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 Maternity Care Financing Challenges and Opportunities Highlighted by the COVID-19 Pandemic Eva H. Allen and Sarah Benatar Maternal mortality and serious morbidity rates are considerably higher in the United States than in other wealthy nations, and women of color are bearing the brunt of this crisis.1 Black and indigenous women2 are two to three times more likely to experience poor maternal and infant outcomes than white women in the United States.3 Even before the COVID-19 pandemic, structural racism—including in how maternity care is delivered and financed— has driven maternal health disparities.4– 8 In this brief, we identify emerging challenges and key priorities for financing maternity care and other services for pregnant and postpartum women in ways that promote health equity. To do so, we draw on a rapid assessment of maternal health care experiences during the pandemic. We find the pandemic has exacerbated existing deficiencies in maternity care financing in the United States in ways that could worsen maternal health outcomes. But, we also find it has created opportunities for addressing these deficiencies, including by keeping new mothers enrolled in Medicaid longer than they would otherwise be eligible. Ensuring access to Medicaid coverage is particularly important given that pandemic-induced health and financial consequences have disproportionately affected communities of color.9–16 In the longer term, strategies such as expanding coverage and reimbursement of evidence-informed services, such as birth center care, and developing value-based payment models for maternity care could help reach maternal health equity. Part of a larger series on the pandemic and maternal health equity, this analysis draws on interviews with maternal care stakeholders (Box 1) and an environmental scan of the literature and publicly available information to describe the strengths and deficiencies of maternal health care financing in the United States and the ways current policies and practices contribute to inequitable maternal health outcomes. We also consider how the pandemic is exacerbating these long- standing issues while simultaneously allowing policymakers, practitioners, and advocates to reevaluate how we approach and pay for maternal health care. Because Medicaid finances a disproportionate share of maternity care and covers a disproportionate share of pregnant women of color,17,18 we focus on Medicaid policies and strategies that can better support perinatal health.19 Key findings from this early work include the following: ›Fragmented, inadequate, and biased funding for perinatal care and health-related social needs have contributed to long-standing inequities in maternal health outcomes. ›Several preexisting funding deficiencies have been exacerbated by the pandemic and will likely be further strained by anticipated Medicaid budget cuts and provider shortages. 1|Covid-19 Challenges and Opportunities for Maternity Care Financing ›However, one policy response spurred by the crisis, increasing funding for home visiting programs, and the Families First Coronavirus Response Act, prohibits providing additional federal financial assistance to state disenrollment from the Medicaid program during the crisis, Medicaid programs. extending Medicaid-enrolled new mothers’ coverage beyond the traditional 60 days after delivery. ›To address the racial and ethnic inequities in maternal health outcomes predating the pandemic, recovery efforts ›Further immediate policy changes to prevent worsening will require additional changes to maternal care payment maternal health outcomes include permanently expanding and delivery systems and investments in community-based access to Medicaid via extended postpartum coverage, social services. adopting the Affordable Care Act Medicaid expansion, 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. 2|Covid-19 Challenges and Opportunities for Maternity Care Financing Background: Maternal Health Financing Medicaid covers out-of-hospital births, low reimbursement Is Fragmented, Inadequate, and Inequitable rates, administrative hurdles (e.g., difficulty contracting with managed-care plans), and restrictive licensing requirements Vast inequities in maternal and infant outcomes preceded the often discourage birth centers and midwives from accepting pandemic.20–24 Many experts have pointed to fragmented and Medicaid-enrolled pregnant women.42–44 In addition, only a few biased care that is ill equipped to adequately address systemic states cover doula services,45 another promising, high-value inequality and disparate needs for medical and social supports model for reducing maternal health disparities by providing as key contributing factors.5,25– 27 Similarly, key informants support and advocating on behalf of women who may face interviewed for this work repeatedly cited scarce and disjointed poor health outcomes.46,47 Medicaid beneficiaries may also funding sources as barriers to delivering holistic and equitable have limited access to less traditional prenatal care models, care to pregnant and postpartum women. such as group prenatal care (e.g., Centering Pregnancy), peer counseling, and maternity care homes.48 Medicaid Plays a Dominant Role in Funding Maternal Finally, though evidence shows a third of pregnancy-related Health Care deaths occur within the year after giving birth,49 postpartum Through Medicaid and the Children’s Health Insurance Program Medicaid coverage lasts just 60 days in almost all states.50 This (CHIP),28–30 the Centers for Medicare & Medicaid Services leaves many women who qualify only for pregnancy-related (CMS) pays for nearly half of all births in the United States. It is coverage without alternative affordable coverage options, also the largest payer for births among women of color: more particularly in states that have not expanded Medicaid and than 65 percent of non-Hispanic Black women and indigenous have lower income eligibility thresholds for parents.51,52 Though women and 60 percent of Hispanic women who gave birth there have been recent federal and state efforts to extend in 2018 were covered by Medicaid.18 Medicaid coverage postpartum coverage for up to 12 months,53,54 the urgency of of specific perinatal services, however, varies by state, and the health crisis threatens their implementation. provider reimbursement rates can be too low to ensure robust provider participation and broad access to care.31,32 In addition, coverage of services addressing pregnant Medicaid enrollees’ Funding to Address Pregnant and Postpartum health-related social needs is often limited and dependent on Women’s Health-Related Social Needs Is Insufficient the availability of services in the community.33–36 and Lacks Coordination Maternal morbidity and mortality in the United States cannot How Medicaid pays for pregnancy-related services has also be divorced from preexisting burdens on women’s health and contributed to disparities in health outcomes. Both Medicaid well-being, such as stress and depression related to poverty, managed-care organizations and fee-for-service programs poor housing conditions, family conflict, and neighborhood typically provide a single bundled payment (traditionally called violence.55,56 Addressing these factors requires access a “global fee”) for all maternity care services delivered during to a range of services (e.g., mental and behavioral health pregnancy (typically prenatal, labor and delivery, and at least services, maternal and infant home visiting, care coordination) some postpartum care).37 The payment is often triggered by that can be instrumental in helping identify and address the delivery and not tied to the length and quality of prenatal care needs of pregnant and postpartum women. Supports that or provision of postpartum care, because providers can bill at link women with intimate partner violence interventions, help delivery regardless of whether the patient attends her visits.38 them secure housing and food, or provide transportation and Medicaid programs pay facility fees for the actual delivery communication assistance, child