Dan Gorenstein: The U.S. has a problem when it comes to taking care of people who are pregnant. 

Every year, some 60,000 women experience health complications related to their pregnancy. 

And about 700 of them die. 

The research is stark: More than half of those deaths are preventable. 

And people of color, particularly Black women, are three times more likely to die than their white counterparts.  

News Montage: Maternal deaths have jumped 14% in 2019-2020… Black women die much more than white women in Louisiana during pregnancy… 5.6 black women die for every white woman.   

 DG: Those disparities have flown under the radar for decades … but they’re getting harder and harder to ignore.  

Today, one step forward. 

The Biden administration’s plan to help states keep pregnant people insured longer after giving birth.  

From the studio at the Leonard Davis Institute at the University of Pennsylvania, I’m Dan Gorenstein. This is Tradeoffs.

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DG: We start our story in Louisiana: one of the first states in the country to take advantage of this new federal program to expand coverage for women postpartum.

Historically the state has really struggled with this issue.

In 2018, their maternal mortality rate exceeded the national average. 

A USA Today investigation ranked Louisiana as the worst in the country.

Stacey Roussel: As a state, we have a saying that we’re on the bottom of the good list and the top of the bad way too often. 

DG: That’s Stacey Roussel, with the nonpartisan Louisiana Budget Project. 

Her organization backs policies to help low-income and working class people. 

Stacey says when it comes to poverty the state also sits high up on the “bad list.” 

SR: Louisiana is one of a handful of states that does not have a minimum wage, so we default to the federal minimum wage of $7.25 an hour, a rate that has not gone up, just purchasing power has been eaten away by inflation. 

DG: In other words, if you are poor in the state it’s tough to get by.

That’s why in Louisiana when you talk about maternal mortality you’ve got to talk about the deep poverty. 

Advocate Frankie Robertson says on the ground that looks like pregnant people with budgets so tight, it’s a struggle to take care of their own health.

FR: Birthing people not having adequate access to get to their appointments. Right? Not having adequate child care, things like that. That may prevent people from being able to address their own health needs. That looks like people not being able to leave work and sacrifice pay to be able to go and sit for hours at a prenatal appointment or a postpartum appointment.

DG: Frankie knows that world well.  She’s worked in maternal and child health for nearly two decades.  She has two kids of her own. 

And she ran the March of Dimes for the Southeastern United States before founding her consulting firm, the Amandla  Group.

Frankie and Stacey have been on Louisiana lawmakers for YEARS to adopt stronger protections for people who are pregnant. 

After a lot of slammed doors, in 2021, a window seemed to open.

Biden: I signed into law the American Rescue Plan, an historic piece of legislation, that delivers immediate relief to millions of people.

DG: The Biden Administration had pushed to include a provision into the American Rescue Plan, that allowed states to expand postpartum Medicaid coverage from two months…that’s just 60 days…to one full year. 

Medicaid covers more than four in ten births nationwide. 

After Congress passed the bill, U.S. Health and Human Services Secretary, Xavier Becerra talked up the significance of the postpartum provision. 

Becerra: It provides a safety net of healthcare access to promote better birth outcomes. The last thing that any of our new mothers need, is to worry that they won’t have the security of health insurance.

DG: Frankie and Stacey seized the opportunity. 

In Louisiana Medicaid covers more than 6-in-10 births. 

DG: Now, the state had already expanded Medicaid under the Affordable Care Act all the way back in 2016.

That means nearly all adults with incomes up to about $18k now have coverage.

That – of course – includes pregnant people. 

But the reality is that people who are pregnant continue to have gaps in their coverage. 

The pair of advocates saw expanding postpartum coverage as a great way to fill those in, guaranteeing most people would have insurance for a full year after delivery – AND Washington would help finance it. 

But they knew they’d have to convince skeptical lawmakers why women were losing coverage. 

Stacey explains some drop off the rolls for paperwork mistakes, like maybe they moved or missed an eligibility check in. 

 Some face a change in income. That can be big in a state that relies on tourism. 

