The views expressed are those of the authors and should not be attributed to the Robert Wood Johnson Foundation or the Urban Institute, its trustees, or its funders. October 2020 Maternal Telehealth Has Expanded Dramatically During the COVID-19 Pandemic Equity Concerns and Promising Approaches Ian Hill and Emmy Burroughs The maternal mortality crisis1 in the United States is particularly acute for women of color. Black and indigenous women2 are two to three times more likely to experience worse maternal health outcomes than white women.3 Increasingly, structural racism has been recognized as a key driver of maternal health disparities and inequities.4–6 This structural racism extends to systems and organizations that provide perinatal7 care and wraparound health and social services for pregnant and postpartum women with low incomes, many of whom are at highest risk of poor maternal health outcomes. In response to the COVID-19 pandemic, health systems, including perinatal service and support providers, have been forced to rely on telehealth, or the remote provision of care through telecommunications technology, to reach their clients. This has resulted in remarkable ingenuity, rapid reimbursement changes, and important experiences that can inform the role of telehealth in maternity and postpartum care going forward. At the same time, it has raised critical questions regarding how to ensure equitable access and the provision of high-quality “virtual” care. Part of a larger series on the pandemic and maternal health equity, this analysis explores what promising maternal care telehealth practices have emerged during the pandemic, what access and equity concerns surrounding maternal health have arisen in light of increased reliance on telehealth, and what lessons can be applied to a postpandemic future. To do so, we conducted literature reviews and in-depth interviews with maternal health stakeholders during a relatively short but intense learning period. Highlights of our findings for how federal, state, and local policymakers, providers, and payers (including both private insurers and Medicaid programs) can capitalize on the potential of telehealth to promote more equitable maternal health now and in the future include: ›encouraging providers to continue their use of maternal telehealth, when appropriate, by making permanent the payment parity policies adopted during the pandemic, so telehealth visits are reimbursed at the same rates as in-person care; ›expanding the scope of permitted and reimbursed maternal telehealth benefits to include services—such as doula support, prenatal risk assessment and postpartum depression screening, home visiting and childbirth education, and substance use disorder treatment and recovery services for pregnant and parenting women—critical to the health and well-being of populations that suffer disproportionate maternal morbidity and mortality, while also qualifying the community-based agencies that deliver those services as reimbursable providers; 1|Maternal Telehealth Has Expanded Dramatically During the Pandemic ›investing in and scaling up digital products that can facilitate privacy, and consent. For maternal health services, there have access to telehealth, distribute health education messages been important shifts in both prenatal and postpartum care, as by text, send appointment reminders and referrals, and well as a broad range of psychosocial support services needed provide wireless blood pressure and weight monitoring to by women and families. help reduce widespread access inequities in current health systems; and The potential of telehealth—its relative ease of use and improved access to and attendance in certain types of care—has quickly ›addressing barriers to access, such as the “digital divide” and become apparent to stakeholders interviewed for this study. At safety net provider capacity limitations, through infrastructure the same time, stakeholders fear increased reliance on telehealth investments in low-income and rural communities, such may create new, or exacerbate existing, health inequities. The as by bolstering access to the internet, smartphones, and “digital divide”—where some individuals and communities data plans in communities or providing grants and technical lack the technical devices and/or broadband internet access assistance to safety net providers to increase their capacity needed for telehealth—means telehealth innovations may to provide telehealth services. not be equally accessible for many in low-income and rural communities.11 Further, according to stakeholders, immigrants and people who do not speak English may fall through the Introduction cracks and not reap the full benefits telehealth could offer. The emergence and rapid spread of the novel coronavirus These dramatic developments are occurring against the in 2020 created an imperative to deliver health care services backdrop of the maternal mortality and morbidity crisis in virtually, which permitted receipt of needed health care while America. The United States experiences some of the worst discouraging further transmission of COVID-19, the disease maternal health outcomes among