Correction: An earlier version of this article referred to Medi-Cal as a California’s version of Medicare. It is California’s version of Medicaid.
The United States has the highest maternal mortality rate of any industrialized country. The $1.9 trillion stimulus bill, signed by President Biden last month, includes a little-known section that could save mothers’ lives.
Every year, hundreds of thousands of people qualify for Medicaid because they are pregnant, with 43 percent of all births covered by the government program in 2016. Medicaid for pregnant people is more far-reaching than Medicaid for parents, so many lose coverage 60 days after their baby’s birth, leaving them to pay out-of-pocket for any mental or physical complications that may arise further out.
The stimulus bill extends Medicaid coverage for up to one year after they give birth.
The bill allows states to opt into this Medicaid expansion, said Jamila Taylor, director of health-care reform at the Century Foundation, a progressive think tank, but it’s still unclear how many will do so. In August, California became the first state to expand its version of Medicaid, Medi-Cal, for women diagnosed with a maternal mental health condition for one year postpartum.
For decades, postpartum care was understood as one appointment, six weeks after the birth, said Stacey McMorrow, a research associate who has studied postpartum insurance coverage at the Urban Institute, a nonprofit research organization. In 2018, the American College of Obstetricians and Gynecology (ACOG), the leading professional organization for OB/GYNs, issued more comprehensive guidelines, encouraging doctors to expand health care during this period.
“To optimize the health of women and infants, postpartum care should become an ongoing process, rather than a single encounter, with services and support tailored to each woman’s individual needs,” the ACOG wrote in a statement. This should include contact with an OB/GYN within the first three weeks postpartum and a comprehensive visit within 12 weeks, as well as other care as needed.
“When women lose coverage at 60 days, it can further entrench them into economic hardship and disrupt the continuity of their care,” said Taylor. It may also contribute to maternal mortality rates, she said, which are far higher for women of color. Black, American Indian and Alaska Native women are two to three times as likely as White women to die from pregnancy-related causes, according to the Centers for Disease Control and Prevention.
For women who lose insurance coverage 60 days after giving birth, McMorrow said, the anxiety can be crippling. Fifty-two percent of uninsured new mothers report feeling “very worried” about not being able to cover their health-care costs, according to McMorrow’s research.
Amber Pendergraph-Leak, now 34, was on Medicaid when she had her first child at age 20. As the 60-day mark loomed, she said, she grew anxious, taking vitamins to try to ward off any potential illnesses or complications. She got an intrauterine device at her six-week postpartum appointment, she said, knowing that soon she would not be able to afford other forms of birth control.
As you near the 60-day point, it’s easy to panic, said Pendergraph-Leak, who now works as a doula in Spartanburg, S.C. “You think, ‘Oh my goodness, Medicaid is going to end. What am I going to do?’”
While Pendergraph-Leak did everything she could to prepare for a period without health insurance, she said, she was confronted with a complication she never could have anticipated. Soon after her IUD insertion, she said, her vision started to blur and she fainted. Her doctor said it was likely the IUD. By the time she had it removed, she said, she was no longer on Medicaid.
“It took me forever to pay off my emergency bill,” said Pendergraph-Leak. The debt hung over her as a new mother.
Many of Pendergraph-Leak’s clients struggle with postpartum anxiety and depression — which can’t be treated in 60 days, she said. Pregnancy-related issues of mental health tend to go untreated, especially in communities of color. In McMorrow’s study, 27 percent of uninsured new mothers said they experienced some degree of postpartum depression.
Pendergraph-Leak, who is Black, tries to destigmatize mental health when talking to her clients, most of whom are women of color. “In my community, therapy isn’t normalized,” she said. She talks to her clients about how much she has personally benefited from seeing a therapist — and eventually, she said, they sometimes agree to give it a try.
After a few weeks, she said, her clients have just started to build rapport with a therapist. When Pendergraph-Link asks them to start again with someone new — who charges on a sliding scale — they usually say “no way.”
There are many physical conditions, too, that can worsen or appear for the first time during pregnancy. Once you give birth, it can feel like you have a “new body” with different problems and points of sensitivity, said Cassie Calderone, a doula who serves low-income people in Chicago. Many of these conditions can’t be treated — or even identified — in 60 days, she said.
“It’s something new that you need to manage,” Calderone said. “And then it’s like, ‘I have 60 days to learn what my body is like.’”
Some of her clients have developed diabetes during pregnancy, she said. Others have struggled with changes in their pelvic floor. While carrying a baby, she said, certain muscles can loosen.
“One client went into her six-week postpartum [appointment] and found out she had diastasis recti,” a condition where muscles in the abdomen expand after pregnancy. “She has to get physical therapy. If she’s not on Medicaid, how is she going to figure that out?”
With Medicaid coverage extended to a full year, people will be able to properly treat these kinds of issues, said Taylor. They’ll also be able to better plan for their reproductive futures, with access to all forms of birth control for the year.
The stimulus provision is a “first step” toward better postpartum care, said Taylor. Like the rest of the stimulus package, she said, the benefits are temporary, expiring after five years. She is hopeful that the accommodation could eventually become permanent, she added, especially because Vice President Harris has repeatedly signaled her commitment to combating high rates of maternal mortality.
Once states opt into this stimulus provision, they still have work to do, said McMorrow. “Historically, we haven’t already done a great job of enrolling eligible women” in similar programs, she said. Government officials need to make sure that people know about the expansion and stay enrolled in Medicaid.
McMorrow will be watching to see “to what extent Medicaid coverage increases in the postpartum period,” she said.
For the people who do benefit from the expansion, McMorrow said, she expects to see immediate mental health impacts. Right away, she said, new mothers will feel relief, no longer counting down to when their coverage will expire in the early days of postpartum.
New mothers “will feel like they have the things they need to make them successful in life,” said Pendergraph-Leak.
Whatever illness or complication might emerge, she said, they’ll know: “I can go in. I can be seen.”