New mothers who otherwise would have lost Medicaid coverage in Colorado after two months now can stay insured for up to a year — a move that the state’s review board recommended to reduce maternal mortality.
The American Rescue Plan Act allows states to extend new mothers’ Medicaid eligibility to 12 months, for the next five years. If Congress doesn’t pass legislation making the extension permanent, Colorado and the other 33 states that opted in will have to apply to keep it in place past 2027.
Colorado’s maternal mortality review committee had recommended extending coverage for the first year after birth and changing protocols to check in with new mothers more often, preferably by bundling their care with their infants’. Mothers covered by Medicaid, who have lower incomes and more stressors, are more likely to die during pregnancy or in the first year after birth than those who have a different form of health insurance.
While the extension is linked to the postpartum period, eligible people can seek care for any health need, not just those related to the pregnancy or birth. Health First Colorado, the state’s Medicaid program, covers about 40% of pregnant people.
The change could be one of the biggest initiatives in recent Medicaid history, in terms of lives saved, said Susanna Snyder, maternal child health manager at the Colorado Department of Health Care Policy and Financing.
“This is definitely in my top three,” she said. “We know that the need is higher in our population.”
In Colorado, adults who don’t have any special circumstances — such as pregnancy — are only eligible for Medicaid if their incomes are below 133% of the poverty line, or roughly $24,360 for two people. During pregnancy and the postpartum period, the cutoff is raised to 195% of the poverty line, or $35,712 for the same two-person family.
Extending mothers’ eligibility will cost about $19 million, with about $10 million paid by the federal government through Medicaid matching funds. The state pays the remaining $9 million.
In a typical year, between 7,000 and 8,000 Coloradans who meet the more-generous income limit during pregnancy would lose Medicaid coverage two months after giving birth, as would about 1,500 women covered by the Children’s Health Insurance Program, Snyder said. During the federally declared public health emergency, however, states haven’t been allowed to disenroll Medicaid recipients, so it hasn’t been an issue, she said.
The COVID-19 public health emergency is expected to last through at least mid-October, and it’s possible the U.S. Department of Health and Human Services could renew it for another 90 days at that point. Still, everyone insured by Medicaid needs to update their contact information with the state as soon as possible and report if they’re pregnant or recently had a baby, so they won’t be disenrolled if they still qualify for coverage, Snyder said.
“It’s really important for people to begin telling us they’re pregnant now,” she said.
Colorado had the third-lowest maternal mortality rate of 30 states with reliable data from 2018 to 2020, according to the Centers for Disease Control and Prevention, with about 14 deaths for every 100,000 births. That’s similar to the odds of dying during pregnancy or shortly after birth in Chile, Bahrain, or Albania.
It’s not clear how many of those were preventable, but a separate review of Colorado maternal deaths between 2014 and 2016 found about 77% were.
That review, which examined 94 deaths among women who were pregnant or who had recently given birth in Colorado found the top causes of death were suicide, accidental drug overdoses, other injuries, homicide and heart conditions.
Tina Sherman, senior campaign director for MomsRising, said providers can not only treat physical and mental health problems, but also screen for domestic violence and educate patients about avoiding accidents. Some people develop new mental health problems during pregnancy, while others are able to get their existing conditions under control because they’re receiving far more care than usual. Cutting off care abruptly during what can be a stressful time sometimes sets them back, she said.
“A lot of times, what we’ll see is moms make improvements” during pregnancy, she said.
The hope is that if providers are able to see new mothers more often because of extended coverage, they can build trust so that the mothers will tell them if they’re struggling, Snyder said. Particularly in communities of color, parents are reluctant to report mental health or substance use problems because they worry their children will be taken away, she said.
Gretchen McGinnis, senior vice president of health care services and accountable care at Colorado Access, said it’s unlikely that maternal mortality is going to drastically drop in the short term, but over time, the trend should improve. Colorado Access is a regional accountable entity and coordinates Medicaid services for people in Adams, Arapahoe, Denver, Douglas and Elbert counties.
If a delivery isn’t complicated for either the mother or baby, most care directly related to the birth is taken care of in the first two months, McGinnis said. But people covered by Medicaid have more barriers to care, such as arranging child care and transportation, so not all are able to make their postpartum visits within that time, she said.
And of course, complicated births require longer care, and new health issues can crop up more than two months after delivery, McGinnis said. That’s a particular concern for mental health challenges, because people tend to have more support in the first months and may find their stress levels rise later, she said.
“The impact of delivering a child and bringing a child into your family is not limited to 60 days,” she said.
The American College of Obstetricians and Gynecologists recommends that new mothers with uncomplicated pregnancies and births have a postpartum visit three weeks later, and again after 12 weeks. Some will need more frequent check-ups, and may need to start one week after birth, especially if they had high blood pressure during pregnancy.
Extending coverage won’t guarantee that everyone gets the right care; that’s going to require providers and the Colorado Access team focused on maternal health to help patients with whatever might get in the way, McGinnis said. But it is a necessary step, she said.
The two-month limit was always somewhat arbitrary, since health problems don’t automatically stop in that time, and new ones can surface later, Sherman said. The United States is the only developed country where deaths in the year after a woman gives birth are rising, she said.
“We are just consistently going in the wrong direction,” she said.
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