Jazz Fest. Bayou fishing trips. Jambalaya.  

It’s pretty common, says Stacey, for people to see a seasonal spike in income, followed by a drop.

SR:  There’s a lot of churn, so people lose their coverage and then come back on to the rolls. And when you have that kind of disruption in care during that first 12 months after the birth of a child, that can be really disruptive. And that’s a really important time to keep moms covered because we know that that’s correlated to keeping babies with those regular doctor visits.

DG: A 2021 federal brief found that some 14,000 pregnant people in Louisiana would benefit from expanding postpartum Medicaid coverage to one year.

Advocates had all they needed.  

The furious lobbying campaign was boosted by testimony from some top health officials like Veronica Gillespie-Bill, an OB-GYN, who sits on the Louisiana Pregnancy-Associated Mortality Review.

Veronica Gillespie-Bill: We’re missing a really critical time to be able to optimize medical conditions to help  birthing persons, get ready for the next pregnancy, to help them with family planning, and to be able to reduce the overall causes of maternal mortality. And in fact, another study showed that having access to care reduced all causes of death. So not just those ones that are related to the pregnancy. So we are 49th in maternal mortality and making this change would make a huge impact on really our women that are suffering the most.

DG: The expansion bill got a lotta love in Baton Rouge… at first. 

Washington would’ve sent the state $63 million  to cover the federal government’s share of the five year program.

Louisiana needed to pony up $18.5…less than $5 million dollars a year.

Lawmakers looked at these numbers…and said they ran out of time to budget for it.

DG: But to the delight of advocates like Frankie Roberston, the Louisiana Department of Health agreed to pick up the tab.

Frankie considers this a win…but in the next breath insists there’s a lot more Louisiana must do to protect people’s health postpartum. 

FR: So this policy is significant. Is it enough alone? No, but it is a must have. It feels like we’re fighting an uphill battle every single legislative session because we are trying to make sure that when someone is pregnant that they have access to adequate nutrition, that they have decent housing and a place to stay, that they have a living wage.

DG: In this state advocates like Frankie and Stacey are always preparing for the next fight. 

One of those is making sure the state’s Medicaid office evaluates the program’s effectiveness.

Federal funding for postpartum Medicaid expansion runs out in just five years. 

SR: To the extent that we can show that having coverage resulted in care would be great. And hopefully it’ll be shown to really have an impact. And hopefully LDH can help in making that case in a few years and telling those stories.

DG: As part of its plan to strengthen the health of people postpartum, the Louisiana Department of Health plans to monitor blood pressure remotely and screen for depression. 

The clock starts on a woman’s Medicaid eligibility window at birth and for the next 12 months, the state is forbidden from kicking that person off for any reason.  

When we come back, the evidence behind expanding postpartum Medicaid coverage nationwide, and its potential impact.

****MIDROLL***

DG: Welcome back.

For years, states have tried to tackle maternal mortality on their own…they’ve adopted review panels, task forces and committees to root out this problem.

Nonetheless…maternal mortality continues to rise. 

In 2020, 861 women died, 107 more than the year before.

Vice President Kamala Harris is shining a light on the issue.

Harris: women in our nation are dying at a higher rate from pregnancy-related causes than in any other wealthy or developed nation in our world. 

DG: Research shows more than half of maternity-related deaths in the U-S happen within a year after giving birth.

That’s why the Biden administration hopes helping states expand Medicaid coverage for pregnant people from 60 days to 12 months can help combat this pernicious problem.

We asked the Kaiser Family Foundation’s Usha Ranji to help us understand this expansion’s  potential impact. 

DG: Usha, you’ve worked on women’s health policy for years. 

As we did reporting for this story, we kept coming across people describing maternal mortality in the U.S. as a ‘crisis.’

In your mind how do 700, 800, 900 deaths – in a country of 330 million – constitute a crisis? 

Usha Ranji:  You know, when I think about this crisis, we are talking about, for the most part, young women. And we are also talking about a rate of pregnancy-related mortality that is 3 to 4 times higher among individuals who are black, as well as Native American compared to people who are white. And on top of that, we also have the fact that many of these deaths, most of them are thought to be preventable. And so when it comes to health care, all of that together adds up to be a crisis.