care services, and items separately, with much higher fees for hospital deliveries than needed to safely raise a baby (e.g., breast pumps, diapers, and birth center deliveries and, traditionally, higher fees for cesarean formula) can reduce stress and anxiety and help women have deliveries than vaginal births. This payment structure incentivizes a healthier pregnancy and care for their child. Incorporating hospital-based births and high-cost interventions that do not wraparound services and linking women with social services necessarily translate into better maternal health outcomes.37,39 are key components of holistic care, as recommended by Black Mamas Matter Alliance.57 In addition, Medicaid programs have historically provided less generous coverage of perinatal services and supports that Since the 1980s, states have been enhancing their Medicaid do not conform with traditional medical models in the United maternity care benefits by adding services such as targeted States. For example, though birth center care has been shown case management, nutritional counseling, health education, to improve quality of care and maternal health outcomes,40 and home visiting.31,58 However, as interviewees noted only 33 state Medicaid programs covered birth center repeatedly, Medicaid coverage of these services often fails to deliveries in 2018.41 Even fewer Medicaid programs cover meet patients’ needs and requires social service providers, home births for women with low-risk pregnancies.31 Even when and even health systems with integrated human services, to 3|Covid-19 Challenges and Opportunities for Maternity Care Financing solicit supplemental support from other sources, such as local anxiety70—at the same time that access to health care and foundations, or rely on community-based organizations that social services are constrained by social distancing measures are already stretched thin. For example, a mix of federal, state, and increased demand for already limited resources. Before and local sources typically fund comprehensive home visiting the pandemic, about a quarter of Americans living in poverty programs to support pregnant and postpartum women and/or were disconnected from social safety net benefits for which young children, but the funding has often been inadequate.59,60 they were eligible, such as nutritional, housing, food, and child As one informant noted, despite home visiting being around for care assistance.36 And the economic fallout from the pandemic decades, Medicaid coverage of this service remains limited.61 has only highlighted the inadequacy of the U.S. safety net.71–73 Caring for women’s health-related social needs clearly extends Interviewees recounted that many state and local government beyond financing, but the ad hoc and unstable funding behind resources, including staff and funding, were redirected to care coordination and wraparound services has undermined emergency health responses. Consequently, some perinatal the effectiveness of such care. health and social service programs have fewer resources while facing greater need for assistance from their clients, particularly Many communities with low incomes have faced years with basics such as food, formula, and diapers. of disinvestment and poor public infrastructure, including lack of affordable housing, fresh-food supermarkets, public Demand for both birth center deliveries and home births rose in transportation, health care, and recreational facilities.62,63 Such the early days of the pandemic, when many states implemented environmental conditions have been shown to negatively affect stay-at-home orders to slow the spread of the coronavirus.74,75 health.64– 66 Key informants emphasized that community-based However, those out-of-hospital alternatives may have been social service organizations and supports often have limited inaccessible to women covered by a state Medicaid program capacity to meet the demand for their services, at least partially that does not cover those services, or because supply has because of the lack of investment in such resources. been limited by low reimbursement, burdensome licensing requirements, or contracting challenges imposed by Medicaid managed-care organizations.44 Maternal Health Financing During COVID-19: Exacerbated Deficiencies and Emerging Solutions Further, maternal health and other safety net health care providers who rely on Medicaid reimbursement have The pandemic has highlighted the need for greater investment experienced financial peril because of the pandemic, which in health care and social services, especially given that may push some providers out of business and further constrain communities of color disproportionately face both the health access to care for underserved communities.76 These financial and financial consequences of the crisis.9–16 Though some difficulties have stemmed from decreased use of services, as public resources for perinatal health care and social services many patients have delayed preventive and nonurgent care have been diverted to the emergency response, federal, state, because of concerns about exposure to the virus and out- and local governments have also increased investment in of-pocket costs.77 Particularly alarming are large reductions protecting public health and allowed for expanded and more in primary and preventive health care use among 40 million efficient flow of COVID-19-related funding to aid individuals, infants and children enrolled in Medicaid and CHIP between families, and business. March and May 2020; compared with the same period in 2019, 1.7 million fewer babies under age 2 received vaccinations, 3.2 million fewer children received developmental screenings, and The Pandemic Has Strained Existing Maternity 7.6 million fewer children received dental services, according Care Funding to recently released CMS data.78 Missing these critical services Little was known about the effects of the coronavirus on can negatively affect children’s long-term development. And pregnant women in the pandemic’s early days, but data available the safety net providers offering these services are experiencing months into the crisis suggest pregnant women are more likely revenue losses that may undermine their viability. to experience severe illness from the virus than nonpregnant women.67 Hispanic and Black women (like their communities Though Congress allocated $175 billion within the Coronavirus at large) are more like to be affected by COVID-19 infections, Aid, Relief, and Economic Security, or CARES, Act Provider adding yet another risk for women already experiencing Relief Fund to reimburse providers for lost revenue, among disproportionately poor birth outcomes. These disparities are other objectives, these funds have been primarily directed to largely attributable to social and economic inequities that have hospitals, rural health care providers, and nursing homes in been exacerbated by the pandemic.68,69 COVID-19 hotspots.79,80 Providers primarily serving Medicaid- enrolled and uninsured patients, such as community health In addition to an increased likelihood of COVID-19 infection, centers, have been among the last to receive the federal pregnant women of color with low incomes face greater risks assistance.81 Across the country, nearly 2,000 community of food insecurity, unstable housing, and depression and health centers have temporarily closed because of patient visit 4|Covid-19 Challenges and Opportunities for Maternity Care Financing declines and staffing challenges, and some may close their pregnancy. This effectively extends postpartum coverage doors permanently absent federal financial aid.82,83 beyond the 60-day limit for the duration of the public health emergency.97,98 However, this requirement does not apply to Unprecedented unemployment rates have resulted in more separate state CHIP programs, meaning pregnant women people becoming eligible for Medicaid as state spending to receiving maternity care through these programs cannot fight the pandemic has increased and state revenues have maintain that coverage beyond 60 days postpartum.99 But even plunged because of falling income and