high-income countries. caused by the virus. This was true generally and with perinatal About 700 women die each year during pregnancy or delivery, care (defined in this paper as inclusive of all prenatal, delivery, or within a year of delivery, from pregnancy-related causes, a and postpartum services). Before the pandemic, telehealth rate that has nearly doubled over recent decades; many more was not widely used, its growth hindered by restrictive women experience severe maternal morbidity.12–16 What’s more, reimbursement policies, high startup costs, insufficient provider stark racial and ethnic disparities persist in these outcomes, buy-in and patient interest, and rigid requirements on provision growing from deeply rooted systemic racism in our health of care.8,9 For example, until this year, only 19 state Medicaid systems and society. Specifically, the maternal mortality rate programs paid for telehealth services delivered to patients for Black and American Indian women in the United States in their homes.10 However, the need to continue providing is two to three times higher than the rate for white women.3 services while minimizing risks for both patients and providers Further, early evidence suggests Hispanic and non-Hispanic pushed the telehealth expansion ahead at light speed. Black pregnant people are disproportionately affected by COVID-19—particularly alarming given that pregnancy may The rapid changes surrounding telehealth have reflected pose an elevated risk for severe COVID-19 illness.17 considerable ingenuity. Across the country, changes have been observed in what services could be provided via telehealth, With support from the Robert Wood Johnson Foundation, what providers could render care via telehealth, and what we conducted literature reviews and in-depth interviews with communication modes could be used and covered (e.g., video, maternal health stakeholders (Box 1) to explore four research phone, text messaging). Significantly, telehealth expansion questions: What promising telehealth practices have emerged has been facilitated by federal and state governments, which surrounding maternal health care? What access and equity have shown a rare nimbleness in creating new reimbursement concerns surrounding maternal health have arisen? What early mechanisms while relaxing rules and regulations regarding the lessons can (or should) be applied to the postpandemic future? Health Insurance Portability and Accountability Act (HIPAA), And what questions demand further study? 2|Maternal Telehealth Has Expanded Dramatically During the Pandemic BOX 1. RESEARCH METHODS In spring and summer 2020, we conducted individual and small-group interviews with 40 maternal health experts, perinatal care providers, consumer advocates, philanthropic funders, and frontline health workers serving pregnant women to identify and examine key concerns about maternal health equity and challenges raised by the pandemic. We also conducted, and periodically updated, a comprehensive scan of publicly available information on maternal health equity during the pandemic from national policy and research organizations, professional and provider trade organizations, and leading maternal and infant health advocacy groups. Our findings primarily reflect insights into and responses to the pandemic that emerged between March and September 2020.  Because of social distancing requirements and the urgency of this topic during the pandemic, this analysis has some limitations. We could not interview mothers directly, and though we interviewed provider and advocate stakeholders, we recognize they do not represent mothers’ viewpoints. In addition, our interviewees were predominantly on the East Coast, but we acknowledge community needs and realities differ by location and understand the importance of authentic community voice, partnership, and engagement as solutions are developed, implemented, and evaluated. We center this work, part of the Urban Institute’s larger Transforming Health and Health Care Systems project, around the Center for Social Inclusion’s definition of racial equity:* when “people, including people of color, are owners, planners, and decisionmakers in the systems that govern their lives” and society “[acknowledges and accounts for] past and current inequities and provides all people, particularly those most impacted by racial inequities, the infrastructure needed to thrive.”  * What is racial equity? Center for Social Inclusion website. https://www.centerforsocialinclusion.org/our-work/what-is-racial-equity. Accessed October 19, 2020.  