How Texas’ Medicaid and CHIP Extension Addresses Birth Equity

Summary

In 2023, the Texas legislature passed House Bill 12, extending Medicaid postpartum coverage from two months to one year. On Jan. 17, 2024, the federal Centers for Medicare and Medicaid Services (CMS) approved the state’s request to permanently extend its Medicaid and Children’s Health Insurance Program (CHIP). That legislation will go into effect in Texas on March 1, 2024. As a result, an estimated 137,000 more Texas mothers will be able to continue seeing their physician, taking needed medications, and receiving mental health services for 12 months after their pregnancy ends. In this brief, we summarize how Texas’ Medicaid and CHIP extension will benefit families and explore the expected impacts of this extension.

Background

The postpartum period is critical for recovering from childbirth and for addressing complications of delivery and managing mental health, infant care, and the transition from obstetric to primary care. Based on data from the Centers for Disease Control and Prevention, about 53% of maternal deaths happen between seven and 365 days postpartum. Loss of health coverage is a primary reason many women do not seek postpartum care.[1]

Extending postpartum Medicaid benefits from 60 days to a full year is not only critical for preventing maternal deaths, but also for ensuring new mothers receive follow-up care for medical and mental health issues. According to the Mayo Clinic, postpartum depression symptoms may not arise until six months or more after childbirth, and they may last for up to a year after giving birth. Twelve months of postpartum Medicaid benefits can also help protect new mothers from incurring medical debt due to being uninsured.

According to the Kaiser Family Foundation, almost half of all Texas births were paid for by Medicaid in 2022. From 2018–21, Texas ranked 14th for the highest number of maternal deaths per 1,000 live births. Until the postpartum extension request was made, Texas was among the few states remaining that had not approved extended postpartum Medicaid coverage.[2]

For several years, extending postpartum Medicaid coverage has been the most critical recommendation of the Texas Maternal Mortality and Morbidity Review Committee, which develops recommendations to reduce preventable pregnancy-related deaths, racial disparities, and maternal morbidity in the state.[3] The committee’s fifth biennial report, the first that had access to recent statistics, indicated Black women in Texas are twice as likely as white women to die from pregnancy-related causes, a trend that has persisted during the past 10 years.[4]

Racial disparities in Black maternal health can be traced to systemic issues such as a shortage of Black medical providers; a history of punitive care and treatment of Black women; and the lack of structural competence training in medical education, which may impact a provider’s ability to treat Black women as equals in health care decision making.[5]

To help improve maternal health and coverage stability and address racial disparities in maternal health, a provision in the American Rescue Plan Act of 2021 gave U.S. states the opportunity to extend Medicaid postpartum coverage from two months to 12 months by executing a state plan amendment (SPA).[6] This new option took effect on April 1, 2022, and was originally in effect through the year 2027. According to the Centers for Medicare & Medicaid Services, Congress made the 12-month extended postpartum coverage option permanent in 2023 to alleviate concerns from states about federal funds being taken away.

Expected Impacts

Coverage will automatically be extended for individuals enrolled in Medicaid or CHIP while they are pregnant, as long as they are within the 12-month postpartum window and still live in Texas. Women enrolled in Healthy Texas Women who are within the 12-month postpartum window will automatically be transferred back to Medicaid or CHIP for the rest of the 12-month postpartum period. And finally, an individual whose pregnancy ended before March 1, 2024, and lost postpartum Medicaid coverage can reenroll in coverage that will extend to 12 months after the end of their pregnancy.