declining sales tax as some states pause or reverse their plans to permanently revenues.84 These forces present monumental challenges for extend postpartum coverage, others continue pursuing this policymakers planning and budgeting for programs focused option.50 Georgia lawmakers approved a measure to apply for on maternal health.85–87 Tennessee, Virginia, and Washington a waiver for extending postpartum Medicaid coverage to six State paused their proposals to extend postpartum Medicaid months,100 and states such as Illinois and New Jersey have coverage for up to one year because of anticipated budget proposed postpartum expansions in their Medicaid Section constraints.88,89 Further, interviewees indicated they expect 1115 demonstration requests, which are currently under review cuts in public funding for the next several budget cycles. at CMS.101,102 Medicaid does not cover all of the health and health-related social services pregnant and postpartum women need, and Some interviewees have noticed higher rates of virtual when budgets are reduced, nonclinical services may be the first postpartum visits during the pandemic than in-person visits to be eliminated, particularly in fee-for-service reimbursement before the pandemic. This may be because virtual visits models. Moreover, Medicaid budget cuts may include provider eliminate the need to secure child care and transportation and payment reductions, which could worsen the financial position allow new mothers to focus on their newborns. Key informants of many safety net health care providers and constrain already therefore thought telehealth—which has grown exponentially limited Medicaid provider networks. during the pandemic, partially because of significant Medicaid flexibilities103—will remain an important tool for improving postpartum visit rates among Medicaid beneficiaries even Silver Linings for Maternity Care after the pandemic. Many informants emphasized that virtual After the national emergency declaration in early March, postpartum visits would need to incorporate the same services CMS began allowing states and providers additional flexibility (e.g., depression screening, referrals) and continue to be to respond to the pandemic by temporarily waiving certain reimbursed at the same rates as in-person visits. Some experts requirements in Medicaid and approving changes requested we spoke with believed some telehealth-facilitated maternity through Medicaid disaster relief state plan amendments.90,91 care should continue after the pandemic: though most prenatal State Medicaid programs began adopting measures intended care visits, particularly for women with high-risk pregnancies, to ease access to coverage and care previously restricted should be conducted in person, components such as by Medicaid policy. Such measures have included removing education or peer support may garner better participation cost-sharing requirements for certain services, suspending virtually.104 Many early childhood home visiting programs also prior authorization requirements, and expanding provider reported increased participation in virtual home visits.105 capacity by allowing out-of-state providers to bill Medicaid and permitting some services to be provided in alternative Informants also reported that philanthropic donors were an settings.92,93 Some states have also attempted to aid important source of stability and added flexibility at the beginning financially stressed providers through measures such as of the pandemic. Foundations and other private funders quickly direct payments and increased reimbursement rates;76,94,95 filled gaps left by diversion of public resources to acute care North Carolina’s Medicaid program increased reimbursement and were responsive to grantees’ shifting priorities. Some for free-standing birth centers by 5 percent.96 organizations redirected funding from programs or activities effectively prohibited by stay-at-home orders (e.g., in-person In addition, to receive the temporary 6.2 percentage-point support groups) to address families’ immediate needs, such as increase in the federal Medicaid matching rate made available assistance with food, diapers, and formula. Many foundations by the Families First Coronavirus Response Act, states must have pledged additional funding to support organizations provide continuous coverage for Medicaid beneficiaries during serving individuals and families hit hard by the pandemic.106–108 the pandemic, including women who enroll on the basis of 5|Covid-19 Challenges and Opportunities for Maternity Care Financing Maternal Health Financing Priorities for the access to Medicaid by streamlining eligibility and enrollment Pandemic and Beyond processes and permanently eliminating work requirements, cost sharing, and other eligibility and enrollment restrictions.122 As the United States struggles to contain the pandemic and revive the economy, looming state Medicaid budget shortfalls ›Increase federal assistance to states. States face dire threaten funding for maternal health care. Social service and financial constraints, and expanding coverage for many health care provider shortages, workforce challenges, and more enrollees on Medicaid rolls could be nearly impossible financial pressures may also be exacerbating disparities in without additional help from the federal government. The 6.2 maternal health outcomes. By drawing attention to these percentage-point increase in the federal share of Medicaid long-standing issues, the pandemic presents an opening for spending is only about half of what states received during the the United States to reevaluate maternal care payment and Great Recession.123,124 In addition, this temporary increase delivery, address these challenges, and promote equity during is set to expire at the end of the fiscal year quarter when and after the pandemic. the public health emergency ends, currently set for January 21, 2021.98,125 Several organizations, including the American College of Obstetricians and Gynecologists, the National Immediate Maternal Health Financing Priorities During Governors Association, and America’s Essential Hospitals, the Pandemic have asked Congress to increase federal assistance for Some emergency policy responses that expanded access Medicaid by at least 12 percentage points relative to to Medicaid coverage during the pandemic could improve prepandemic levels.126,127 In addition, the U.S. Government maternal outcomes broadly and could be maintained and Accountability Office recently recommended Congress use expanded during and beyond the pandemic. Federal and state a Medicaid funding formula that accounts for states’ current governments can look to the following to promote equitable economic conditions to permanently provide more timely maternal health outcomes: and better-targeted assistance to state Medicaid programs in future economic downturns.128 ›Permanently extend postpartum Medicaid coverage beyond 60 days. Uninsured new mothers face many ›Ensure funding for home visiting programs. Home challenges, including untreated pregnancy-related health visiting programs provide critical support to disadvantaged conditions and unaffordable health care.109 Thus, continuous families at risk of poor maternal and health outcomes. These Medicaid coverage after delivery could improve new evidence-based programs have shown to improve maternal mothers’ health outcomes and access to needed care. Even health and family economic security, as well as child health when the public health emergency subsides, the economy and school readiness.129 Thus, they are critical during the may take years to fully recover, potentially leaving many pandemic, when so many families have been destabilized. Americans—disproportionately people of color, people living Despite initial service disruptions, many home visiting in poverty, and unemployed people—without access to programs have rapidly transitioned to a virtual environment, health insurance. Policy analysts, providers, and advocates and they continue helping families navigate available have therefore called for permanent expansion of postpartum assistance and secure their basic needs, as