Promising Maternal Telehealth Practices From beneficial—so scaling back the frequency of contacts because the Field of COVID-19 might not necessarily be negative. Perinatal care is traditionally thought of as “high-touch” care. During our interviews with maternal health stakeholders and Providers need to carefully observe rapid changes in maternal providers, we learned that most of their patients reportedly and fetal development, and long-standing prenatal protocols have smartphones, if not computers, so reaching women call for routine and regular physical exams and close monitoring via telehealth had generally not been problematic. Indeed, of women’s blood pressure, glucose, and weight gain, as well many providers reported that attendance at prenatal care as the health of the developing baby. visits has improved since the pandemic, because of the increased convenience of telehealth and elimination of Yet, aside from lab tests and certain types of monitoring, perinatal traditional barriers to keeping appointments for women with care also lends itself to virtual delivery, since conversations, low incomes, such as lack of transportation and/or affordable education, support, and question-and-answer sessions can child care. Some practitioners said group prenatal care occur via teleconference and phone. Plus, as stakeholders told sessions were “much better attended,” while others said us, telehealth has allowed certain formerly routine practices to telehealth could be a “game changer” for postpartum care, continue during the pandemic: during a telehealth visit, no one which has traditionally had notoriously low attendance rates has to wear a mask, and partners can attend and participate. but has seen much improved attendance via telehealth. Some Further, providers can save their scarce personal protective providers also believed mental health counseling—needed equipment resources for in-person care, something that is now more than ever given myriad stresses associated with particularly important as such shortages persist across the the pandemic—can succeed virtually. (Some women appear country. Finally, maternity care in the United States traditionally more comfortable, and less threatened, by virtual mental involves more visits than clinically necessary18—though more health encounters given the physical distance and privacy visits focused on addressing psychosocial issues could be telehealth affords.) 3|Maternal Telehealth Has Expanded Dramatically During the Pandemic Once again, changes in federal policy surrounding HIPAA and ›In New Jersey, the Department of Health modified policies its enforcement have facilitated the proliferation of telehealth. to permit virtual provision of doula support, home visiting, Specifically, the U.S. Department of Health and Human and early intervention services.28 Like California and North Services announced providers subject to HIPAA rules would Carolina, New Jersey also temporarily relaxed requirements have greater flexibility for virtual communications with patients surrounding the delivery of telehealth services and will now during the public health emergency,19 asserting that providers cover audio-only telephone visits.29 State-regulated health would not be penalized for using non–HIPAA compliant insurers are required to reimburse telehealth services at the communication technologies to deliver telehealth services. The same rates as in-person services. department’s statement explicitly confirmed that FaceTime, Facebook Messenger video chat, Google Hangouts video, Private-sector products and organizations—both non- and for- Zoom, and Skype were acceptable platforms for provision profit—as well as local and university-based initiatives have also of care, while confirming that HIPAA enforcement discretion expanded their presence and efforts in the wake of COVID-19, would apply to all telehealth services, not just those associated facilitating the virtual provision of high-quality care. Many of with diagnosis or treatment of COVID-19.8 these efforts, such as those below, have targeted underserved communities in hopes of addressing maternal health inequities: Medicaid pays for nearly half of all births in the United States and is the largest payer for births among women of color: ›Maven: more than 65 percent of non-Hispanic Black women and In March, Massachusetts’ state Medicaid program contracted indigenous women and 60 percent of Hispanic women with Maven, a digital health company that provides health care who gave birth in 2018 were covered by Medicaid.20 Before services to women and families—including a wide array of the pandemic, only 19 state Medicaid programs paid for maternity services—via on-demand chat windows and video telehealth services delivered to patients in their homes, and appointments.30 Through this contract, Maven has agreed not all reimbursed these services at the same rates as in- to provide telehealth services to Medicaid beneficiaries person care.8 But in the past six months, all 50 states and experiencing COVID-19 symptoms to facilitate access to care the District of Columbia have expanded telehealth for their during the pandemic. The company has reportedly provided Medicaid populations.21 On maternal telehealth, our research more than 10,000 physician appointments per week to this identified a number of initiatives to enhance Medicaid and population since the beginning of the contract.31 Available private insurance coverage and payment policies in response maternity services include fertility and pregnancy care, birth to the pandemic: planning, mental health counseling, lactation coaching, and pediatric services. ›In April, California Governor Gavin Newsom issued an executive order to loosen state-level privacy and consent ›Babyscripts: