Recent data show that U.S. maternal mortality rates are rising, and Black, American Indian, and Alaska Native people giving birth are two to four times more likely to die from pregnancy-related complications than their white counterparts. Emerging data also indicate that implications of the COVID-19 pandemic may further exacerbate these disparities.
As the health insurer for 45 percent of births in the U.S. and 66 percent of births to Black mothers, Medicaid has a critical role to play in leading policy changes that support clinical improvements, enhanced services, and community investments necessary to reduce racial disparities in maternal health outcomes. This Policy Cheat Sheet explores what states are doing to improve maternal health outcomes and what additional opportunities exist.
What policy levers are available to state Medicaid programs?
There are several levers state Medicaid agencies have direct influence over — such as benefit design and eligibility criteria, among others. Relevant strategies include:
- Extending postpartum coverage beyond 60 days;
- Enhancing benefits to cover evidence-based models, such as home visiting programs;
- Developing value-based payment models that reward improved health outcomes and close racial and ethnic disparity gaps;
- Enhancing surveillance and data collection on maternal mortality and morbidity; and
- Managed care organizations (MCOs) contracting strategies to drive innovation and equity.
Medicaid can also work with sister agencies such as public health to further advance policies and programs by bringing stakeholders together to, for example, implement quality improvement initiatives and create statewide maternal mortality review committees for greater oversight. Enhanced partnerships with sister agencies can also ensure that provider licensure requirements align with policy goals, including access to freestanding birth centers. To further drive equity, Medicaid agencies can work with community organizations to ensure that these strategies are intentionally tailored to positively impact communities of color.
What notable policies are states implementing?
In recent years, states have increased attention to high-value, evidence-based policies that aim to improve maternal health outcomes. Key policy highlights include the following (for full state-level detail, see a recently published map from the Commonwealth Fund):
- Payment Reform. Thirty-four states have implemented at least one payment reform policy related to maternal health. Among these, the most common value-based payment policy is reduced payment or nonpayment for procedures that are not medically indicated, such as cesarean sections. Bundled payments for maternity episode of care, pay-for-performance, and comprehensive payments for mother and newborn care are other payment reform options states have adopted.
- Models of Care Delivery. Nearly half of states have incorporated at least one of the following care delivery models: (1) care coordination/case management as a benefit for high-risk pregnancies; (2) group prenatal care; and (3) pregnancy or maternity medical homes.
- MCO Data Reporting Requirements. Nearly 78 percent of states using managed care have integrated maternal health data reporting requirements into MCO contracts. Common performance measures include timeliness of prenatal care, frequency of ongoing prenatal care, postpartum care, and smoking cessation.
- Midwifery-Led Care. In 2010, the Affordable Care Act mandated that all insurance plans must cover licensed or certified midwives. Since then, 60 percent of states have implemented payment parity initiatives to ensure that midwives are equally reimbursed for equivalent services provided by physicians and hospitals.
- Doula Services. Doula services, widely known for improving birth outcomes and experiences for communities with low-incomes, are now covered by Medicaid statewide or through pilot programs or separate state funds in five states — New Jersey, New York, Minnesota, Oregon, and Washington State. There are also additional states proactively pursuing Medicaid coverage of doula care.
- Postpartum Coverage Expansion. Twenty-three states and the District of Columbia have introduced legislation to support postpartum coverage. However, California and Texas are the only states that have had success in implementing some version of postpartum coverage extension using state funds. The postpartum period provides a key opportunity to address maternal health.
- Changes in Telemedicine. Prior to the COVID-19 pandemic, eight states — Arizona, Colorado, Illinois, Massachusetts, Missouri, Texas, Virginia, and Wisconsin — specifically mentioned pregnancy-related care in their telemedicine laws. Although the U.S. Department of Health and Human Services increased flexibilities around telehealth access and coverage during the public health emergency, four additional states — Alabama, Alaska, New Hampshire, and North Carolina — expanded their states’ telemedicine policies to specifically include pregnancy-related care or enhance midwifery services in response to the pandemic.
- Provider Bias Training. More states are interested in addressing institutional racism in care delivery. California, Maryland, and Michigan are implementing evidence-based provider bias training programs within the perinatal care continuum to close gaps in maternal health disparities.
What’s the impact so far?
A 30,000-foot view of the policy landscape indicates that there are considerable advances underway in maternal health policy across states, and research shows that when implemented appropriately, diverse policy strategies have a positive impact on maternal outcomes. And, some states are reporting promising results. For example, California’s long-established Maternal Quality Care Collaborative — a multi-stakeholder organization committed to improving maternal health outcomes — reduced maternal mortality by 55 percent between 2006 and 2013. North Carolina has been the only state to implement a pregnancy medical home benefit to improve perinatal care quality and outcomes to Medicaid enrollees. More recently, New Jersey’s Nurture NJ program is a strong example of how using Medicaid along with a multifaceted public health approach for targeted communities can begin addressing racism in maternal health care. These are important successes. However, disparities in outcomes for pregnant and birthing persons of color remain stark.
What more can states do?
The preventable death of any person giving birth is a tragedy, however, the disproportionate mortality rate among Black, American Indian, and Alaska Native individuals is recognized as a national problem requiring urgent action. Although the root causes for disparities in maternal health outcomes extend beyond Medicaid, the program has a unique role to play in ending these disparities. As the primary payer for more than half of all births to Black mothers, Medicaid programs can define benefits, measures, and build collaborative partnerships to specifically target racial health disparities. Yet, few states have used Medicaid to explicitly target racial health inequities in maternal health outcomes. For example, while many states provide additional case management or benefits to high-risk pregnant members, few states define race as a high-risk factor for these interventions. Additionally, data can sometimes mask underlying and persistent racial disparities, even if the aggregate trend looks positive, and identifying the most appropriate race explicit policies can be difficult if state data is not stratified by race, ethnicity, or geography despite clear, national-level data supporting the advancement of these policies. In addition to policy efforts, such as provider bias training, there are other early examples of states implementing race explicit strategies to impact maternal health outcomes, including community-based approaches.
What’s the bottom line?
States are taking significant steps to improve maternal health outcomes across different programmatic areas: (1) coverage and benefits; (2) care delivery transformation; and (3) data and oversight, but there are opportunities to further promote more equitable outcomes. Given the unparalleled role that Medicaid plays in covering births in the U.S., states can collectively transform maternal health nationally — particularly among births to Black, American Indian, and Alaska Native people. By building on existing policies, learning from other states, and using race explicit strategies that acknowledge historically disenfranchised communities, states can lead the charge to eliminate maternal health disparities in the U.S.