The nearly 25,000 Mississippians who use Medicaid health insurance to cover pregnancy will continue to lose their health benefits just 60 days after birth, after a proposed extension fell casualty to a long session of gamesmanship over control of the Mississippi Division of Medicaid.
As part of the Medicaid “tech bill” overhaul, Senate Bill 2799, the Mississippi Legislature originally included an extension of Medicaid benefits for a year postpartum—a move maternal health experts supported to ensure postpartum people can access health services they need not just before and during, but after birth, too. Medicaid covers more than two-thirds of births in Mississippi, the third highest rate in the U.S., which means that 67% of new mothers covered by Medicaid lose their health benefits two months after they give birth.
But in the 2021 session’s last days, an extended fight between the House and Senate that threatened to kill the Medicaid guidelines entirely led to a compromise bill just barely surviving the final legislative deadline. Left behind on the table was the provision extending Medicaid eligibility for new mothers, a concession that left a foul taste in the mouth of its backers in the Senate, and left mothers at risk.
Sen. Brice Wiggins, R-Pascagoula, one of the legislators involved with the bill’s final passage, expressed regret over the last-minute changes in an April 1 interview with the Mississippi Free Press. “It was something that could have been done for the health of mothers and babies. It’s been recommended by the experts. … The Senate had been for that all along,” he said.
‘We Couldn’t Choose The Right Thing’
Postpartum is a dangerous period for Mississippians. Of all maternal mortality deaths specifically tied to pregnancy complications, 86% happen postpartum, compared to about one-third nationally. More Mississippi moms are dying in this postpartum period than nearly anywhere else in the U.S.
Moreover, Black moms are more likely to die, despite socio-economic status. In Mississippi, Black people are nearly three times more likely to die from pregnancy-related deaths.
Health experts say ensuring continuous health coverage and access during the postpartum period, or the “fourth trimester,” is crucial to intervene when postpartum complications arise.
Dr. Charlene Collier, OB-GYN and director of the Mississippi Maternal Mortality Committee, says the 60-day Medicaid cutoff is illogical at best, and deadly at worst.
“There’s no single medical or biological point in time that 60 days is tied to where all of the risks related to pregnancy are complete and that a mother no longer needs any medical care that may relate to being pregnant or postpartum,” Collier said. She added that there are a number of conditions that are only beginning to present and may worsen around that time, including postpartum depression and maternal cardiac diseases, which are among the leading causes of death for mothers in Mississippi.
Citing that the Centers for Disease Control and Prevention just published the maternal mortality rate for 2019 that increased from 2018, Collier said lacking health-care access continues to be the biggest barrier to improving outcomes, invalidating other solutions for the maternal mortality crisis.
“Doctors and hospitals’ hands are tied to help these moms when their cause of death goes beyond that (60 days) and they’re on Medicaid,” she said. “So all of the other recommendations about improving health or improving care or care quality really fall short when the mom can’t even access the care.”
Under Collier’s direction and with stakeholders across the state, the MMRC reviewed every pregnancy-related death in Mississippi from 2013 to 2016 and found alarming trends. Most deaths were preventable, and racial disparities persisted in nearly every pregnancy-related cause of death. Overall, the state’s maternal mortality rate was 33 deaths per 100,000 births, one of the highest rates in the country and almost twice the national rate—and Black Mississippi mothers died at nearly three times the rate of white women.
Based on the data, the Maternal Mortality Review Committee Members made the following recommendations:
- Due to the high rate of mothers using Medicaid who died of pregnancy-related deaths and the late-stage postpartum deaths, extend Medicaid up to a year after birth
- Expand mental health and substance use disorder services for postpartum people
- Support access to community-based support programs, like pairing pregnant and postpartum people with doulas
To date, none of these recommendations have been followed.
Mississippi Legislature: Responsible for Preventable Deaths?
Based on the MMRC finding that most pregnancy-related deaths are preventable, Collier says some of the blame for and responsibility to prevent these deaths falls on the Mississippi Legislature.
“When we review maternal deaths, we determine if they were preventable, and we look at the factors that contribute to preventable deaths. It’s impossible not to include these policy causes and these choices made by our politicians that affect the health care of people in Mississippi as among the contributing factors,” Collier said.
“It’s hard not to hold them accountable when there is a viable solution to at least part of the problem, and it’s not supported.”
“We are able to look at clinical care. We’re able to look at what mothers do, the choices they make, the environments they live in,” she continued. “And we have to look at our policy choices as well and our legislators and the individuals who choose not to support this just as much as any other factor that can contribute to maternal deaths and poor maternal and infant health. It’s among those causes, too.”
