accessed Nov. 4, 2020. commonwealthfund.org Issue Brief, January 2021 About the Commonwealth Fund The mission of the Commonwealth Fund is to promote a high-performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society’s most vulnerable, including low-income people, the uninsured, and people of color. Support for this research was provided by the Commonwealth Fund. The views presented here are those of the authors and not necessarily those of the Commonwealth Fund or its directors, officers, or staff.