requirements.22 Further, California enacted temporary Before the pandemic, digital health startup Babyscripts emergency changes to its Medi-Cal telehealth policy developed a virtual care platform to facilitate remote aimed at increasing access to virtual care, including new monitoring and delivery of prenatal care. Its customers coverage for telephone visits. Though telephonic visits were consist of health systems and OB/GYN practices across not reimbursed before the pandemic, they must now be the country. Once providers receive access to the digital reimbursed at the same rate as video and in-person visits platform, they can enroll their patients, who interact with during the public health emergency.23,24 the system through a mobile app.32 The number of health systems using the Babyscripts platform has skyrocketed this ›North Carolina also updated its state Medicaid telehealth year, with safety net providers accounting for much of the policies to relax certain requirements and reimburse a growth.33 Patients connected with Babyscripts may receive broader array of services. Effective March 2020, providers wireless blood pressure monitoring, weight monitoring, could bill for certain prenatal care, postpartum care, and educational messages from care coordinators, appointment maternal support services conducted via telehealth. For reminders, and referrals to social supports.33 example, providers may now administer pregnancy risk and postpartum depression screenings virtually.25 Additionally, ›Baltimore Digital Equity Coalition: eligible providers may now provide virtual maternal support Formed in response to the pandemic, the Baltimore Digital services, such as childbirth education and postpartum Equity Coalition seeks to advance digital equity and “close visits.26 The state enacted coverage and payment parity the digital divide.”34 The coalition consists of more than with in-person care for these and other Medicaid telehealth 50 organizations attempting to improve access to digital services, meaning providers receive the same rates for virtual devices, internet connectivity, digital skills training, and care that they received for in-person care.27 technical support in Baltimore. The group aims to coordinate 4|Maternal Telehealth Has Expanded Dramatically During the Pandemic responses across organizations—in the health and other Finally, many major private insurers (including Aetna, Blue sectors—and develop long-term solutions, extending Cross Blue Shield, and United Healthcare)—whether voluntarily beyond the pandemic. or by state law—are changing their telehealth policies to help both consumers and providers. These changes have included ›UCSF-SF Respect Initiative: waiving cost-sharing for select telehealth services, expanding Before the pandemic, maternity care providers and virtual mental health and/or substance use services, and researchers at the University of California, San Francisco, instituting provider payment parity requirements.39 (UCSF) General Hospital implemented the SF Respect Initiative.33 This initiative involved the design of new prenatal care models for Medicaid beneficiaries, including a pilot of Concerns Around Access, Equity, virtual visits. In response to the pandemic, UCSF scaled and Sustainability up this telehealth component from pilot phase to common practice. Additionally, UCSF researchers have developed Though the maternal health stakeholders and providers with guidance for providers implementing telehealth in safety net whom we spoke were considerably optimistic about how care settings serving patients with limited English proficiency well telehealth could work for their clients, they also voiced and/or digital literacy. many concerns about whether all populations would benefit equally from emerging practices. These concerns centered on ›Ancient Song Doula Services: people who might not possess the laptops or smartphones Ancient Song Doula Services, like many other doula needed for telehealth, or who might own a smartphone but organizations, has pivoted to provide virtual services to all lack WiFi access and can only afford a limited data plan. And, clients during the pandemic. Because some clients may of course, stakeholders acknowledged that many poor urban not have smartphones, providers can deliver services via communities lack access to broadband internet, as do many phone calls, text messages, and WhatsApp. Further, Ancient rural areas across the United States. They said these problems Song developed an online doula training for nurses to better with accessing telehealth may accrue disproportionately support pregnant people of color.35 to communities of color and low-income communities of color. Indeed, two studies of different New York City health ›Mamatoto Village: systems found that Black patients were significantly less likely A D.C. nonprofit offering perinatal supports to women, to access telehealth than their white counterparts during Mamatoto Village transitioned to offering virtual support the pandemic.40,41 services via video and phone, as well as online childbirth and parenting education. The organization also created A A second set of concerns among our stakeholders