After almost a decade of Medicaid-expansion options, data are starting to catch up indicating its health benefits. States that expand or extend Medicaid coverage reduce uninsurance rates, increase health access and reduce their maternal mortality rates, particularly among Black mothers.
The 38 states that have expanded Medicaid ostensibly already extend this coverage to some new mothers because people with incomes up to 138% of the federal poverty level, or about $21,960 for a mother of two, can already access Medicaid. Three other states that haven’t expanded Medicaid eligibility to people with low-incomes, Georgia, Texas and South Carolina, have adopted Medicaid waivers or policies to extend coverage to postpartum people.
As is, Mississippi will be one of just nine states that have not in some way extended these health benefits postpartum. Currently, under the federal public health emergency, postpartum benefits are federally mandated to be indefinitely extended, but that protection is slated to lift soon.
“Many in the Mississippi Legislature claim to support babies and families in this state, and their actions aren’t supporting that. And this is something that hopefully the federal policy changes will then make Mississippi do,” Collier said. “But it’s sad we couldn’t choose to do the right thing for our moms.”
‘The House Wanted To Play Games’
Though Medicaid expansion has been DOA at the Mississippi Legislature since the Affordable Care Act authorized it in 2014, recent momentum around maternal health fostered a rare bi-partisan support for extending benefits.
Previously, Medicaid guidelines established in the Families First Coronavirus Response Act just over one year ago barred states from disenrolling new mothers in Medicaid after only two months on the program, extending the benefits to a full year postpartum.
Those benefits spawned bi-partisan support in the Mississippi Senate around the need to intervene on maternal and infant mortality, with key figures backing the legislation necessary to make the postpartum benefits a permanent fixture of the Medicaid program.
The provisions of the recurring Medicaid tech bill govern the costs and services that Medicaid covers in the State of Mississippi, under the auspices of the Mississippi Division of Medicaid, which answers directly to the governor’s office. Language to add the postpartum extension was included in the Senate version of the bill from its filing until March 30, the session’s end.
Sen. Kevin Blackwell, R-Southaven, chairman of the Senate Medicaid Committee and author of the original tech bill called the inclusion of a postpartum Medicaid extension a “no-brainer” during a Feb. 1 committee discussion.
But the House had other designs for the bill. Rep. Trey Lamar, R-Senatobia, chairman of the powerful House Ways and Means Committee, previously introduced House Bill 1013, a piece of legislation that would have wrenched the Division of Medicaid out of the governor’s office and placed it under the authority of a commission majority-controlled by Legislative appointments.
Lamar’s bill was dead on arrival in the Senate, double-referred and expired without further action. But as was par for the course in a contentious session filled with zombie bills and bitter infighting between the House and Senate, the Medicaid Commission made a sudden return.
The same day Lamar’s bill died in the Senate, the House Medicaid Committee struck the entire tech bill—S.B. 2799—including the postpartum extension, dumping the language from the Medicaid Commission bill on top of it.
Finally, the House held the tech bill after passing it, letting it die on the calendar instead of transmitting it back to the Senate. It took a rules suspension and two-thirds of the Senate to revive S.B. 2799 on March 12, and by then, time was already running out.
With the session drawing to a close, the Senate version of the Medicaid tech bill and the postpartum expansion it contained had to be reconciled in conference with the House bill, still dedicated to the creation of the Medicaid Commission.
“We were not on board with the commission,” Sen. Wiggins, who was one of the Senate conferees, explained. “(So) then it’s a process of, are you going to take our language or not?” The final agreement between the two parties would not emerge until March 30, days before the end of the session and the last chance for the tech bill.
“At some point they gave (up) on the commission,” Wiggins said.
Refusing to Budge on the Postpartum Expansion
The House conferees would not budge on the postpartum expansion. “At that stage in the game, the House was wanting to play games with the postpartum language. It could have been done earlier in the session … but that’s not what they did,” Wiggins said.
The Senate got most of the Medicaid tech bill that it had wanted, but at the cost of the postpartum expansion.
Playing hardball, and risking the death of the entire tech bill, could have left the guidelines of the state’s entire Medicaid program in the hands of a single man. “The governor would run Medicaid. That’s the bottom line,” Wiggins said. “The statute (includes) coverage for many different things, such as drugs, dialysis, doctor reimbursement, nursing homes—anything that touches health care would be affected.”
The Senate version of the Medicaid tech bill now awaits the governor’s signature, without the provisions that will expand Medicaid eligibility to new mothers when the pandemic recedes. Reviving those protections will not be a quick or easy process.