well as providing Medicaid coverage beyond the federal emergency declaration emotional support and domestic-violence interventions. In period.110–112 Given that many maternal deaths occur after addition, home visitors help ensure pregnant women attend delivery, several state maternal mortality review committees their prenatal appointments and newborns receive well-child recommend extending Medicaid postpartum coverage visits and vaccinations.105,130,131 Home visiting advocates are beyond 60 days.113–118 Further, Congress is considering the calling on federal and state governments to make immediate Helping MOMS Act, which would allow states to extend and long-term investments, such as increasing funding for Medicaid and CHIP coverage to one year postpartum.53,119 the Maternal, Infant, and Early Childhood Home Visiting program, to provide vital support to families in need during ›Ensure broad access to Medicaid. Access to health and after the pandemic.132 insurance coverage can help decrease maternal health disparities by increasing access to health care even before a woman becomes pregnant. Research shows women living Long-Term Maternal Health Financing Priorities Beyond in states that have expanded Medicaid under the Affordable the Pandemic Care Act have better access to preventive care, experience The current and anticipated maternity care funding challenges fewer adverse health outcomes during and after pregnancy, highlight the need to ensure Medicaid covers care models and have lower maternal mortality rates than women living and strategies that improve outcomes at a lower cost, and in states that did not expand Medicaid.120 Adopting the that Medicaid pays for maternity care in a way that promotes Medicaid expansion is an urgent priority for the remaining quality, equitable, and cost-effective care. Additionally, pregnant states that have not done so.121 States can promote better and postpartum women urgently require investments in social 6|Covid-19 Challenges and Opportunities for Maternity Care Financing services and supports that address their health-related social ›Promote high-quality maternity care through managed- needs. To achieve these goals, the following strategies could care contracting. To better integrate and coordinate care be considered by state and federal policymakers: for pregnant enrollees and encourage use of alternative payment models for maternity care, state Medicaid programs ›Ensure Medicaid provides reimbursement for evidence- could leverage their purchasing power and incorporate informed care. As states address forthcoming fiscal requirements or incentives in managed-care contracts. pressures, it is critical to focus on evidence-informed models States could require that managed-care organizations and strategies, such as midwives, birth centers, and doulas, screen for and address enrollees’ social needs, contract with that have been shown to improve pregnant and postpartum birth centers, or report on maternal health equity measures. women’s health outcomes and meet their health-related An increasing number of states already uses managed- social needs at a lower cost. A recently completed evaluation care contracts to address Medicaid beneficiaries’ health- of enhanced prenatal care models for Medicaid beneficiaries related social needs, such as by requiring managed-care implemented under the Strong Start for Mothers and organizations to screen beneficiaries for certain conditions Newborns initiative found that women receiving birth center and refer them to social services, or to collaborate with and midwife care had better birth outcomes and less costly community-based organizations to address enrollees’ births than women who received traditional care.40 Similarly, social needs.141 evidence suggests doula care improves maternal and infant health outcomes, including lower rates of cesarean ›Shore up social safety net programs. To improve the deliveries and preterm births, and can reduce racial health availability and capacity of social services and supports, disparities.46,133–136 Maternal health equity activists and including funding for housing, nutritional assistance, and advocates have elevated these models as approaches that child care, considerable investments are needed at the advance health equity.137–139 federal, state, and local levels. Though the health care sector has been increasing capacity for addressing patients’ health- ›Develop and implement value-based payment related social needs,142 it is not clear that health care dollars approaches for maternity care. Many stakeholders are a viable or efficient source for ensuring all communities agreed state Medicaid programs must reevaluate payment have the resources needed to meet needs of residents with approaches for maternity care and implement value-based low incomes, particularly amid the economic fallout from models that incentivize high-quality care and integrate the pandemic. wraparound social services by tying reimbursement to outcomes and measures that promote health equity. New payment models tied to structural, process, and performance Conclusion measures are urgently needed. These measures include early-initiation prenatal care; number of prenatal care visits The COVID-19 crisis shed new light on the deep racial health attended by patient; provision of health education; provision disparities that have long manifested in poor maternal health of linguistically and culturally specific care; care continuity; outcomes and misaligned incentives for payment for maternity patient satisfaction; screenings for substance use disorder, care services in the United States. Though the pandemic could health-related social needs, and postpartum depression; detract attention and funding from maternal health and further and referrals to address identified health and social needs. worsen maternal health inequities, it could also catalyze a shift To reward narrowing racial and ethnic maternal health toward a health care system where egregious disparities are no inequities, payment models tied to risk-adjusted mother longer tolerated. As the United States navigates the pandemic and infant outcome measures, such as rates of postpartum and plans for recovery, it has critical opportunities to prioritize complications, cesarean sections, preterm births, and changes that reduce maternal mortality and eliminate racial newborns with low birth weight, must be developed. And disparities in maternal and infant health outcomes. to create and sustain these payment models, states will also need to invest in better data collection systems.140 7|Covid-19 Challenges and Opportunities for Maternity Care Financing References 1 Delbanco S, Lehan M, Montalvo T, Levin-Scherz J. The rising U.S. maternal mortality rate demands action from employers. Harvard Business Review. June 28, 2019. https://hbr.org/2019/06/the-rising-u-s-maternal-mortality-rate-demands-action-from-employers. Accessed October 12, 2020. 2 We recognize some people who become pregnant and give birth do not identify as women. In this brief, we use “women” and “mothers” as shorthand for all people who might need pregnancy, birth, and postpartum care. “Maternal care” includes these services and anyone requiring them. 3 Centers for Disease Control and Prevention. Racial and Ethnic Disparities Continue in Pregnancy-Related Deaths. Atlanta: Centers for Disease Control and Prevention; 2019. https://www.cdc.gov/media/releases/2019/p0905-racial-ethnic-disparities-pregnancy-deaths.html. Accessed October 12, 2020. 4 The impact of institutional racism on maternal and child health. National Institute for Children’s Health Quality website. https://www.nichq.org/insight/ impact-institutional-racism-maternal-and-child-health. Accessed October 12, 2020. 5 Taylor J, Novoa C, Hamm K, Phadke S. Eliminating Racial Disparities in Maternal and Infant Mortality. 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Accessed October 12, 2020. 19 We use “perinatal” to describe the full antenatal and postpartum experience, rather than just the few weeks before and after delivery. 