was Black Mama’s Guide to Living and Thriving to offer support that many communities might face language barriers when and guidance on wellness, mental health, childbirth, healthy accessing telehealth services. Women and families whose eating, and other topics during the pandemic.33 primary language is not English may not have the same level of access to telehealth support if their providers do not speak ›Penn Medicine Pregnancy Watch: their native language or if interpreter and translation services A tool developed by Penn Medicine, Pregnancy Watch sends are unavailable. These concerns are exacerbated for vulnerable text messages to pregnant and newly postpartum women immigrant communities, who face both language and trust who are experiencing symptoms of COVID-19. These texts barriers related to immigration enforcement. Some providers are sent twice daily, so individuals can be closely monitored said they had had limited experience using interpreters during and triaged to maternal-fetal specialists if symptoms telehealth visits but found that it was cumbersome. Further, worsen.36 Pregnancy Watch is a spin-off of the larger COVID both studies mentioned above found that patients who Watch initiative at the University of Pennsylvania with the indicated Spanish was their preferred language were less likely same objective. to have used telehealth than those who preferred English. ›CHCF Tipping Point for Telehealth Initiative: Concerns over patient privacy have also surfaced as maternal In May, the California Healthcare Foundation (CHCF) approved health systems have increasingly relied on telehealth. more than $6 million in funding aimed at improving Medi- Obstetrical providers and care coordinators described how Cal beneficiaries’ access to telehealth, increasing telehealth pregnant women and new mothers may not always have a capabilities among safety net providers, and advancing private space to do their televisits. Some providers shared telehealth policy and payment changes.37 In August, CHCF that they encourage their patients to take a visit from their car began providing funds to 40 safety net providers to start or or in a closet, use an online chat box rather than a laptop’s scale up telehealth services.38 or phone’s speaker, or simply wear headphones if a private 5|Maternal Telehealth Has Expanded Dramatically During the Pandemic space is not available. Other providers worried about how they and more established institutions. Midwives, doulas, community would handle situations where they might witness, during a health workers, social workers, mental health providers, video call, something illegal, unsafe, or dangerous that would substance use disorder providers, home visitors, and outreach normally trigger mandatory reporting. They speculated that workers were all identified as critical providers that work with they might need to incorporate informed consent procedures communities of color. Cultural and linguistic equity will suffer, to acknowledge that risk before beginning a video call, a tactic said our stakeholders, if this full range of providers is left out of that might jeopardize some women’s willingness to participate coverage and payment policies for telehealth care. in telehealth. Providers warned us that all previous, in-person care could Lessons and Questions Moving Forward not be replaced by telehealth. High-risk pregnant women need to be seen in person more frequently than their lower- In some ways, the rapid expansion and deployment of risk counterparts. Some types of care, like home visiting, are telehealth, both generally and in maternal health care, intentionally designed to include a focus on providing advice represents an advance in care that has emerged during the and guidance on setting up a safe home environment for the COVID-19 pandemic. Many traditional assumptions that newborn, a support that is more challenging to provide virtually. telehealth is inferior to in-person care are being challenged. And while some mental health therapists supported the provision Chronic weaknesses in our health system are being addressed of virtual counseling, they also said that it was more challenging (at least in part) by telehealth, including lack of transportation to pick up on a client’s subtle visual and nonverbal cues over a (for people who do not have cars or who live in rural areas or in video screen. Relatedly, some providers speculated that liability communities with inadequate public transportation), insufficient risks might increase if too much traditional, hands-on care was or unsafe child care, and overcrowded public clinics where replaced by virtual care and adverse events occurred during a women may wait hours for a routine, 10-minute visit. Because woman’s pregnancy, delivery, or postpartum recovery. smartphones (if not computers) are increasingly ubiquitous, the convenience of telehealth is apparent and manifests itself in Some maternal health providers and stakeholders worried that higher attendance at visits. Still, telehealth is not working equally health systems might increase their use of telehealth for the well for all populations and cannot adequately substitute for in- wrong