The push to address the soaring U.S. maternal morality rate is colliding with a broader, more ideological public health imperative: Republican-led efforts to scale back Medicaid.
The safety net program pays for half of all births in the nation. Democrats and many public health experts see it as a natural vessel for slowing the death toll of pregnant women and new mothers, by extending care in the crucial year following childbirth.
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But concern over the potentially staggering cost has already quashed efforts in states such as Texas and left liberals in Congress glum over the prospects for a nationwide legislative fix.
“Medicaid represents the best of America and the administration’s effort to gut it would be a massive step backwards on confronting America’s maternal mortality crisis,” Sen. Elizabeth Warren (D-Mass.) wrote in an email.
The dynamic mirrors the federal response to the opioid epidemic, in which Republicans and the Trump administration support making addiction services more available while simultaneously working to shrink Medicaid, the largest single payer of behavioral and maternal health care.
Research has shown the risk of death after childbirth persists for a full year, from such factors as heart disease, stroke, infections and severe bleeding. Black and Native American women are about three times more likely to die from a pregnancy-related cause as white women, according to the Centers for Disease Control and Prevention.
Warren, along with fellow 2020 Democratic presidential contenders Sens. Bernie Sanders, Cory Booker and Amy Klobuchar, back extending Medicaid’s current requirement to cover new mothers from 60 days to one year after childbirth. Democratic proposals in the Senate from Dick Durbin of Illinois, and in the House, from Reps. Robin Kelly of Illinois and Ayanna Pressley of Massachusetts would do that along with provide states grants to improve hospital deliver practices, among other things.
But the efforts aren’t yielding GOP buy-in across the country, as conservative lawmakers keen on shrinking the program press for narrower fixes, such as increased data collection on deaths and a national standard of best medical practices. Proposals to enhance Medicaid coverage to address maternal mortality haven’t attracted a single Republican co-sponsor in Congress, with both sides at loggerheads on whether to grow or shrink the entitlement program.
“All mothers must have access to adequate care before and after delivery, and we should provide states with the tools and flexibility they need to ensure coverage of their most vulnerable populations,” Sen. John Cornyn (R-Texas) told POLITICO.
A Republican aide said GOP lawmakers are focused on getting a better picture of how many pregnant and postpartum women actually need coverage before exploring how to expand access to care. “That is a laborious process to undertake as we have to talk to both the states, stakeholders, and CMS to discern what coverage gaps exist. And we need to know the role other sources of coverage play as well,” the aide said.
Democrats say the prospect of expanding Medicaid benefits scares Republicans in an era of pitched partisan battles over health policy.
“Following the ACA and repeal Obamacare debates, health care, especially Medicaid experience, has become a hot issue — not quite a third rail but definitely hot and our GOP counterparts are a little squeamish,” a Democratic aide working on the issue said.
President Donald Trump last year signed a maternal care measure that directed millions of dollars in new spending to help states collect data on maternal mortality, but has been mum on extending Medicaid coverage to new mothers. His administration will weigh whether to allow Missouri to use its Medicaid programs to offer extended coverage to mothers struggling with addiction — but not the broader Medicaid population.
Meanwhile, the administration is aggressively pursuing an overhaul of Medicaid, finalizing proposals to allow states to apply for block grants that cap program spending and approving requests to condition benefits on work. The administration’s separate efforts to overturn Obamacare would also jeopardize federal subsidies that low-income mothers use to purchase coverage.
The focus on maternal mortality is driven by rising trend lines showing about 700 women die each year due to pregnancy related conditions a rate that’s more than doubled over the last three decades. About a third of the fatalities occur between one week and one year postpartum, according to a recent CDC report, putting the U.S. behind other developed countries for maternal health. And 60 percent of maternal deaths are preventable, with African American women and other minorities disproportionately affected.
Researchers studying the pattern say that extending Medicaid coverage would provide comprehensive benefits for chronic health conditions like heart disease, which accounts for a quarter of maternal deaths.
“The postpartum period is such a period of vulnerability,” said Houston physician Lisa Hollier, immediate past president of American College of Obstetricians and Gynecologists and chair of Texas’s Maternal Mortality and Morbidity task force. “The transition time [from pregnancy to full recovery] is one when we see unmet health needs.”
Obamacare helped boost coverage for new mothers. The uninsured rate for women who reported giving birth in the past year fell to 11.3 percent in 2016 from 19.2 percent in 2013 according to a study in Health Affairs.
The gains in states that expanded their Medicaid programs under Obamacare were especially pronounced, with the uninsured rate among new mothers falling 56 percent compared with 29 percent in non-expansion states.
But the Republican-led push to dial back Medicaid expansion has put a spotlight on controlling spending across the entire program.
Some states are exploring alternatives. Missouri’s Department of Social Services this month intends to ask the Trump administration for a waiver that would allow it to offer Medicaid coverage to postpartum women struggling with substance abuse for one year after they give birth. The move would cover about 1,500 of the 24,000 women in the state whose benefits lapse 60 days after childbirth.
The state’s Republican-controlled legislature endorsed the idea last year after killing a broader expansion of Medicaid benefits to postpartum women.
In Texas, where 382 women died within a year of giving birth between 2012 and 2015, Republican Gov. Greg Abbott this week downplayed the state’s maternal mortality rate on Twitter and said that the state was already doing enough to deal with the issue.
Last month, legislators opted to develop postpartum care services within an existing state program geared towards family planning, which will cost about $56 million over five years, instead of extending Medicaid for 12 months, which carried a five-year price tag of nearly $1 billion in state and federal funds.
Kay Ghahremani, the state’s Medicaid director disputes the cost analysis, saying it would actually save money in the long run by promoting wellness and averting potential emergencies.
“It’s the most important thing we can do for maternal health in this state,” said Ghahremani, now president of the Texas Association of Community Health Plans. “We don’t want to see a single mom die from things that are avoidable.”