ISSUE BRIEF | FEBRUARY 2021 POSTPARTUM MEDICAID Addressing gaps in coverage to improve maternal health Receiving medical care at all stages of childbearing from preconception and pregnancy to delivery and postpartum has implications for 3 in 5 MATERNAL DEATHS IN women’s health, infant health, and later episodes of pregnancy. This brief explores the postpartum period when some women are at risk of illness or death due to pregnancy-related complications. Medical care after pregnancy has the potential to address pregnancy-related injury THE UNITED STATES ARE or illness as well as control lingering conditions that could impact a PREVENTABLE 1 subsequent pregnancy. Medicaid is a critical source of coverage for maternal care in Mississippi and covers the greatest portion of births each year as well as the most women at risk of negative outcomes. Medicaid expansion in other states is an indicator of the benefits of extended coverage for postpartum women. Early results show higher usage of recommended services before, during, and after a pregnancy. Uninterrupted access to services through continued health coverage allows women who are at the greatest risk to access 86% OF MATERNAL DEATHS timely care which saves lives. States, too, could benefit through reduced costs for complicated care. From 2013 to 2016, 136 Mississippi women died due to pregnancy- IN MISSISSIPPI OCCUR related causes. Most of these deaths occurred after pregnancy POSTPARTUM2 and many after Medicaid coverage ended at 60 days following a delivery. Health experts recommend extending Medicaid coverage for pregnant women to 12 months after delivery as a crucial step in supporting good maternal health and preventing pregnancy-related death. More than 22,000 Mississippi mothers are covered by Medicaid every year (61% of all deliveries in 2019)2,3. FIGURE 1. TIMING OF PREGNANCY-RELATED DEATHS IN POSTPARTUM PERIOD (2013-2016) 86% of Pregnancy-Related Deaths After Pregnancy POSTPARTUM REFERS TO THE PERIOD 14% 49% 37% AFTER PREGNANCY Pregnancy Within 6 Weeks > 6 Weeks ^ Birth Source: Mississippi State Department of Health. Mississippi Maternal Mortality Report, 2013-2016. (2019). 1 4 Center for Mississippi Health Policy | Brief: POSTPARTUM MEDICAID � FEBRUARY 2021 MATERNAL Health Coverage Can Impact Pregnancy Care and Risks MORBIDITY Lack of health insurance often translates to delayed care for health ILLNESS RELATED conditions. For women with health concerns but no insurance prior to TO PREGNANCY OR pregnancy, risks of complications during or after pregnancy are higher. CHILDBIRTH Twenty-five percent of recently pregnant women in 2018 did not have insurance just before becoming pregnant4. More than one in three (35%) Mississippi Medicaid covered deliveries occur to women with at least one known pregnancy risk factor3. Mississippi Medicaid covers care for the greatest portion of pregnant women with identified risk factors at time of delivery. Mississippi Medicaid reports nearly half (46%) of covered women who delivered babies in 2019 did not have a postpartum visit at all, while 46% the average number of visits is just over one (1.1) visit per woman5. The American College of Obstetricians and Gynecologists (ACOG) recommends that all women who have recently delivered have an initial postpartum OF MEDICAID-COVERED assessment within three weeks and a comprehensive check-up no later than DELIVERIES REPORTED 12 weeks6. Despite changes in medical guidelines, many initial visits occur NO POSTPARTUM VISIT7 around six weeks postpartum. Postpartum visits are opportunities for identifying unresolved health concerns, counseling on family planning and contraception, screening for postpartum depression and domestic abuse, and promoting healthy behaviors like smoking cessation and healthy diet and exercise. Any necessary referrals and treatment plans can be initiated at these visits, but care sought after 60 days postpartum is currently not covered by Medicaid, making it unlikely low-income women will continue to get necessary care. RISK FACTORS FOR Pregnancy-Related Illness and Death in Mississippi MATERNAL Maternal mortality rates in the United States appear to have increased MORBIDITY & in the last 30 years. Mississippi’s rate of maternal mortality of 22.1 per PRETERM BIRTH 100,000 live births is well above the national average of 17.47. However, Black women in the state are affected more than other racial groups (51.9 Short time deaths per 100,000 compared to 18 for White women)2. Health issues period between that endanger women’s lives after delivery include blood clots, high blood pregnancies (<18 pressure, infections, heart conditions, depression, and substance use. months) These are treatable with standard medical care--if care is properly sought Prior preterm birth and delivered. No insurance prior to As the following chart shows, women in Mississippi have died six months pregnancy or more after a pregnancy from associated, treatable conditions. Some Health conditions women experience serious pregnancy-related injury or illness that impacts like high blood their health long after delivery. Nearly 500 Medicaid-covered women were pressure, diabetes, identified as having experienced Severe Maternal Morbidity (SMM) at or and obesity immediately after delivery in 20178. Conditions of SMM indicate higher risk of death. Mississippi reported the highest levels of SMM out of 26 states reporting such data. 2 4 Center for Mississippi Health Policy | Brief: POSTPARTUM MEDICAID � FEBRUARY 2021 MATERNAL FIGURE 2. NUMBER OF MATERNAL DEATHS BY CAUSE AND MONTH (2013-2016) MORTALITY     REFERS TO DEATHS OF WOMEN WHO ARE     PREGNANT, PREGNANT WITHIN 42 DAYS OF DEATH, OR PREGNANT UP TO ONE   YEAR PRIOR TO DEATH       BLACK WOMEN IN MISSISSIPPI ARE 3x  ­ Source: Mississippi State Department of Health. Mississippi Maternal Mortality Report, 2013-2016. (2019). ­ MORE LIKELY TO DIE FROM PREGNANCY