July 7, 2023, update: This story has been updated to reflect Gov. Mike Parson’s signature of SB 45, which expands postpartum Medicaid coverage for up to a year.

Missouri has one of the highest maternal mortality rates in the nation. As part of a bipartisan push, lawmakers in the General Assembly took steps to reduce the rate of maternal-related deaths by passing a measure allowing postpartum Medicaid expansion.

The health care legislation, SB 45, was signed into law by Republican Gov. Mike Parson on July 6. It will cover low-income postpartum people on Medicaid for up to one year. It goes into effect at the end of August.

At this time, coverage is provided for 60 days after a person gives birth, although a majority of pregnancy-related deaths occur between 43 days and one year after pregnancy. A 2022 report from the Missouri Pregnancy-Associated Mortality Review found that 75% of pregnancy-related deaths in Missouri were determined to be preventable. 

With Parson’s signature, Missouri will join 32 states and Washington, D.C. that have expanded Medicaid for one year postpartum. An estimated 4,500 Missourians would gain access to the coverage, according to a study commissioned by the Missouri Foundation for Health. 

The effort was one of the few instances of bipartisan agreement throughout the legislative session. 

“This really was a long time coming. And it truly is a triumph over politics,” said Michelle Trupiano, the executive director of the Missouri Family Health Council, a nonprofit organization that administers Missouri’s family planning program. 

“We’re committed to looking at the facts. And the fact that Missouri is ranked one of the highest in maternal mortality, and we all know that you know that Black Missourians have an even higher maternal mortality rate,” Trupiano added. “We needed to do something real, that wasn’t just about talk, but that was going to make a difference. And so I think legislators put politics aside to concentrate on real policy change that’s not just performative.” 

Missouri’s pregnancy-associated mortality ratio from 2017-2019 was 59.5 deaths per 100,000 live births, according to data compiled by the mortality review board. In Jackson County, however, the rate was much higher at 84.5 deaths per 100,000 live births, according to the county health department. 

Mental health conditions, including substance use disorder and depression, and cardiovascular disease are the top drivers of pregnancy-associated deaths in Missouri. Health care professionals are anticipating improved outcomes once parents have access to continuous coverage. 

A study analyzed the effects of pandemic-era postpartum Medicaid expansion in Texas, and found that those who gave birth during the expansion period used twice as many postpartum services, 10 times as many contraceptive services and 37% fewer services for subsequent pregnancies within the first year postpartum. The study also found that postpartum people and others who had the extended coverage used three times the number of mental health and substance use disorder services and were much more likely to seek preventative care. 

The Missouri Foundation for Health study estimates that expanded postpartum Medicaid coverage could bring a 25% reduction in postpartum hospitalization risk for those with cardiomyopathy. Among parents with diabetes, expansion brings an estimated 10% reduction in total cost of care. Data also shows that longer coverage and increased access to primary care could reduce pregnancy rates by 50% in the postpartum period, something Trupiano sees as a crucial piece of the puzzle. 

“We want to ensure people are supported, especially in that postpartum period, both in terms of mental health screenings and care, but also in terms of their family planning, care and being able to space their births as they plan for future pregnancies. They are able to access that full range of reproductive health care that will help them in planning and thinking for the future,” she said. 

For groups that work to help address Missouri’s poor maternal health outcomes, the extension in coverage signals a new phase of their work, according to Tracy Russell, the executive director of Nurture KC, a group that supports families from preconception up to 18 months after a child is born. 

“I think it’s going to have a profound impact,” Russell said. “So much of what our community health workers try to do is cover the gaps that exist in the current system. We’ve always believed that that direct service piece is so important, but so is the policy in terms of having the broadest impact and bringing about cultural change when it comes to these issues.” 

She added: “We’ll see the tangible benefit of this expanded access to care through the postpartum extension, but it’s also going to change the culture and how we think about how best to serve our families.” 

Why pass postpartum Medicaid expansion now?

The push to expand postpartum coverage for those on Medicaid in Missouri has been a yearslong effort. 

In 2018, lawmakers approved an extension of Medicaid coverage for those with mental health concerns or substance use disorder. Since then, according to Casey Hanson, the director of outreach and engagement at Kids Win Missouri, a coalition of lawmakers and advocates has been working behind the scenes to get lawmakers on board with expanding postpartum coverage. 

“In the Capitol, it was really helpful to have folk that are typically on different sides of issues,” Hanson said. “We had some of our pro-choice advocate friends as well as pro-life advocates all on the same page on this one. That really allowed us to message to a lot of different legislators and use a lot of different voices to uplift the issue.” 

The decision to extend Medicaid coverage was helped in part by a federal subsidy from the American Rescue Plan Act, which matches funding and covers 65% of the cost. Once the extension is fully implemented, according to the fiscal analysis commissioned by the Missouri Foundation for Health, the program will cost the state an estimated $2.6 million annually. By accepting incentives set forth in ARPA, Missouri is in line to receive more than $1.15 billion in federal funding over the next two years, which will allow flexibility in covering other costs. 

Earlier in the session, lawmakers were considering a provision to prevent those who had previously had an abortion from receiving the expansion, similar to Texas expansion legislation that included similar stipulations. The language in Missouri’s bill was later stripped over concern that the federal government may not grant the waiver for the extension, similar to what has happened in Texas. 

“The reality of the matter is, abortion is illegal in Missouri at this point, and Medicaid does not cover abortion services of any kind,” Hanson continued. “So some of the concerns that were raised to kind of bring that into the conversation were really just unfounded.” 

She added: “We did have pro-life advocates in our inner coalition who kind of helped to let them know that this is a pro-life bill at its core. It really is talking about not only saving the lives of moms, but making sure their babies grow up with moms. I think at the end of the day that won out.” 

Where else can the legislature make strides when it comes to maternal health?

Advocates say the postpartum Medicaid expansion should just be the beginning when it comes to supporting new parents and their health in Missouri. 

Increased access and quality of care is necessary if the state wants to see improvements in health markers, according to Russell. Nurture KC has recently started offering access to doula care and would like to see the state include that as a part of Medicaid coverage. 

“It’s not just access to care. It’s also the quality of care within that access. Organizationally, we now offer doula services to our pregnant moms because we know it improves birth outcomes,” she said, pointing to lowered rates of cesarean sections when a doula’s services are utilized. 

Ensuring a representative health care workforce and addressing other social determinants of health should also be a priority, Russell said. For example, many pregnant people struggle to make it to doctor’s appointments due to a lack of transportation. Those are areas, she said, where policy changes could have widespread impacts. But overall, the General Assembly’s decision to pursue the expansion is a win for the health of all Missourians and should be celebrated, Russell said. 

“I think this extended coverage really plays into that in terms of let’s value women, whether they’re pregnant or not, just for their own well-being and health,” Russell said. “I think when Missourians chose to expand Medicaid, that was a huge leap in terms of valuing someone’s health, regardless of whether they’re pregnant or not. I think this extended coverage continues to prioritize the value of women and it’s very important.”