20 Callaghan WM. Overview of maternal mortality in the United States. Seminars in Perinatology 2012;36(1):2–6. https://doi.org/10.1053/j. semperi.2011.09.002. Published February 2012. Accessed October 12, 2020. 21 Creanga AA, Syverson C, Seed K, Callaghan WM. Pregnancy-related mortality in the United States, 2011–2013. Obstetrics and Gynecology 2017;130(2):366–73. https://doi.org/10.1097/aog.0000000000002114. Published August 2017. Accessed October 12, 2020. 8|Covid-19 Challenges and Opportunities for Maternity Care Financing 22 Saftlas AF, Koonin LM, Atrash HK. Racial disparity in pregnancy-related mortality associated with livebirth: Can established risk factors explain it? American Journal of Epidemiology 2000;152(5):413–19. https://doi.org/10.1093/aje/152.5.413. Published September 1, 2000. Accessed October 12, 2020. 23 Singh GK. Maternal Mortality in the United States, 1935–2007: Substantial Racial/Ethnic, Socioeconomic, and Geographic Disparities Persist. Rockville, MD: U.S. Department of Health and Human Services, Health Resources and Services Administration; 2010. https://www.hrsa.gov/ourstories/mchb75th/ mchb75maternalmortality.pdf. Accessed October 12, 2020. 24 Moaddab A, Dildy GA, Brown HL, et al. Health care disparity and state-specific pregnancy-related mortality in the United States, 2005–2014. Obstetrics and Gynecology 2016;128(4):869–75. https://doi.org/10.1097/aog.0000000000001628. Published October 2016. Accessed October 12, 2020. 25 Committee on Health Care for Underserved Women. Importance of social determinants of health and cultural awareness in the delivery of reproductive health care. Opinion no. 729. Obstetrics and Gynecology 2018;131:e43–e48. https://www.acog.org/clinical/clinical-guidance/committee-opinion/ articles/2018/01/importance-of-social-determinants-of-health-and-cultural-awareness-in-the-delivery-of-reproductive-health-care. Published January 2018. Accessed October 12, 2020. 26 Johnson SR. Maternal mortality crisis fueled by fragmented care. Modern Healthcare. June 15, 2019. https://www.modernhealthcare.com/safety-quality/ maternal-mortality-crisis-fueled-fragmented-care. Accessed October 12, 2020. 27 Wong PC, Kitsantas P. A review of maternal mortality and quality of care in the U.S.A. Journal of Maternal-Fetal and Neonatal Medicine 2019;33(19):3355– 67. https://doi.org/10.1080/14767058.2019.1571032. Published February 3, 2019. Accessed October 12, 2020. 28 In some states, CHIP is an important coverage option for women who do not quality for Medicaid based on income or immigration status. For simplicity, however, we discuss only Medicaid throughout, because CHIP covers a much smaller proportion of pregnant women overall. 29 Association of State and Territorial Health Officials. State Children’s Health Insurance Program (S-CHIP) coverage during pregnancy. 2016. https://www. astho.org/Maternal-and-Child-Health/State-Childrens-Health-Insurance-Program-S-CHIP-Coverage-During-Pregnancy/. Accessed October 12, 2020. 30 Medicaid and CHIP Payment and Access Commission. Medicaid’s role in financing maternity care. 2020. https://www.macpac.gov/wp-content/ uploads/2020/01/Medicaid%E2%80%99s-Role-in-Financing-Maternity-Care.pdf. Published January 2020. Accessed October 12, 2020. 31 Gifford K, Walls J, Ranji U, Salganicoff A, Gomez I. Medicaid Coverage of Pregnancy and Perinatal Benefits: Results From a State Survey. Menlo Park, CA: Henry J. Kaiser Family Foundation; 2017. https://www.kff.org/womens-health-policy/report/medicaid-coverage-of-pregnancy-and-perinatal-benefits- results-from-a-state-survey/. Accessed October 12, 2020. 32 Holgash K, Heberlein M. (2019). Physician Acceptance of New Medicaid Patients: What Matters and What Doesn’t. Health Affairs Blog. https://www. healthaffairs.org/do/10.1377/hblog20190401.678690/full/. 33 Renfrow J. Study: States lack guidelines for using Medicaid funding for social services. Fierce Healthcare. May 10, 2019. https://www.fiercehealthcare.com/ payer/states-without-guidelines-for-medicaid-funding-social-services. Accessed October 12, 2020. 34 Katch H. Medicaid Can Partner with Housing Providers and Others to Address Enrollees’ Social Needs. Washington: Center on Budget and Policy Priorities; 2020. https://www.cbpp.org/research/health/medicaid-can-partner-with-housing-providers-and-others-to-address-enrollees-social. Accessed October 12, 2020. 35 Nuamah A, Opthof E. (2020). On My Block: The Impact of Community Resources on Health Outcomes and Medical Spending. Center for Health Care Strategies Inc. https://www.chcs.org/on-my-block-the-impact-of-community-resources-on-health-outcomes-and-medical-spending/. 36 Minton S, Giannarelli L. Five things you may not know about the U.S. social safety net. Urban Institute. 2020. https://www.urban.org/research/publication/ five-things-you-may-not-know-about-us-social-safety-net. Published February 4, 2019. Accessed October 12, 2020. 37 Health Care Payment Learning and Action Network. Clinical episode payment models: Maternity care. 2016. http://hcp-lan.org/workproducts/maternity- whitepaper-final.pdf. Accessed October 12, 2020. 38 Centers for Medicare & Medicaid Services, Center for Medicaid and CHIP Services. Lessons learned about payment strategies to improve postpartum care in Medicaid and CHIP. 2019. https://www.medicaid.gov/medicaid/quality-of-care/downloads/postpartum-payment-strategies.pdf. Accessed October 12, 2020. 39 Maternity care. Center for Healthcare Quality and Payment Reform website. http://www.chqpr.org/maternitycare.html. Accessed October 12, 2020. 40 Centers for Medicare & Medicaid Services. Findings at a glance: Strong Start for Mothers and Newborns: Evaluation of full performance period (2018). https://innovation.cms.gov/files/reports/strongstart-prenatal-fg-finalevalrpt.pdf. Accessed October 12, 2020. 41 Medicaid benefits: Freestanding birth center services. Henry J. Kaiser Family Foundation website. https://www.kff.org/other/state-indicator/medicaid- benefits-freestanding-birth-center-services/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D. Accessed October 12, 2020. 42 Variations in 2015 Medicaid CNM/CM reimbursement for normal vaginal delivery (CPT 59400): How attractive is your state to these high value providers? American College of Nurse-Midwives website. https://www.midwife.org/acnm/files/ccLibraryFiles/Filename/000000005129/MedicaidPayment-CPT59400. pdf. Accessed October 13, 2020. 9|Covid-19 Challenges and Opportunities for Maternity Care Financing 43 Hill I, Dubay L, Courtot B, et al. Strong Start for Mothers and Newborns Evaluation: Year 5 Project Synthesis. Volume 1: Cross-Cutting Findings. Baltimore: Centers for Medicare & Medicaid Services; 2018. https://downloads.cms.gov/files/cmmi/strongstart-prenatal-finalevalrpt-v1.pdf. Accessed October 13, 2020. 44 Benatar S. (2020). Enhanced Medicaid Support for Out-of-Hospital Births Could Protect Moms and Babies and Reduce Hospital Strain. Urban Institute. https://www.urban.org/urban-wire/enhanced-medicaid-support-out-hospital-births-could-protect-moms-and-babies-and-reduce-hospital-strain. 45 Gebel C, Hodin S. (2020). Expanding Access to Doula Care: State of the Union. Maternal Health Task Force. https://www.mhtf.org/2020/01/08/expanding- access-to-doula-care/. 46 Gruber KJ, Cupito SH, Dobson CF. Impact of doulas on healthy birth outcomes. Journal of Perinatal Education 2013;22(1):49–58. https://www.ncbi.nlm.nih. gov/pmc/articles/PMC3647727/. Accessed October 12, 2020. 47 Dekker R. Evidence on: Doulas. Evidence Based Birth website. https://evidencebasedbirth.com/the-evidence-for-doulas/. Published March 27, 2013. Accessed October 13, 2020. 48 Hill I, Benatar S, Courtot B. et al. Strong Start for Mothers and Newborns Evaluation: Year 4 Annual Report. Volume 1: Cross-Cutting Findings. Baltimore: Centers for Medicare & Medicaid Services; 2018. https://downloads.cms.gov/files/cmmi/strongstart-snhancedprenatalcaremodels_evalrptyr4v1.pdf. Accessed October 13, 2020. 49 Pregnancy-related deaths. Centers for Disease Control and Prevention website. https://www.cdc.gov/vitalsigns/maternal-deaths/. Updated May 7, 2019. Accessed October 13, 2020. 