Postpartum Coverage Offers Preconception Care for a Later Pregnancy COMPLICATIONS THAN WHITE WOMEN 2 Preterm birth is a leading cause of infant deaths and is impacted by many of the same risk factors that contribute to preventable maternal morbidity and mortality. Extending postpartum coverage can treat these issues and may also benefit future pregnancies and offset higher costs to the state. Preterm birth is one of the top costs for Medicaid and impacts infant and child health for years. The average medical costs in the first year of life for a preterm baby was more than $110,000 in 2017 compared to $5,400 for a full-term baby9. Preterm Birth Costs are Postpartum women covered by Medicaid maintain their insurance coverage Substantial & Climb with after pregnancy in Medicaid expansion states (and are more likely to have Every Week of Prematurity12 coverage before becoming pregnant). Studies have shown that women in $70K these states are significantly more likely to get health counseling before $68,199 pregnancy, take folic acid during pregnancy, and use effective methods of $50K contraception postpartum10. Maternal death rates have dropped by almost 2 deaths per 100,000 live births (1.6) in expansion states, which researchers $30K attribute to improved access to care via insurance coverage prior to $24,613 becoming pregnant and after delivery11. $12,678 $10K $3,667 Most Postpartum Care Occurs After Medicaid Coverage Ends 30wk 32wk 34wk 36wk A recent study of over 160,000 women with employer-sponsored insurance illustrated that pregnancy-related healthcare spending continues for the full year following a birth13. In the study, most (81%) postpartum healthcare 3 4 Center for Mississippi Health Policy | Brief: POSTPARTUM MEDICAID � FEBRUARY 2021 expenses occurred between 60 days and twelve months following delivery. A The Mississippi Maternal full year of postpartum care was estimated to cost $3,100 per person. Surgery, Mortality Review ambulance services, and emergency room visits accounted for the greatest Committee has laid out portion of costs but reflected low-frequency events. additional steps for government, insurance Low-frequency events (e.g. heart failure or hemorrhage) did not occur for most companies, and medical insured births studied, but when they did occur, these events often happened providers to take to after 60 days postpartum and had high associated costs. Under the current support the health of Medicaid policy of ending coverage at 60 days postpartum, uninsured, low- pregnant and post- income women needing care would either delay getting services, or seek care partum women. that left them with medical debt or hospitals burdened by uncompensated care. DISCUSSION Extending postpartum coverage has the potential to protect maternal health and promote infant health by removing a primary barrier to care that is closely associated with poor maternal and child health. While continued coverage means increased access to care, utilization of care is necessary for improved women’s health. Experience in states that expanded Medicaid suggest that continued coverage postpartum improves utilization of beneficial care. It is critical that managed care organizations administering Medicaid benefits continue to support postpartum women with robust care coordination to make use of improved access. Extending Medicaid coverage to one year after delivery would provide an opportunity to receive this care. SOURCES 1. Centers for Disease Control and Prevention (CDC). (May 2019). Pregnancy-Related Deaths. Retrieved from https://www.cdc.gov/vitalsigns/maternal-deaths/index.html 2. Mississippi State Department of Health. (2019). Mississippi Maternal Mortality Report, 2013-2016. National Academy for State Health Policy. 3. Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS), Division of Vital Statistics, Natality Public-Use data 2016-2019, on CDC WONDER Online Database, October 2020. 4. Mississippi State Department of Health. (2018). PRAMS Surveillance Report Brief https://msdh. ms.gov/msdhsite/_static/resources/10774.pdf 5. Mississippi Division of Medicaid. (August 2020). Pre-and Post-Natal Medicaid Utilization Info Request. 6. American College of Obstetricians and Gynecologists. (2018). Committee Opinion No. 736. 7. Hoyert, D. & Minino, A. Maternal Mortality in the United States: Changes in coding, publication, and data release, 2018. National Vital Statistics Reports; vol 69 no 2. Hyattsville, MD: National Center for Health Statistics. 2020. Plaza Building, Suite 700 8. Mississippi State Department of Health. (2017). Hospital Discharge Data. Severe Maternal Morbidity 120 N. Congress Street Conditions, 2017. Jackson, MS 39201 9. Mississippi Division of Medicaid. (2017). Presentation to Mississippi Medical Care Advisory Committee. P 601.709.2133 | F 601.709.2134 10. Myerson, R., Crawford, S., and Wherry, L. (November 2020). Medicaid Expansion Increased Preconception Health Counseling, Folic Acid Intake, and Postpartum Contraception. Health Affairs, 39(11), 1883-1890. www.mshealthpolicy.com @mshealthpolicy 11. Zephyrin, L., Coleman, A., Nuzum, R., & Getachew, Y. (November 2019). Increasing Postpartum Medicaid Coverage Could Reduce Maternal Deaths and Improve Outcomes. Retrieved from https:// www.commonwealthfund.org/blog/2019/increasing-postpartum-medicaid-coverage The Center for Mississippi Health Policy is an independent, non-partisan, 12. Mississippi State Department of Health. (2017). Hospital Discharge Data. Preterm Births, 2017. non-profit organization that provides 13. Bloschichak, A. & Martin, K. (2020). Most Postpartum Spending Occurs Beyond 60 Days After objective information to inform health Delivery. Retrieved from https://healthcostinstitute.org/hcci-research/most-postpartum-spending- policy decisions. occurs-beyond-60-days-after-delivery 4 4 Center for Mississippi Health Policy | Brief: POSTPARTUM MEDICAID � FEBRUARY 2021