Perinatal insurance coverage and behavioural health-related maternal mortality

Abstract

Increases in postpartum maternal deaths, including a substantial number associated with behavioural health conditions, are a public health crisis and have contributed to overall increases in maternal mortality. A leading hypothesis to explain this pattern suggests lack of availability or continuity of resources for behavioural health treatment after delivery, often secondary to lapses in insurance coverage. Extending postpartum Medicaid coverage through the first year postpartum could mitigate excess morbidity and mortality among postpartum individuals, particularly those with behavioural health conditions.

The weeks and months following birth set the stage for long-term health and wellness. Health insurance facilitates access to health care, and insurance eligibility and benefit design have an important impact on postpartum health. Due to the way the United States (US) finances perinatal care, many people lose insurance coverage in the months following birth. In turn, birthing individuals often experience inadequate or no postpartum care.

Given rising maternal morbidity and mortality in the US, which disproportionately affects Black and Indigenous people, rural residents, and lower-income individuals, lack of sustained coverage remains particularly problematic. Further, increases in postpartum maternal deaths, including a substantial number associated with behavioural health conditions, have lead to overall increases in US maternal mortality (CDC Foundation, 2018; Goldman-Mellor & Margerison, 2019; Hall et al., 2020; Mangla et al., 2019; Metz et al., 2016; Smid et al., 2020). Behavioural health conditions, such as suicide and overdose, complicate an increasing proportion of births, which include a disproportionate number of births funded by Medicaid (Hirai et al., 2021; McKee et al., 2020). Extending postpartum Medicaid coverage through the first year postpartum could mitigate excess morbidity and mortality among postpartum individuals, particularly those with behavioural health conditions.

State Medicaid programs fund 42% of all births in the United States (Martin et al., 2019). The proportion of births covered by Medicaid ranges by state, from 20% in Vermont to 71% in New Mexico (Kaiser Family Foundation, 2021a). Pregnancy-related Medicaid coverage includes the period between the beginning of pregnancy until 60 days after birth. Beyond 60 days postpartum, individuals must re-qualify for Medicaid as a low income adult. Many states have a large gap in income eligibility for pregnancy-related Medicaid For instance, in Texas, pregnant people qualify for Medicaid at incomes up to 207% FPL, but only parents making 17% FPL ($3,636 annually for a family of three) would remain eligible for Medicaid after re-applying at 60 days postpartum (Kaiser Family Foundation, 2021b, 2021c). As a result, rates of uninsurance beyond 60 days postpartum have important implications for health care access.

In a study examining data from 2005 to 2013, nearly half (47%) of all postpartum individuals spent at least one month uninsured in the 6 months following birth (Daw et al., 2017). An analysis of 2015–2017 data suggests that approximately a third of individuals experienced a gap or transition in health insurance between pregnancy and three months postpartum. Postpartum uninsurance rates varied by state to as high as half of all postpartum individuals in Texas (Daw et al., 2017). These high rates of postpartum uninsurance should cause alarm, particularly given rising rates of maternal morbidity and mortality in the first year postpartum.

Half of all pregnancy-related maternal deaths happen after birth, and a third of all pregnancy related maternal deaths happen beyond the first week postpartum (Petersen et al., 2019). Twenty one percent of maternal deaths cases occur between seven and 42 days postpartum, and 12% percent occur in the late postpartum period, beyond 43 days postpartum (Petersen et al., 2019). In some states, these numbers are much higher. According to the Texas Maternal Mortality and Morbidity Task Force, 56% of all maternal deaths in Texas occurred more than 60 days after the end of a pregnancy (Texas Department of State Health Services, 2020). Importantly, most maternal deaths are preventable (Vital Signs: Pregnancy-related Deaths, 2019).

Reports from multiple maternal mortality review committees (MMRCs) have highlighted the increasing contribution of pregnancy-associated deaths due to suicide and overdose in the late postpartum period to overall increases in maternal mortality (CDC Foundation, 2018; Goldman-Mellor & Margerison, 2019; Metz et al., 2016). For example, among all maternal deaths occurring in Colorado between 2004 and 2012, a third were associated with self-harm (Metz et al., 2016). Deaths were evenly distributed throughout the first year postpartum (mean 6.2 months + 3.3 months postpartum) with less than 10% of self-harm deaths occurring during pregnancy; most occurred postpartum. This finding corresponds with data in a recent retrospective cohort study that found rates of opioid overdose deaths lowest in the third trimester of pregnancy and the highest between 7 and 12 months postpartum (Schiff et al., 2018). A leading hypothesis to explain this pattern suggests lack of availability or continuity of resources for behavioural health treatment after delivery, often secondary to lapses in insurance coverage (Connolly & Gillbard, 2021; Mangla et al., 2019; Nielsen et al., 2020).

Citing these late postpartum deaths, multiple state MMRCs have called for extensions of Medicaid through the first years postpartum as a strategy for mitigating preventable maternal morbidity and mortality (Eckert, 2021). The call to extend pregnancy-related Medicaid coverage beyond 60 days postpartum has also gained the support of over 60 national organisations including the American Medical Association and the American College of Obstetricians and Gynaecologists (American College of Obstetricians & Gynecologists, 2021). These calls have coincided with a recent proliferation of state and federal efforts to extend pregnancy-related Medicaid eligibility through the first year postpartum (The American College of Obstetricians & Gynecologists, 2021). Twenty one states and the District of Columbia have introduced proposals to extend Medicaid eligibility beyond 60 days, and federal legislation on this topic has also gained traction in Congress with new legislation introduced in 2021 (HR 6142, 2020; National Academy for State Health Policy, 2020).

Extending Medicaid coverage past 60 days postpartum represents a necessary but not sufficient policy solution if state Medicaid programs do not cover the services postpartum individuals need to thrive (Babbs et al., 2021). For example, only 34 states and the District of Columbia cover postpartum mental health screening as a Medicaid benefit to identify postpartum depression (Babbs et al., 2021). Further, few program have requirements or incentives for clinicians to ensure that postpartum individuals receive treatment for postpartum depression. With limited coverage through 60 days postpartum, benefits may end during treatment or before it begins. Treatment disruption may also occur postpartum for people with opioid use disorder or other substance use. California, which extended postpartum Medicaid eligibility for individuals with certain mental health conditions, serves as an exception (https://files.medical.ca.gov/pubsdoco/PPCE/PPCE_Landing.aspx). The adoption of ACA-related Medicaid expansion in the 12 states without expansion and a universal extension of postpartum Medicaid eligibility to all women eligible for pregnancy-related Medicaid offer more durable and comprehensive options to ensure access to needed care after childbirth (National Academy for State Health Policy, 2020; Black Maternal Health Mombibus Act of 2021, 2021).

Rising maternal morbidity and mortality rates, especially associated with behavioural health conditions, during the first year postpartum represent a public health crisis in the US. Extending pregnancy-related Medicaid eligibility through the first postpartum year could assist in ensuring access to needed care during the first year postpartum and mitigating excess maternal morbidity and mortality.