50 View each state’s efforts to extend Medicaid coverage to postpartum women. National Academy for State Health Policy website. https://www.nashp.org/ view-each-states-efforts-to-extend-medicaid-coverage-to-postpartum-women/. Updated September 29, 2020. Accessed October 13, 2020. 51 Ranji U, Gomez I, Salganicoff A. Expanding postpartum Medicaid coverage. Henry J. Kaiser Family Foundation. 2019. https://www.kff.org/womens-health- policy/issue-brief/expanding-postpartum-medicaid-coverage/. Published May 22, 2019. Accessed October 13, 2020. 52 Table 5: Medicaid income eligibility limits for adults as a percent of the federal poverty level, January 2019. Henry J. Kaiser Family Foundation website. http://files.kff.org/attachment/Report-Medicaid-and-CHIP-Eligibility-as-of-Jan-2019-Table-5. Accessed October 13, 2020. 53 Helping MOMS Act of 2020, H.R. 4996. 116th Cong. (2019–20). 54 Eckert E. (2020). It’s Past Time to Provide Continuous Medicaid Coverage for One Year Postpartum. Health Affairs Blog. https://www.healthaffairs.org/ do/10.1377/hblog20200203.639479/. 55 National Partnership for Women and Families. Black women’s maternal health: A multifaceted approach to addressing persistent and dire health disparities. 2018. https://www.nationalpartnership.org/our-work/health/reports/black-womens-maternal-health.html. Published April 2018. Accessed October 13, 2020. 56 Vilda D, Wallace M, Dyer L, Harville E, Theall K. Income inequality and racial disparities in pregnancy-related mortality in the U.S. SSM—Population Health 2019;9:100477. https://dx.doi.org/10.1016%2Fj.ssmph.2019.100477. Published August 28, 2019. Accessed October 13, 2020. 57 Muse S. Setting the Standard for Holistic Care of and for Black Women. Atlanta: Black Mamas Matter Alliance; 2018. http://blackmamasmatter.org/wp- content/uploads/2018/04/BMMA_BlackPaper_April-2018.pdf. Accessed October 13, 2020. 58 Hill I, Hogan S, Palmer L, et al. Medicaid Outreach and Enrollment for Pregnant Women: What Is the State of the Art? Washington: Urban Institute; 2009. https://www.urban.org/sites/default/files/publication/30386/411898-Medicaid-Outreach-and-Enrollment-for-Pregnant-Women-What-Is-the-State-of-the- Art-.PDF. Accessed October 13, 2020. 59 Herzfeldt-Kamprath R, Calsyn M, Huelskoetter T. Medicaid and Home Visiting: Best Practices From States. Washington: Center for American Progress; 2017. https://www.americanprogress.org/issues/early-childhood/reports/2017/01/25/297160/medicaid-and-home-visiting/. Accessed October 13, 2020. 60 Wright Burak E. (2019). How Are States Using Medicaid to Pay for Home Visiting? New Paper Offers More Clarity. Georgetown University Health Policy Institute, Center for Children and Families. https://ccf.georgetown.edu/2019/01/24/how-are-states-using-medicaid-to-pay-for-home-visiting-new-paper- offers-more-clarity/. 61 Sandstrom H, White R. Scale Evidence-Based Home Visiting to Reduce Poverty and Improve Health. Washington: U.S. Partnership on Mobility from Poverty; 2018. https://www.mobilitypartnership.org/scale-evidence-based-home-visiting-programs-reduce-poverty-and-improve-health. Accessed October 13, 2020. 62 Bishaw A. Changes in Areas with Concentrated Poverty: 2000 to 2010. Washington: U.S. Department of Commerce, Economics and Statistics Administration; 2014. http://www.census.gov/content/dam/Census/library/publications/2014/acs/acs-27.pdf. Accessed October 13, 2020. 63 Kneebone E. The growth and spread of concentrated poverty, 2000 to 2008–2012. Brookings Institution website. http://www.brookings.edu/research/ interactives/2014/concentrated-poverty#/M10420. Published July 31, 2014. Accessed October 13, 2020. 64 Braveman PA, Cubbin C, Egerter S, et al. Socioeconomic status in health research: One size does not fit all. JAMA 2005;294(22):2879–88. https://www.doi.org/10.1001/jama.294.22.2879. Published December 14, 2005. Accessed October 13, 2020. 10|Covid-19 Challenges and Opportunities for Maternity Care Financing 65 Marks JS. Why your zip code may be more important than your genetic code. Huffington Post. May 25, 2011. http://www.huffingtonpost.com/ james-s-marks/why-your-zip-code-maybe_b_190650.html. Accessed October 13, 2020. 66 How do neighborhood conditions shape health? An excerpt from Making the Case for Linking Community Development and Health. San Francisco: Build Healthy Places Network; 2015. https://www.buildhealthyplaces.org/content/uploads/2015/09/How-Do-Neighborhood-Conditions-Shape-Health.pdf. Accessed October 13, 2020. 67 Delahoy MJ, Whitaker M, O’Halloran A, et al. Characteristics and maternal and birth outcomes of hospitalized pregnant women with laboratory-confirmed COVID-19—COVID-NET, 13 states, March 1–August 22, 2020. Morbidity and Mortality Weekly Report 2020;69(38):1347–54. https://www.cdc.gov/mmwr/ volumes/69/wr/mm6938e1.htm?s_cid=mm6938e1_w. Published September 25, 2020. Accessed October 13, 2020. 68 Centers for Disease Control and Prevention. Health equity considerations and racial and ethnic minority groups. https://www.cdc.gov/coronavirus/2019- ncov/community/health-equity/race-ethnicity.html. Updated July 24, 2020. Accessed October 13, 2020. 69 Kijakazi K. (2020). COVID-19 Racial Health Disparities Highlight Why We Need to Address Structural Racism. Urban Institute. https://www.urban.org/urban- wire/covid-19-racial-health-disparities-highlight-why-we-need-address-structural-racism. 70 Davenport MH, Meyer S, Meah VL, Strynadka MC, Khurana R. Moms are not OK: COVID-19 and maternal mental health. Frontiers in Global Women’s Health 2020. https://doi.org/10.3389/fgwh.2020.00001. Published June 19, 2020. Accessed October 15, 2020. 71 Shafer P, Avila CJ. (2020). 4 Ways COVID-19 Has Exposed Gaps in the U.S. Social Safety Net. The Conversation. https://theconversation.com/4-ways- covid-19-has-exposed-gaps-in-the-us-social-safety-net-138233. 72 Aaron HJ. (2020). The Social Safety Net: The Gaps That COVID-19 Spotlights. Brookings Institution. https://www.brookings.edu/blog/up-front/2020/06/23/ the-social-safety-net-the-gaps-that-covid-19-spotlights/. 73 Broadus J. COVID-19 shows fraying U.S. safety net, Berkeley scholars say. Berkeley News. July 6, 2020. https://news.berkeley.edu/2020/07/06/covid-19- shows-fraying-u-s-safety-net-berkeley-scholars-say/. Accessed October 13, 2020. 74 Molla R. The demand for midwives is surging. Here’s why I made the switch to home birth. Vox. April 28, 2020. https://www.vox.com/first- person/2020/4/28/21225201/coronavirus-covid-19-pregnancy-home-birth. Accessed October 13, 2020. 75 Schmidt S. Pregnant women are opting for home births as hospitals prepare for coronavirus. Washington Post. March 20, 2020. https://www. washingtonpost.com/dc-md-va/2020/03/20/pregnant-women-worried-about-hospitals-amid-coronavirus-are-turning-home-births-an-alternative/. Accessed October 13, 2020. 76 Musumeci M, Rudowitz R, Hinton E, Dolan R, Pham O. Options to support Medicaid providers in response to COVID-19. Henry J. Kaiser Family Foundation. 2020. https://www.kff.org/coronavirus-covid-19/issue-brief/options-to-support-medicaid-providers-in-response-to-covid-19/. Published June 17, 2020. Accessed October 13, 2020. 77 Gonzalez D, Zuckerman S, Kenney GM, Karpman M. Almost half of adults in families losing work during the pandemic avoided health care because of costs or COVID-19 concerns. Urban Institute. 2020. https://www.urban.org/research/publication/almost-half-adults-families-losing-work-during-pandemic- avoided-health-care-because-costs-or-covid-19-concerns. Published July 10, 2020. Accessed October 13, 2020. 78 Centers for Medicare & Medicaid Services. Fact sheet: Service use among Medicaid & CHIP beneficiaries age 18 and under during COVID-19. 2020. https://www.cms.gov/newsroom/fact-sheets/fact-sheet-service-use-among-medicaid-chip-beneficiaries-age-18-and-under-during-covid-19. Published September 23, 2020. Accessed October 13, 2020. 79 Coronavirus Aid, Relief, and Economic Security Act, H.R. 748, 116th Cong. (2019–20). 80 U.S. Department of Health and Human Services. HHS Announces Additional Allocations of CARES Act Provider Relief Fund. Washington: U.S. Department of Health and Human Services; 2020. https://www.hhs.gov/about/news/2020/04/22/hhs-announces-additional-allocations-of-cares-act-provider-relief- fund.html. Accessed October 13, 2020. 