reasons. For example, a managed-care plan might see person care when high medical or psychosocial risks demand telehealth as a way to reduce costs by reducing access to in- more hands-on care and support. person care. Meanwhile, state Medicaid officials worry that the increased utilization and popularity of telehealth could lead to Given these opposing forces, and drawing on the lessons waste and abuse within the health care sector, such as excess learned through this research, we present the following utilization of health services—even when not necessarily suggestions for how policymakers, providers, and payers can needed—simply because these services are more readily capitalize on the promising potential of telehealth to promote available via telehealth and covered by insurance.42 more equitable care delivery and outcomes now and in the future. Reimbursement for maternal telehealth was a prominent issue on the minds of a wide range of providers during our interviews. While examples of payment rate parity between State and Federal Policy Changes in-person and virtual care exist, there are also many cases ›Given emerging evidence that overall access to care may where telehealth visits are reimbursed at lower rates.6 Only improve with more telehealth—specifically, that populations 6 states required payment parity among commercial payers facing chronic transportation and child care barriers before the pandemic; while that number has increased to seem more likely to keep critical prenatal and postpartum 16 as of September, most states have no such policies in appointments when telehealth is an option—federal and place.43 Interestingly, some providers told us that telehealth state governments could consider making permanent many visits are arguably more time intensive, more frequent, and of the telehealth policies that have been adopted temporarily more demanding (in terms of communication) than in-person in response to the public health emergency. care, and thus should be reimbursed at higher rates and/or reflected in global bundled payments for maternity care. Finally, ›State Medicaid programs and private payers could providers cited examples of states and communities where encourage increased use of maternal telehealth by adopting some types of telehealth are not reimbursed at all, including payment parity policies so telehealth visits—including text messaging, a service frequently used by doulas and other telephone-only contacts—are reimbursed at the same rates providers serving vulnerable communities of color. as in-person care. For maternal health providers, stakeholders told us advances in ›Medicaid programs could broaden the range of services telehealth need to include all birth workers, not just physicians permissible via telehealth—services that are critical 6|Maternal Telehealth Has Expanded Dramatically During the Pandemic to the health and well-being of populations that suffer ›Governments could also bolster safety net providers’ disproportionate maternal morbidity and mortality— capacity to deliver telehealth through the provision of grants including doula support, prenatal risk assessment and and technical assistance. postpartum depression screening, home visiting, early intervention, mental health and substance use disorder Maternal health stakeholders also raised many concerns counseling, and maternal support services like childbirth about the increased reliance on telehealth. Therefore, it will and parenting education. be critical to monitor the effects of increased access to and use of telehealth and make adjustments and improvements ›Alongside such benefits expansion, Medicaid programs on an ongoing basis. It will be imperative to engage patient could qualify as providers the myriad small, community- voices in these efforts. Critical questions for researchers and based agencies that render critical, nonmedical maternal policymakers to ask and answer moving forward include support services, as exemplified by Ancient Song Doula the following: Services and Mamatoto Village. ›How does an increase in telehealth affect outcomes and quality of care, across populations and in both urban and Private-Sector Digital Products rural communities, generally? ›Private and public payers, including state Medicaid programs and Medicaid managed-care organizations, could cover ›How does increased use of telehealth affect maternal health and make available to their enrollees private-sector digital equity, specifically? Does it exacerbate disparate outcomes products like those mentioned in this paper. Products that for Black and indigenous populations, or does it help level facilitate access to telehealth, send appointment reminders the playing field? and helpful educational messages via text, provide wireless blood pressure and weight monitoring, and facilitate referrals ›How do we ensure that cultural, ethnic, and language to community support services could reduce access inequities are not exacerbated by telehealth? inequities that are widespread in current health systems. ›In light of relaxed HIPAA rules, what privacy risks does telehealth pose, particularly for people with substance use Infrastructure Investments to Address Inequity disorders, individuals with mental health concerns, and other and Disparities stigmatized groups? › Federal, state, and local governments could make infrastructure investments to expand communities’ internet Clear, data-driven, and patient-centered answers to these access and connectivity and reduce the digital divide so all questions will help determine whether increased reliance on populations can equally benefit from advances being made telehealth helps, or harms, our country’s efforts to address in telehealth. maternal health inequity. 