DG: Usha, you’ve said before that maternal mortality represents one of the starkest racial and ethnic inequities in all of health care. 

What makes you say that?

UR:  If you look at the data, if you look at pregnancy related mortality and you look at it across income, across educational levels, one constant that is there is that Black women are affected more. The rates are still higher. And so really we have to address issues of racism and bias. You know, for example, from the state of California, where there have been a lot of efforts to address pregnancy related mortality and there’s actually been a decline in the overall rates, but that there is still quite a wide gap when it comes to race and ethnicity. 

DG: Usha, what’s your sense of why…how is racism and bias manifesting themselves?

UR: I’ve listened to a lot of the stories that individuals have told about their experiences. Some very high profile people like Serena Williams, for example, who after giving birth, 

Serena Williams: I put a little make up on so I could take pictures with the baby. And I remember getting up and I couldn’t breathe.

UR: you know, tells the story of not being listened to when she knew that she had a health condition and something wasn’t right, 

SW: I’m like listen I need you to run a CAT Scan with dye, because I have a pulmonary embolism in my lungs. I’ve had this before, I know my body.

UR: But also a lot of other people who are not as high profile and not as visible.. And a common theme among many of them is people saying that they or their loved one knew something wasn’t right, and that they weren’t being listened to.

DG: So about this policy…the Biden administration believes helping states cover the cost of extending coverage for women on Medicaid from 60 days to a year will reduce maternal deaths. 

I’m guessing this could have a big impact on the dozen states that have not expanded Medicaid under the ACA. Usha, can you walk us through how that would work? 

UR: Sure. The problem comes down to a pretty sharp cliff in Medicaid eligibility between the pregnancy and postpartum periods. take Mississippi, for example. So according to state information program information, a pregnant person in Mississippi can earn about $2,2000 a month and qualify for Medicaid coverage during the pregnancy through 60 days postpartum. But then after you have the child, the income eligibility really changes. And if you earn more than about $285 a month, you may no longer qualify for Medicaid coverage and you could become uninsured. 

DG: So far nearly 40 states have adopted or have pending legislation to extend pregnancy-related Medicaid beyond 60 days – including 9 non expansion states. 

Is there evidence that having health care coverage reduces maternal mortality? 

UR: Yes. So the closest we have is one study so far that compared maternal mortality rates in states that had expanded their Medicaid programs to states that had not. And what they found was that Medicaid expansion was statistically significantly associated with lower maternal mortality rates. And so, I think one take away suggests that insurance coverage before a person becomes pregnant, as well as sustained coverage after the pregnancy, could contribute to a decrease in maternal mortality.

DG: Yeah, Usha, but this is just one study. Do these findings make sense to you?

UR: To me, it makes sense because, broader access to health care across someone’s lifespan would help address and identify earlier problems that we know are common when it comes to pregnancy related mortality, for example, things like mental health, chronic conditions like heart disease.

DG: Fair enough. And it seems like an area we need to learn a lot more about.  

At the same time – there’s broad agreement that insurance is no silver bullet. 

How do you see the limitations of extending Medicaid coverage? Like, really, what’s this not going to do?

UR: I would say that by itself, health coverage definitely does not mitigate or address all the underlying issues that we know shape the health of people who are pregnant and new parents. issues like income, poverty, housing that all play a role in somebody’s health. So insurance in isolation is limited, but it’s also an important policy lever that we have at hand right now 

DG: There’s a chance all states will be required to expand postpartum coverage for a full year …that provision is tucked into the Build Back Better plan that passed the House, but is stalled in the Senate. 

Nobody we talked to for this story said a few more months of Medicaid would solve the nation’s maternal mortality problem.  

Everybody we talked to agreed it will take digging into issues like poverty, housing, hunger, structural racism and bias if the country is serious about eliminating deaths and complications that are preventable.  

I’m Dan Gorenstein, this is Tradeoffs.