As of 2020, 42% of women across the United States had Medicaid as their insurance coverage at the time they gave birth. Medicaid is a government health insurance program for people who qualify according to income and certain disabilities, and until recently, most states only allowed continuous Medicaid pregnancy coverage for 60 days after delivery. (Getty Images)
Without coverage from Idaho’s Medicaid program, Moscow resident Erin Singer is convinced she would have felt forced to seek an abortion when she got pregnant with her son in 2017.
And without coverage from Medicaid after she gave birth, Singer wouldn’t have been able to afford the physical therapy required to treat the debilitating pelvic condition she developed during pregnancy.
Singer discovered she was pregnant just a few days before a rheumatologist told her the frequent headaches, aches and pains and the multiple miscarriages she had experienced were likely due to an autoimmune disease that causes abnormal blood clotting. To safely continue her pregnancy, Singer had to take an injectable blood thinner.
Without insurance, the medication can cost between $75 and $250 per month, which Singer said she wouldn’t have been able to afford.
“It’s not just the baby that could have a problem (without it), I could have a stroke. And I had a (2-year-old) daughter to think about,” Singer said.
As of 2020, 42% of women across the United States had Medicaid as their insurance coverage at the time they gave birth. Medicaid is a government health insurance program for people who qualify according to income and certain disabilities, and until recently, most states only allowed continuous Medicaid pregnancy coverage for 60 days after delivery. After that, postpartum individuals are required to submit monthly proof of eligibility. Research has shown that continuity of care following childbirth is associated with better health outcomes for the person who gave birth and the infant.
According to the Centers for Disease Control and Prevention, 1,205 maternal deaths were recorded in 2021 — a nearly 40% increase over the previous year’s number of 861. The year before that, there were 754. Those numbers are thought to be partially attributed to the COVID-19 pandemic, but pre-COVID, the United States still had some of the highest maternal mortality rates of industrialized nations.
The 2018 rate of 17.4 deaths per 100,000 live births was more than double the next highest rate in France of 8.7 deaths.
The CDC also notes that for every maternal death, there are about 100 “near misses,” when a person comes close to losing their life during or after a pregnancy.
The federal American Rescue Plan Act allowed states to change the continuous Medicaid coverage to one full year following delivery without applying for a waiver, and as of March 24, all but three states — Idaho, Iowa and Nebraska — have already expanded, intend to expand or have legislation pending that would expand the coverage.
Of the 13 states that have abortion bans in effect, Idaho is the only one that has not expanded coverage.
Despite state surplus and constituent support, Idaho committee chairman tabled bill
Rep. John Vander Woude, R-Nampa, who is chairman of the Idaho House Health and Welfare Committee, announced Tuesday that the committee would not hear House Bill 201 to expand the coverage before the Idaho Legislature adjourns for the year.
Idaho’s maternal mortality rate per 100,000 live births increased from 18.1 in 2019 to 32.5 in 2020, according to the state’s Maternal Mortality Review Committee. Eight of the 11 women who died in 2020 — or 72% — were covered by Medicaid.
That committee’s work will not be able to continue past July after lawmakers tabled the bill that would have renewed it. Hillarie Hagen, health policy associate for the advocacy group Idaho Voices for Children, said to her knowledge, that will make Idaho the only state in the country without a committee to review deaths that happen during and after a pregnancy.
Vander Woude noted that he had about 30 voicemails and numerous emails supporting the bill but said his concerns with the overall budget need to be addressed first.
“I was supportive of this one, but I’m trying to get control of the Medicaid budget before we expand it, so that’s the reason I’m holding on to it,” Vander Woude said.
According to the bill’s fiscal note, the cost to the state’s general fund would have been about $6.2 million on an annual basis, with a federal match of $28.7 million. As of March 24, the state’s budget chief Alex Adams said after the budget items approved by the Legislature are signed into law, the state is still expected to have a surplus of about $416 million at the end of the 2023 fiscal year in July. The state’s budget chief acknowledged in 2022 that federal dollars played a role in the record-breaking surplus.
