Medicaid expansion improves women’s postpartum care, researchers say

SALT LAKE CITY — Medicaid expansion improves new moms’ access to care after delivery, especially for those at high risk of postpartum complications, according to a new study.

The findings shed light on successes of expansion, as well as the need for increased access to postpartum care, researchers said.

“Medicaid expansion’s a step in the right direction, but other policies that extend postpartum coverage should be considered, and making sure that we help women make the transition in the postpartum period to ensure that they are receiving high-quality care,” said Sarah H. Gordon, lead author of the study and assistant professor at Boston University School of Public Health.

Care after delivery

In 2018, the American College of Obstetricians and Gynecologists’ Presidential Task Force recommended that postpartum care become an “ongoing process,” and said that as many as 40% of women don’t attend a postpartum visit. Meanwhile, more than half of pregnancy-related deaths in the U.S. happen after childbirth, according to the task force.

An average of 700 women die every year from pregnancy-related issues, the Centers for Disease Control and Prevention says. And an average of about 15% of new mothers in Utah experience postpartum depression symptoms, a number that increases to 21% among low-income mothers, according to the Kem C. Gardner Policy Institute.

The new study, published in the academic journal Maternal & Child Health, examined Medicaid claims data from 2013 to 2015 in Colorado and Utah, comparing the numbers of postpartum visits in the two states 60 days after delivery — the duration of Medicaid eligibility for women postpregnancy.

The researchers also assessed Medicaid coverage and use of outpatient services six months after delivery.

Colorado expanded Medicaid in 2014, and Utah fully expanded coverage starting this year.

After Colorado expanded Medicaid, the researchers found that new mothers received better coverage retention after delivery and used more postpartum care compared to women in Utah, Gordon said.

In 2014, researchers said Utah saw declining Medicaid coverage rates among postpartum women as they transitioned to insurance under the federal marketplace. Though the women were still covered, they “did not use postpartum care at the same rates as women in Colorado used Medicaid-financed outpatient care,” according to the study.

The researchers weren’t able to discover why women who transitioned from Medicaid to private insurance received less care, Gordon explained. But she believes experiencing a change in insurance after having a baby is a “disruptive and stressful experience” that can involve finding a new doctor, needing to afford copays, and receiving different benefits.

Utah and Colorado were examined because they both had “innovative” data sources where all health care claims were aggregated in one place. The states’ similarities also made them easy to compare, Gordon said.

Because the researchers analyzed insurance claims data, they were able to identify women at high risk of complications — those who had serious problems like sepsis or hemorrhage at their times of delivery, Gordon said. Those women contribute disproportionately to high mortality rates among pregnant women. Under Medicaid expansion, that group accessed postpartum care at higher rates.

“It basically shows that these policies benefit the high-risk group that we really want to target in terms of reducing maternal morbidity and mortality,” according to Gordon.

Gordon said she was in Utah during the 2018 legislative session while debates centered around Medicaid expansion. One person who testified to legislators worried that expansion would take funding away from groups who were already eligible, like pregnant women, Gordon recalled.

“And I think this study is actually an example of how expansion can benefit those groups who were traditionally eligible,” she said.

The researchers suggested extending Medicaid pregnancy eligibility to 12 months after delivery.

Utah Medicaid expansion

The timeliness of Medicaid expansion issues in Utah made it a good candidate for such an analysis, Gordon said.

“I think this study really shows that the decision to fully implement a traditional Medicaid expansion is going to benefit pregnant women and new moms. And since the birth rate is really high in Utah, I think that’s a finding that a lot of people can get behind in the state,” according to Gordon.

In 2018, Utahns voted for a full Medicaid expansion through a ballot initiative. Legislators replaced it with a bill they said would save the state money. The bill required the state to work through a couple of options before Medicaid would be fully expanded. Utah received federal approval to fully expand Medicaid to 138% of the federal poverty level starting Jan. 1, with some limitations including a community engagement requirement.

Under the pre-expansion model in Utah, pregnant women with incomes below 138% of the federal poverty level were eligible for temporary Medicaid. Sixty days after delivery, women who made more than the federal poverty level dropped off the Medicaid program for pregnant woman.

Under the full expansion, eligibility went up to 144% of the federal poverty level for pregnant women, said Utah Medicaid spokeswoman Kolbi Young. After 60 days pass following their delivery, the women’s eligibility is reevaluated and they might be moved to the adult expansion program, as their family is now larger.

If a woman’s income is more than 138% of the federal poverty level for a family of her size, they will fall off the program after 60 days, Young said.

Historically in Utah, being dropped off Medicaid after 60 days is what made it difficult for many moms to receive postpartum care, according to Jessica Sanders, University of Utah assistant professor of obstetrics and gynecology.

Sanders was unaffiliated with the study and also serves as research director for the U. family planning division.

“For a lot of moms, that wasn’t enough time to come back in for a follow-up visit, either to have their postpartum care, or to access family planning services and contraception to safely and healthfully space their next pregnancy,” Sanders said.

Expanding coverage to 138% has allowed more time to access care, including for mental health issues and postpartum depression, which often don’t arise until later after giving birth.

“That’s a space where expanded access is really, really beneficial for maternal health,” Sanders said, “and in turn, better for the health of new babies.”

Courtney Bullard, education and collaborations director for advocacy group Utah Health Policy Project, said, “I’m really hoping that this can help new mothers in our state.”

“We have a lot of mothers who use Medicaid. And now, once they come off of pregnancy Medicaid, hopefully because we have Medicaid expansion, that benefit can act as a support network for moms,” Bullard said.

She said she hopes research will help lead to women receiving increased continuity of care through Medicaid expansion in Utah down the road.

Jessie Mandle, senior policy analyst with Voices for Utah Children, said, “Now moms will be able to have coverage for longer. This report just highlights how important it is for moms to have coverage beyond 60 days. ... And so we’re in a much better position now with expansion, it’s just so critical for mom’s health, and also for the health of the baby, too.”

Rep. Suzanne Harrison, D-Draper, had been eyeing legislation ahead of this upcoming session that would have covered pregnancy for those with incomes up to 185% of the poverty level. Currently in the federal marketplace, if you are pregnant and it’s not open enrollment period, you can’t get on a plan if you make more than 138% of the federal poverty level, Harrison said.

The bill would have also helped women get enrolled in the federal marketplace after their 60 days in Medicaid are up.

Harrison decided to put the idea on hold until a future session due to uncertainty about full Medicaid expansion and how many women will need additional coverage.

“To me, it is beneficial for us to be getting good prenatal care. We want healthy moms and healthy babies, and in terms of bang for your buck on investment, this is a no brainer in terms of helping everyone be healthy,” she said.

“Too many of our new moms are dying well after that birth period, they’re dying within the first year due to substance abuse or mental health issues, and to me, this is just devastating, and I hope that we can find solutions as a state to help minimize the loss of these new moms,” Harrison said.

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