7|Maternal Telehealth Has Expanded Dramatically During the Pandemic References 1 Delbanco S, Lehan M, Montalvo T, Levin-Scherz J. 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Raleigh: North Carolina Department of Health and Human Services; 2020. https://medicaid.ncdhhs.gov/blog/2020/05/07/special-bulletin-covid-19-84-telehealth-and-virtual- patient-communications-clinical. Accessed October 16, 2020. 27 Community Care of North Carolina. Summary of NC Medicaid telehealth provisions in response to COVID-19. 2020. https://www.communitycarenc.org/ files/telehealth-provisions-phase-2. Updated March 22, 2020. Accessed October 16, 2020. 28 What resources or guidance is there for expecting mothers, new mothers, and health care providers? What rules are in place for labor and delivery during COVID-19? State of New Jersey COVID-19 Information Hub website. https://covid19.nj.gov/faqs/nj-information/health-care-professionals/what-resources- or-guidance-is-there-for-expecting-mothers-new-mothers-and-health-care-providers. Updated June 29, 2020. Accessed October 16, 2020. 29 New Jersey Division of Consumer Affairs. 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California Health Care Foundation website. https://www.chcf.org/project/tipping-point-telehealth-initiative/#.X4nW9Is1C54. Published August 17, 2020. Accessed October 16, 2020. 38 Connected Care Accelerator. Center for Care Innovations website. https://www.careinnovations.org/programs/connected-care-accelerator/. Accessed October 16, 2020. 39 Hudman J, McDermott D, Shanosky N, Cox C. How private insurers are using telehealth to respond to the pandemic. Peterson-KFF Health System Tracker. 2020. https://www.healthsystemtracker.org/brief/how-private-insurers-are-using-telehealth-to-respond-to-the-pandemic/. Published August 6, 2020. Accessed October 16, 2020. 40 Chunara R, Zhao Y, Chen J, et al. Telemedicine and healthcare disparities: A cohort study in a large healthcare system in New York City during COVID-19. Journal of the American Medical Informatics Association 2020; ocaa217. https://doi.org/10.1093/jamia/ocaa217. Published August 31, 2020. 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The views expressed are those of the authors and should not be attributed to the Robert Wood Johnson Foundation. About the Authors Ian Hill is a Senior Fellow in the Health Policy Center at the Urban Institute. He has over 30 years of experience directing evaluation and technical assistance projects on health insurance programs for mothers, children and families. He is a nationally recognized qualitative researcher with extensive experience developing case studies of health program implementation and conducting focus groups with health care consumers, providers, and administrators. Emily Burroughs is a Research Assistant in the Health Policy Center. She primarily conducts research and analysis focused on access to health care coverage, as well as child and maternal health. Her qualitative data collection experience includes conducting key informant interviews and focus groups with a wide range of participants, such as healthcare consumers, providers, and administrators. Acknowledgments We thank study participants who shared their valuable time and insights with us, as well as our colleagues Kimá Joy Taylor, Sarah Benatar, Jenny Haley, Eva Allen, and Sarah Coquillat for their collaboration on data collection and analysis. Our thanks also extend to Hendree Jones, Rachel Kenney, Genevieve M. Kenney, and Stephen Zuckerman for their helpful comments and suggestions. About the Robert Wood Johnson Foundation For more than 45 years the Robert Wood Johnson Foundation has worked to improve health and health care. We are working alongside others to build a national Culture of Health that provides everyone in America a fair and just opportunity for health and well-being. For more information, visit www.rwjf.org. Follow the Foundation on Twitter at www.rwjf.org/twitter or on Facebook at www.rwjf.org/facebook. About the Urban Institute The nonprofit Urban Institute is a leading research organization dedicated to developing evidence-based insights that improve people’s lives and strengthen communities. For 50 years, Urban has been the trusted source for rigorous analysis of complex social and economic issues; strategic advice to policymakers, philanthropists, and practitioners; and new, promising ideas that expand opportunities for all. Our work inspires effective decisions that advance fairness and enhance the well-being of people and places. 10|Maternal Telehealth Has Expanded Dramatically During the Pandemic