81 Coughlin TA, Ramos C, Blavin F, Zuckerman S. (2020). Federal COVID-19 Provider Relief Funds: Following the Money. Urban Institute. https://www.urban. org/urban-wire/federal-covid-19-provider-relief-funds-following-money. 82 Corallo B, Tolbert J. Impact of coronavirus on community health centers. Henry J. Kaiser Family Foundation. 2020. https://www.kff.org/coronavirus- covid-19/issue-brief/impact-of-coronavirus-on-community-health-centers/. Accessed October 13, 2020. 83 Ollove M. (2020). Community Health Centers Excluded From Federal Coronavirus Aid. Pew Charitable Trusts. https://www.pewtrusts.org/en/research-and- analysis/blogs/stateline/2020/06/22/community-health-centers-excluded-from-federal-coronavirus-aid. 84 Banthin J, Simpson M, Buettgens M, Blumberg LJ, Wang R. Changes in health insurance coverage due to the COVID-19 recession. Urban Institute. 2020. https://www.urban.org/research/publication/changes-health-insurance-coverage-due-covid-19-recession. Published July 13, 2020. Accessed October 13, 2020. 85 Pifer R. States brace for ‘nearly certain’ Medicaid budget shortfalls amid COVID-19. Healthcare Dive. 2020. https://www.healthcaredive.com/news/states- brace-for-nearly-certain-medicaid-budget-shortfalls-amid-covid-19/578120/. Published May 18, 2020. Accessed October 13, 2020. 86 Rudowitz R, Hinton E. Early look at Medicaid spending and enrollment trends amid COVID-19. Henry J. Kaiser Family Foundation. 2020. https://www.kff. org/medicaid/issue-brief/early-look-at-medicaid-spending-and-enrollment-trends-amid-covid-19/. Published May 15, 2020. Accessed October 13, 2020. 11|Covid-19 Challenges and Opportunities for Maternity Care Financing 87 Aron-Dine A, Hayes K, Broaddus M. With Need Rising, Medicaid Is At Risk for Cuts. Washington: Center on Budget and Policy Priorities; 2020. https:// www.cbpp.org/research/health/with-need-rising-medicaid-is-at-risk-for-cuts. Published July 22, 2020. Accessed October 13, 2020. 88 Smith S. TennCare postpartum care expansion cut from revised state budget. WBIR. June 8, 2020. https://www.wbir.com/article/life/tenncare-postpartum- care-expansion-cut-from-revised-state-budget/51-8587612b-7c73-4566-b5e2-be7f524ace0d. Accessed October 13, 2020. 89 Painchaud A. States respond to COVID-19: Postpartum Medicaid coverage, contact tracing. America’s Essential Hospitals. 2020. https://essentialhospitals. org/policy/states-respond-covid-19-postpartum-medicaid-coverage-contact-tracing/ Published April 28, 2020. Accessed October 22, 2020. 90 Centers for Medicare & Medicaid Services. CMS Takes Action Nationwide to Aggressively Respond to Coronavirus National Emergency. Baltimore: Centers for Medicare & Medicaid Services; 2020. https://www.cms.gov/newsroom/press-releases/cms-takes-action-nationwide-aggressively-respond-coronavirus- national-emergency. Accessed October 13, 2020. 91 See table 2 in Medicaid emergency authority tracker: Approved state actions to address COVID-19. Henry J. Kaiser Family Foundation website. https://www.kff.org/coronavirus-covid-19/issue-brief/medicaid-emergency-authority-tracker-approved-state-actions-to-address-covid-19/#Table2. Published October 7, 2020. Accessed October 13, 2020. 92 Medicaid emergency authority tracker: Approved state actions to address COVID-19. Henry J. Kaiser Family Foundation website. https://www.kff.org/ coronavirus-covid-19/issue-brief/medicaid-emergency-authority-tracker-approved-state-actions-to-address-covid-19/. Published October 7, 2020. Accessed October 13, 2020. 93 Dolan R, Artiga S. State actions to facilitate access to Medicaid and CHIP coverage in response to COVID-19. Henry J. Kaiser Family Foundation. 2020. https://www.kff.org/coronavirus-covid-19/issue-brief/state-actions-to-facilitate-access-to-medicaid-and-chip-coverage-in-response-to-covid-19/. Published May 22, 2020. Accessed October 13, 2020. 94 Guyer J, Boozang P. New Hampshire COVID-19 directed payment. State Health and Value Strategies. 2020. https://www.shvs.org/new-hampshire-covid- 19-directed-payment/. Published June 17, 2020. Accessed October 13, 2020. 95 Stephens K. Virginia Medicaid Agency announces emergency relief support for providers. Wavy. July 1, 2020. https://www.wavy.com/news/virginia/virginia- medicaid-agency-announces-emergency-relief-support-for-providers/. Accessed October 13, 2020. 96 Freestanding birth center services. North Carolina Department of Medical Assistance website. https://files.nc.gov/ncdma/documents/Fee-Schedules/ Freestanding-birth-centers/FSBC-Fee-Schedule--May-2020--COVID-19-.pdf. Accessed October 13, 2020. 97 Postpartum Medicaid coverage extended during COVID-19: Resources for your practice. American College of Obstetricians and Gynecologists website. https://www.acog.org/practice-management/payment-resources/resources/postpartum-medicaid-coverage-extended-during-covid-19. Accessed October 13, 2020. 98 HHS renews COVID-19 national public health emergency declaration. American Hospital Association website. https://www.aha.org/news/headline/2020- 10-02-hhs-renews-covid-19-national-public-health-emergency-declaration. Published October 2, 2020. Accessed October 13, 2020. 99 Collins S. Access to coverage and preventive care for pregnant women and children. National Conference of State Legislatures. 2020. https://www.ncsl. org/Portals/1/Documents/Health/SCollinsMCHFellows_34936.pdf. Published September 10, 2020. Accessed October 13, 2020. 100 Amy J. Georgia lawmakers approve more health coverage for new moms. Savannah Now. June 25, 2020. https://www.savannahnow.com/ news/20200625/georgia-lawmakers-approve-more-health-coverage-for-new-moms. Accessed October 13, 2020. 101 Illinois continuity of care and administrative simplification 1115 waiver. Medicaid.gov. https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Waivers/1115/downloads/il/il-continuity-care-admin-simplification-pa.pdf. Accessed October 13, 2020. 102 Jacobs LJ (assistant commissioner, New Jersey), letter to Nocito J (project officer, Centers for Medicare & Medicaid Services), regarding NJ 1115 comprehensive demonstration amendment. February 27, 2020. https://www.medicaid.gov/medicaid/section-1115-demonstrations/downloads/nj-1115- request-pa.pdf. Accessed October 13, 2020. 103 Centers for Medicare & Medicaid Services. State Medicaid & CHIP Telehealth Toolkit: Policy Considerations for States Expanding Use of Telehealth. Baltimore: Centers for Medicare & Medicaid Services; 2020. https://www.medicaid.gov/medicaid/benefits/downloads/medicaid-chip-telehealth-toolkit.pdf. Accessed October 13, 2020. 104 Hill I, Burroughs E. Maternal telehealth has expanded dramatically during the COVID-19 pandemic: Equity concerns and promising approaches. Urban Institute. 2020. 105 Yard R, Lewy D. (2020). The Crucial Role of Home Visiting During COVID-19: Supporting Young Children and Families. Center for Health Care Strategies. https://www.chcs.org/the-crucial-role-of-home-visiting-during-covid-19-supporting-young-children-and-families/. 106 Haley J, Benatar S. Improving patient and provider experiences to advance maternal health equity. Urban Institute. 2020. 107 Foundations pledge support for COVID-19 relief – Update (3/29/2020). Philanthropy News Digest. March 29, 2020. https://philanthropynewsdigest.org/ news/foundations-pledge-support-for-covid-19-relief-update-3-29-2020. 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Phoenix, AZ: Arizona Department of Health Services; 2019. https://azdhs.gov/ documents/operations/managing-excellence/breakthrough-plans/maternal-mortality-breakthrough-plan.pdf. Accessed October 13, 2020. 114 Georgia Department of Public Health. Maternal Mortality Report 2014. Atlanta: Georgia Department of Public Health; 2019. https://reviewtoaction.org/sites/ default/files/portal_resources/Maternal%20Mortality%20BookletGeorgia.FINAL_.hq_.pdf. Accessed October 13, 2020. 115 Maryland Department of Health. Maryland Maternal Mortality Review: 2019 Annual Report. Annapolis, MD: Maryland Department of Health; 2020. https:// phpa.health.maryland.gov/mch/Documents/Health-General%20Article,%20%C2%A713-1207,%20Annotated%20Code%20of%20Maryland%20-%20 2019%20Annual%20Report%20%E2%80%93%20Maryland%20Maternal%20Mortality%20Review.pdf. Accessed October 13, 2020. 