“There’s a three-year repealer in the bill, meaning it’s not up for reconsideration for another three years,” Wiggins said. By that time, Mississippi may have new political leadership entirely—until then, the state’s new mothers will have to make do with the Medicaid provisions as they are.
By press time, Reps. Sam Mims, R-McComb; Jason White, R-West; and Joey Hood, R-Ackerman—the three House conferees to the final Medicaid tech bill—had not responded to requests for comment from the Mississippi Free Press. Sen. Kevin Blackwell, R-Southaven, also did not respond to a request for an interview.
Uninsured Before and After Pregnancy
Some states that have extended postpartum benefits cover the full cost with state funds, while others have requested federal waivers.
The recently passed federal American Rescue Plan also adds provisions that formally offer states the ability to extend postpartum Medicaid under their current state-federal payment match. Currently, the feds cover 85% of Mississippi’s Medicaid program—and that stands to increase 5% more based on new expansion incentives from the Biden administration.
The average Medicaid enrollee costs about $8,000 per year. As is, 10-month postpartum extension would cost the state $100 monthly per enrollee. If the state took up the Biden administration’s offer on expansion incentives that add 5% to states’ federal match, it would cost less monthly—about $16 million total for the 24,500 births covered annually.
Health experts estimate that costs of bulking up the number of insured mothers would be offset by improved health outcomes that save money down the road on costly chronic disease, reduced uncompensated care costs, and of course, lives saved.
Dr. Collier, of the state maternal mortality committee, says too many mothers are uninsured before and after pregnancy, which leaves them in lurch for piecemeal health care after pregnancy that only begets the cycle. Almost one in five women of reproductive age in Mississippi lack health insurance, likely only qualifying for Medicaid while pregnant.
Once benefits cut off, “Basically moms are left to fend for themselves through emergency care when it’s needed, which by the way is much more expensive for our state than any ongoing, outpatient or primary medical care,” Collier said.
“There’s no accountability or responsibility of the medical system for what happens to her in a lot of ways. There’s nothing that many physicians or providers can do. They’re left, unable to continue with visits or referrals if needed … (as) mothers face either being charged out of pocket, or just only seeking medical care through emergency departments or the various ways they have to piece together their health care when they don’t have continuous coverage.”
Mississippians often struggle to qualify for Medicaid, with their eligibility for the program revolving around health status in addition to income level.
A Cycle of Disrupted Care
States that took up the feds on the 10%-90% split where the State is only on the hook for 10% of new costs, expanded eligibility to folks with up to 138% of the federal poverty level, or about $20,000 for a family of three. In Mississippi, you have to meet certain eligibility requirements, like pregnancy or disability, to qualify.
Being a caregiver is one of those eligibility designations, but a parent of two cannot make more than $5,700 yearly. So a single mother of two would have to make under $500 monthly to keep her Medicaid benefits after 60 days postpartum. Most will not qualify after then, and will lose benefits and enter or continue a cycle of disrupted care.
“For too many mothers in Mississippi, the only medical care they get is when they are pregnant. So that may be the first time we identify multiple medical problems, but then there are many medical conditions that can develop during pregnancy, like severe hypertension, diabetes, depression, and these are conditions that require ongoing care and maintenance,” Collier said.
“These are not expensive things. This is primary medical care in some ways, and many ways it’s maintenance of what was going on during pregnancy and the immediate postpartum period that gets artificially and arbitrarily cut off at six weeks.” As such, Collier says, most go without medical treatment that’s recommended, advised and needed.
If mothers qualified for Medicaid during pregnancy but not after 60 days postpartum, she likely falls in the massive “insurance gap” created by states’ failure to expand Medicaid.
Mississippi has one of the biggest gaps in the country, with nearly 200,000 of the state’s 300,000 uninsured likely qualifying for Medicaid if the state were to expand—meaning the state’s uninsurance rate would shrink by over half, one of the largest shares in the U.S.
Over the past few years, the Mississippi Hospital Association has sponsored a so-far rejected expansion plan called “Mississippi Cares” that would bring the state’s 10% cost share of Medicaid expansion to $0—similar to original Obama administration incentives that covered 100% of the state’s costs from 2014 to 2016.
By not expanding, the State of Mississippi is passing up on an estimated $5 million daily.
“It’s really shameful that the day after Mississippi chooses not to extend postpartum coverage, we are learning that maternal mortality is yet again rising in our country,” Collier said. “And we’re not doing one of the fundamental things that is needed.”