American moms face grim reality
The statistics on United States (US) maternal health outcomes are grave, and the data reveals stark racial health disparities. As a country, the US is one of the worst wealthy nations in the world in terms of maternal morbidity. Furthermore, poor maternal health outcomes disproportionately impact Black and Indigenous mothers, who are two to three times more likely than white mothers to experience maternal morbidity.
Figure 1: Kaiser Family Foundation
*Percent of births for each is roughly 2/3rds, per KFF calculations
Which state levers best support Medicaid moms and babies?
The data on US maternal health outcomes has established a clarion call for several states, and these states have pursued evidence-based strategies to improve outcomes.
First, these states have extended Medicaid postpartum coverage to one year, which enables more mothers to receive services, and at critical times. An additional 720,000 mothers (i.e., an approximately 45% increase) would be covered if all remaining states expanded postpartum coverage to one year, the period during which 50% of pregnancy-related deaths occur. This extension would be especially critical for mothers with existing gaps in outcomes (e.g., postpartum depression).
Secondly, these states cover additional benefits that can improve outcomes both by delivering critical care in new ways as well as providing supplementary services to improve current care delivery. Benefits that create new care models (e.g., doula supports) can more holistically address a myriad of barriers that Medicaid mothers face, including coordination with physicians for appropriate care, among others. Studies have shown doula-supported births reduce C-Sections and increase positive birth experiences. In addition, benefits like covered home visits have been shown to benefit both mother and child via decreased infant emergency room visits and increased breastfeeding rates. Lastly, benefits that augment existing pathways can also target certain access gaps and specific needs outside of clinical settings (e.g., lactation consults for breastfeeding complications).
Which States Are Pulling Promising Levers?
Leading states are taking a holistic view on supporting Medicaid moms and babies and are pulling the promising levers to promote better outcomes. The map and rankings below track current efforts across 50 states (and the District of Columbia) on their use of these levers.
Grading current state action
Figure 2: 17A, Usage of Medicaid maternal health levers
Ideas for where to go next
For covered benefit-related levers, holistic delivery model changes (e.g., home visits, doula supports) are the most promising interventions to improve maternal health disparities and promote better outcomes for Medicaid babies from birth. Additional ideas – broken out by providers, managed care organizations (MCOs), and agencies – are presented below.
Payment model: Find ways to take on more and higher-risk agreements to pay for additional services
Care model: Pilot high-touch, proactive care models (e.g., home visiting, doula supports) with focus on most vulnerable populations; telehealth (clinical and nonclinical) and home visits can be used break down barriers. Data-sharing and risk agreements can be used to get reimbursement; state Medicaid agencies may also reimburse for services provided to mothers with SUD or high-risk pregnancies
Care delivery: Use data to pilot high-touch care delivery with highest risk populations to bring costs down; piece together disparate health care delivery (e.g., traditional ob-gyn follow-ups, lactation consults, doula supports)
Pay for levers that work and lobby state for additional reimbursements, especially focused on breaking access barriers; find ways to incorporate whole-family health interventions to bring down costs
Data: Improve data collection (e.g., demographics, clinical goals), for internal tracking and to share with providers to improve outcomes
Coverage and benefits: Increase coverage time periods and reimbursed levers
Payment reform: Additional payment reforms (e.g., value-based care, payment disincentives for C-Sections, etc.)
Data: Support data improvements to empower MCOs, providers to track outcomes
 https://ajph.aphapublications.org/doi/10.2105/AJPH.2013.301361; https://pubmed.ncbi.nlm.nih.gov/24187116/; https://pubmed.ncbi.nlm.nih.gov/30399451/