Missouri ranked 44th nationwide for its maternal mortality rate in 2019. And Black mothers in the state are four times as likely as white women to die from pregnancy-related issues, higher than the nationwide average.
Yet Missouri is not among the many states that are seeking to take advantage of an offer from the federal government to pay for extended health care for postpartum mothers. Currently, Missouri provides coverage to low-income mothers during pregnancy and up to 60 days after childbirth.
In an effort to improve maternal health and address racial disparities, the American Rescue Plan Act, which Congress approved last year, allows states to extend their postpartum Medicaid coverage up to a year after birth. The new option is available to states for five years, starting April 1 of this year.
According to the Kaiser Family Foundation, 19 states so far are planning to take advantage of the 12-month extension; 12 states, including Kansas, have legislation pending to draw down the extra funds; and four states have adopted limited coverage extensions.
Missouri legislature looked to tackle maternal mortality
Bills introduced in this year’s legislative session sought to authorize the yearlong extension. They garnered support from women’s health groups across the political spectrum.
Sen. Jill Schupp, D-St. Louis County, introduced a bill that would expand the coverage. Her legislation was eventually combined into a bipartisan bill, sponsored by Sen. Elaine Gannon, a Republican from southeast Missouri.
The bill, which would have used the federal framework, was stalled by gridlock in the deeply divided Senate.
According to 2018 data recently released by the Missouri Department of Health and Senior Services, Black mothers in Missouri have maternal mortality rates four times those of white parents.
In Missouri, according to the report, 63% of pregnancy-related deaths occur between 43 days to a year after childbirth. Most pregnancy-related deaths in Missouri are preventable, the report continues.
In 2018, mental health conditions were considered the leading cause of pregnancy-related deaths in Missouri. According to the report, 14.6% of recent mothers in 2019 reported experiencing postpartum depression. Mental health conditions were the leading underlying cause of pregnancy-related deaths at 50%.
Kathy Alford, who sits on the board of Kansas City’s Pregnancy and Postpartum Resource Center, told The Beacon that postpartum depression often doesn’t set in until four to six weeks after delivery.
“So what about those women who maybe hesitate to seek treatment or maybe six weeks out are just getting to that place where they’re just saying, ‘Something’s not right. This is not normal,’” Alford, a longtime nurse, said.
“Are you telling me that it’s not OK for you to extend their coverage for a year? If they want to get their medications, if that’s the course that they need, how will they go and see counselors or a psychiatrist? It just makes sense to extend, because these women are coming back to our ERs for many different medical reasons, but definitely psychiatric ones as well,” she added.
The 2018 data found that substance use disorder contributed to 54% of pregnancy-related deaths. The report also found that the rate of pregnancy-associated deaths for women on Medicaid was more than four times greater than the rate for those with private insurance.
Missouri lawmakers in 2018 passed a provision to add some benefits, such as a yearlong Medicaid extension, to low-income mothers with substance use disorder. But a state official wrote to the Centers for Medicare and Medicaid Services in February, asking to pause those benefits. Todd Richardson, director of the MO HealthNet division, said the state predicted that enrollment in the postpartum extension would drop as more people applied for overall expanded Medicaid coverage.
Alford said that a year’s worth of postpartum Medicaid coverage could provide a lot of room for education with Missouri’s mothers.
“If we say, ‘You know what, we’ll cover you and monitor your blood pressure for the next 12 months. And we will cover your medications for 12 months,’ that gives them time to make those necessary lifestyle changes to actually see the difference, and to give them hope that ‘I’ve got enough time to fix this,’” Alford said.
“And we can do a lot of teaching and education in that time frame too,” she added. “I just think getting them in the door for 60 days just isn’t going to cut it. We need more time.”
From 2012 to 2014 in Missouri, 6.4% of women were diagnosed with gestational diabetes, which is a factor in mortality rates. In the same period, 26% of pregnancy-related deaths in the state were due to cardiomyopathy, a heart disease, which is mostly diagnosed in the postpartum period.
The DHSS report recommends that the state should extend Medicaid coverage to one year after childbirth for all conditions, including medical, mental health and substance use disorder.
Although there seems to be a bipartisan consensus that the expansion is necessary for Missouri’s mothers, it is no small cost to fund.
The Senate bill’s fiscal analysis had a $4.4 million estimate in state costs for the 2023 budget year. The federal government would subsidize the rest of the estimated $12.3 million the entire plan would cost. By 2024, the plan could cost the state up to $10.5 million, with $20 million from the federal government.
Alford said that good medical care for women during pregnancy and after childbirth results in healthier babies and saves costs down the road.
“It’s more costly to treat the children long-term who were born to these moms that didn’t receive the care that you needed early on,” Alford said. “You’ll just have a better prognosis if intervention is early on.”
According to the proposed legislation’s fiscal analysis, 4,565 women who received Medicaid benefits during pregnancy would likely have qualified for the extended coverage
Numbers from 2018 provided by DHSS found that 46,455 people who were enrolled in state-provided pregnancy coverage lost coverage after 60 days. Some of those parents moved to other assistance, but nearly 20,000 received no further coverage.
What issues in Missouri complicate coverage?
Other issues contribute to the disparity in maternal mortality rates, according to Sheldon Weisgrau, vice president of health policy at the Missouri Foundation for Health.
“Putting aside that Missouri is worse than the national average, both overall and for Black women, access to health care is not the only reason for the disparities between Black mothers and white mothers in maternal mortality,” Weisgrau said. “But that said, access to health care is an important factor.”
Half of Missouri’s Black mothers experienced “late entry into prenatal care,” according to the DHSS report.
Another issue for Missouri’s mothers is parental leave. Missouri does not require employers to provide paid family leave, often forcing pregnant people to make the choice between a paycheck and postpartum recovery, according to the report.
Thirty percent of white mothers received paid maternity leave, while 20% of Black mothers received paid maternity leave.
Weisgrau concluded that expansion of benefits from 60 days to a year wouldn’t end Missouri’s maternal mortality disparities, but would be a step in the right direction in improving maternal health for Missouri’s mothers.
“A lot of the maternal mortality is due to mental health and substance use disorders and other behavioral health issues and there’s certainly a pretty stark racial disparity in statistics for those disorders,” Weisgrau said.
“There’s ample evidence that covering more people under expansion reduces disparities, because a disproportionate number of people that are being covered are people of color and people who are previously uninsured. And there tends to be racial disparities in that data as well. And so it certainly doesn’t eliminate disparities, but it does go a long way towards narrowing the gap.”
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