116 Texas Department of State Health Services. Maternal Mortality and Morbidity Task Force and Department of State Health Services Joint Biennial Report. Austin, TX: Texas Department of State Health Services; 2018. https://www.dshs.texas.gov/mch/Maternal-Mortality-and-Morbidity-Review-Committee.aspx. Accessed October 13, 2020. 117 Utah Department of Health. Maternal Mortality in Utah: 2015–2016. Salt Lake City: Utah Department of Health; 2018. https://reviewtoaction.org/sites/ default/files/portal_resources/PMR%20Update%200718_0.pdf. Accessed October 13, 2020. 118 Washington State Department of Health. Maternal Mortality Review: A Report on Maternal Deaths in Washington, 2014–2015. Seattle: Washington Department of Health; 2017. www.doh.wa.gov/Portals/1/Documents/Pubs/140-154-MMRReport.pdf. Accessed October 13, 2020. 119 House passes AHA-supported Helping MOMS Act. American Hospital Association website. https://www.aha.org/news/headline/2020-09-30-house- passes-aha-supported-helping-moms-act. Published September 30, 2020. Accessed October 13, 2020. 120 Searing A, Cohen Ross D. Medicaid expansion fills gaps in maternal health coverage leading to healthier mothers and babies. Georgetown Health Policy Institute, Center for Children and Families. 2019. https://ccf.georgetown.edu/wp-content/uploads/2019/05/Maternal-Health-3a.pdf. Published May 2019. Accessed October 13, 2020. 121 Status of state Medicaid expansion decisions: Interactive map. Henry J. Kaiser Family Foundation website. https://www.kff.org/medicaid/issue-brief/status- of-state-medicaid-expansion-decisions-interactive-map/. Published October 1, 2020. Accessed October 13, 2020. 122 Aron-Dine A. Eligibility Restrictions in Recent Medicaid Waivers Would Cause Many Thousands of People to Become Uninsured. Washington: Center on Budget and Policy Priorities; 2018. https://www.cbpp.org/research/health/eligibility-restrictions-in-recent-medicaid-waivers-would-cause-many-thousands- of. Accessed October 13, 2020. 123 Belz S, Sheiner L. (2020). How Will the Coronavirus Affect State and Local Government Budgets? Brookings Institution. https://www.brookings.edu/blog/ up-front/2020/03/23/how-will-the-coronavirus-affect-state-and-local-government-budgets/. 124 Park E. (2020). Critical Need for Further, Large FMAP Increases to Sustain State Medicaid Programs During Economic Crisis. Georgetown University Health Policy Institute, Center for Children and Families. https://ccf.georgetown.edu/2020/05/04/critical-need-for-further-large-fmap-increases-to-sustain-state- medicaid-programs-during-economic-crisis/. 125 Rudowitz R, Corallo B, Garfield R. How much fiscal relief can states expect from the temporary increase in the Medicaid FMAP? Henry J. Kaiser Family Foundation. 2020. https://www.kff.org/coronavirus-covid-19/issue-brief/how-much-fiscal-relief-can-states-expect-from-the-temporary-increase-in-the- medicaid-fmap/. Published July 22, 2020. Accessed October 13, 2020. 126 American Academy of Family Physicians; American Cancer Society Cancer Action Network; American Federation of State, County, and Municipal Employees; et al., letter to Pelosi N, McConnell M, McCarthy K, Schumer C, regarding further enhancing the federal medical assistance percentage for Medicaid by at least 12 percentage points, https://www.aafp.org/dam/AAFP/documents/advocacy/payment/medicaid/LT-Congress-FMAPPolicy-060220. pdf. Accessed October 13, 2020. 13|Covid-19 Challenges and Opportunities for Maternity Care Financing 127 National Governors Association, National Association of Counties, National League of Cities, et al., letter to McConnell M, Schumer C, Pelosi N, McCarthy K, regarding enhancing the federal Medicaid match rate, July 10, 2020, https://www.nga.org/advocacy-communications/organizations-letter-advocating- for-enhanced-federal-medicaid-match/. Accessed October 13, 2020. 128 Government Accountability Office. 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Published April 14, 2020. Accessed October 13, 2020. 139 WithinReach. (2020). Achieving Health Equity for Black Moms and Babies: A Conversation with Nurse-Midwife, Victoria Fletcher. https://withinreachwa.org/ achieving-health-equity-for-black-moms-and-babies. 140 Taylor KJ, Allen EA, Hill I, et al. The pandemic has increased demand for data and accountability to decrease maternal health inequity. Urban Institute. 2020. 141 Hinton E, Rudowitz R, Diaz M, Singer N. 10 things to know about Medicaid managed care. Henry J. Kaiser Family Foundation. 2020. https://www.kff.org/ medicaid/issue-brief/10-things-to-know-about-medicaid-managed-care/. Published December 16, 2019. Accessed October 13, 2020. 142 Kenney GM, Waidmann T, Skopec L, Allen EH. What Would It Take to Reduce Inequities in Healthy Life Expectancy? Washington: Urban Institute; 2019. https://www.urban.org/research/publication/what-would-it-take-reduce-inequities-healthy-life-expectancy. Accessed October 13, 2020. 14|Covid-19 Challenges and Opportunities for Maternity Care Financing 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. About the Authors Eva H. Allen is a research associate in the Health Policy Center at the Urban Institute, where her work focuses on the effects of Medicaid policies and initiatives on disadvantaged populations, including people with chronic physical and mental health conditions, pregnant and postpartum women, and people with substance use disorders. Ms. Allen has played a key role in several federal demonstration evaluations as well as research projects on a range of topics, including opioid use disorder and treatment, maternal and child health, long term care services and supports, and cross-sector collaborations to address social determinants of health. Her current work also includes a focus on integrating health and racial equity in research and policy analysis. Ms. Allen is experienced in qualitative research methods and adept at communicating complex policy issues and research findings to diverse audiences. Allen holds an MPP from George Mason University, with emphasis in Social Policy. Sarah Benatar is a principal research associate in the Health Policy Center. Her research investigates how public policies affect vulnerable populations’ health outcomes, access to care, use of services, and enrollment in coverage programs, with a particular focus on maternal and child health. Benatar has led and participated in several projects focused on maternal and child health, the Children’s Health Insurance Program, and Medicaid, combining qualitative and quantitative methods to achieve the richest findings. She is working on a national evaluation of the Centers for Medicare and Medicaid Services’ Strong Start for Mothers and Newborns enhanced prenatal care program; she leads the evaluation’s process measurement and monitoring task and is a senior member of the case study team. Benatar is also deputy project director for a multiyear evaluation of a home visitation and community-based program intervention in Los Angeles, aimed at improving health and developmental outcomes for low-income mothers and children. She is coleading a study to examine the impact of the Affordable Care Act on women’s preventive health care service use. Additional recent work includes an evaluation of ongoing efforts to redesign the county clinic system in San Mateo County, California, an evaluation of a physician incentive program in Los Angeles, a review of recent family planning research, and a feasibility assessment of a universal vaccine-purchasing program for children in New York State. Benatar holds a PhD in public policy from George Washington University. Acknowledgments We thank study participants who shared their valuable time and insights with us and our colleagues Ian Hill, Kimá Joy Taylor, Jenny Haley, Emmy Burroughs, and Sarah Coquillat for collaboration on data collection and analysis. Our thanks also extend to Elisabeth Wright Burak, Maggie Clark, Genevieve M. Kenney, Edwin Park, Jessica Schubel, 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. 15|Covid-19 Challenges and Opportunities for Maternity Care Financing