The extension of postpartum Medicaid to 12 months also means mothers can be monitored for specific conditions they may be more susceptible to after giving birth, which will lower the maternal mortality rate in Texas.[7] This assertation is backed by 2022 research findings that after implementation of the postpartum Medicaid coverage extension, women used twice as many postpartum services — including two to 10 times as much preventive care, contraception use, and mental/behavioral health services. In addition, there were 37% fewer short interval pregnancies among mothers during the first year postpartum.[8]

Moreover, the Texas Medical Association is concerned about whether extended postpartum Medicaid coverage will be implemented effectively and be communicated in a way that ensures eligible mothers learn about coverage extension and how to access services they need. In addition, Texas OB-GYNs worry about meeting increased demand for their services, especially given the worsening workforce shortages in obstetrics and gynecology after the Dobbs v. Jackson Women’s Health Organization decision that overturned Roe v. Wade in 2022.[9]

Conclusion

In summary, Texas has joined the ranks of 45 states and the District of Columbia to be aligned with the federal recommendation for 12 months postpartum Medicaid benefits. Although challenges exist, this policy is a move toward improved health for pregnant and postpartum women in Texas:

• Research demonstrates that health care coverage in postpartum is associated with utilization of postpartum visits thereby improving health in the first year after birth.[10]
• The extension from 60 days to 12 months coverage has the potential to improve maternal health for approximately 137,000 Texas mothers.
• This legislation allows mothers to continue seeing their physician, taking needed medications, and receiving mental health services for 12 months after their pregnancy ends.
• According to March of Dimes, Medicaid coverage percentage at the time of birth is highest among Hispanic and Black women. Given this, postpartum extension has the potential to reduce racial disparities by eliminating gaps in coverage for those most at risk for mortality and morbidity.[11]

Notes

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[1] Susanna Trost et al., Pregnancy-Related Deaths: Data from Maternal Mortality Review Committees in 36 US States, Centers for Disease Control and Prevention Division of Reproductive Health, 2022, https://www.cdc.gov/reproductivehealth/maternal-mortality/docs/pdf/Pregnancy-Related-Deaths-Data-MMRCs-2017-2019-H.pdf.

[2] Taylor Goldenstein, “Medicaid Coverage for Texas Mothers To Increase to 12 Months Postpartum After Federal Sign-Off,” Houston Chronicle, January 17, 2024, https://www.houstonchronicle.com/politics/texas/article/medicaid-texas-postpartum-18613069.php.

[3] Eleanor Klibanoff, “New Texas Maternal Mortality Report Shows Disparities Persist,” The Texas Tribune, December 16, 2022, https://www.texastribune.org/2022/12/15/texas-maternal-mortality-report/.

[4] Klibanoff, “New Texas Maternal Mortality Report Shows Disparities Persist.”

[5] Brittany Chambers et al., “Clinicians’ Perspectives on Racism and Black Women’s Maternal Health,” Women’s Health Reports 3, no. 1 (May 2022): 477–8, https://doi.org/10.1089/whr.2021.0148.

[6] “State Efforts to Extend Medicaid Postpartum Coverage,” National Academy for State Health Policy, last modified February 1, 2024, https://nashp.org/state-tracker/view-each-states-efforts-to-extend-medicaid-postpartum-coverage/.

[7] Nicole Villalpando, “Feds Approve Medicaid for Texas Mothers up to 12 Months After Birth Beginning March 1,” The Austin-American Statesman, January 22, 2024, https://www.statesman.com/story/news/healthcare/2024/01/22/medicaid-texas-approved-12-months-postpartum-care-pregnant-moms/72261199007/.

[8] Xiao Wang et al., “Extending Postpartum Medicaid Beyond 60 Days Improves Care Access and Uncovers Unmet Needs in a Texas Medicaid Health Maintenance Organization,” Frontiers in Public Health 10 (May 2022): 5–6, https://doi.org/10.3389%2Ffpubh.2022.841832.

[9] Sandhya Raman and Ariel Cohen, “OB-GYN Workforce Shortages Could Worsen Maternal Health Crisis,” Roll Call, March 16, 2023, https://rollcall.com/2023/03/16/ob-gyn-workforce-shortages-could-worsen-maternal-health-crisis/.

[10] Saldanha et al., “Health Insurance Coverage and Postpartum Outcomes in the US: A Systematic Review,” JAMA Network Open (2023), https://bit.ly/3Idd0Oi.

[11] Racial breakdown of births on Medicaid from National Center for Health Statistics final natality data retrieved February 27, 2024, from www.marchofdimes.org/peristats.

 

 

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