Vander Woude also said there weren’t enough cosponsors to feel comfortable advancing the bill.
“I think it’s a good idea, I just don’t think it’s quite ready yet, and maybe next year we can get something like this passed,” he said.
Hagen said Idaho Voices for Children was incredibly disappointed by the lack of action and that she disagreed with the statement that there wasn’t enough support to get it through.
“Last year, legislators said they wanted to pass policies to support the health of mothers, and now they’re about to leave town without passing House Bill 201, which would’ve done just that,” Hagen said. “I have personally talked to so many moms who have had very tragic pregnancy stories because of lack of access to health care coverage, and it’s devastating to think of how many more stories I’ll have to listen to before we can try to pass this again next legislative session.”
South Dakota, Arkansas appear on the verge of achieving expansion
Two other states with abortion bans, South Dakota and Arkansas, appear to be close to expansion.
South Dakota Sen. Reynold Nesiba, D-Sioux Falls, sponsored a bill in January to expand coverage, but asked the committee to table the bill in mid-February because he had confirmed Republican Gov. Kristi Noem applied for the expansion on the state’s behalf, making the legislation unnecessary.
“I made sure the application was already in,” Nesiba said.
South Dakota also voted to pass Medicaid expansion for the entire state in 2022, which will take effect July 1.
Ian Fury, press secretary for Noem, told States Newsroom via email that the state had submitted its application on March 15. If it is approved by the Centers for Medicare and Medicaid Services, the postpartum expansion would also become effective July 1.
In Arkansas, House Bill 1010 to expand postpartum coverage is awaiting action with Rep. Aaron Pilkington, R-Knoxville, as its sponsor. Pilkington said he is still working with state agencies to pencil out the numbers in a way that keeps the budget at net zero with the expansion, but he’s optimistic it will work out and have widespread support among legislators.
It’s one of six bills Pilkington has sponsored during the 2023 legislative session, along with bills to require Medicaid reimbursement for depression screening for pregnant women and requiring certain employers to provide paid maternity leave. He also sponsored a bill in 2021 allowing oral contraceptives to be prescribed by pharmacists to those over the age of 18.
“I tell people all the time that I want Arkansas to be the best place to give birth, and I’m pro-life, and I think that goes hand-in-hand in what we’re trying to do,” Pilkington said.
Arkansas has a strict abortion ban at any stage of pregnancy with no exceptions for rape or incest, only an exception to save the patient’s life. With that ban in place, Pilkington said, support needs to be available, especially given the state’s high maternal mortality rate of 81 deaths per 100,000 live births.
“Let’s put our money where our mouth is, so if we’re going to have 3,000 more births (per year), we need to make sure we’re taking care of those mothers and giving them access to health insurance and care,” he said.
Democratic lawmakers in Iowa rolled out a package of reproductive health care-related legislation this month, but it is not expected to advance. Iowa legislators decided not to expand postpartum Medicaid coverage in 2022.
In Nebraska, lawmakers discussed the idea in 2022 but indefinitely tabled the bill in April.
Idaho governor, health department to explore options moving forward
For the next year, it appears Idaho will be without extended postpartum coverage and without a maternal mortality review committee.
Although South Dakota was able to expand coverage without the Legislature, it’s unclear if Idaho’s administrative rule process will allow the Idaho Department of Health and Welfare or Republican Gov. Brad Little to do the same.
Madison Hardy, spokesperson for Little’s office, said the governor will continue to work with the Legislature on finding ways to best serve Idaho families and pregnant women.
“Access to health care is a priority for the governor. The governor is committed to working collaboratively with his partners in the legislative branch but will always consider options that best serve Idahoans,” Hardy said in a statement. “Fortunately, today’s Medicaid program serves postpartum women in need of care if they choose to transition to Medicaid expansion.”
Niki Forbing-Orr, spokesperson for the Idaho Department of Health and Welfare, said the department is evaluating its options and had no further comment on the issue.
For Erin Singer, whose son is now 5 and daughter is 8, watching the Legislature’s lack of action is deeply upsetting.
“Honestly without Medicaid, I probably would’ve had to have an abortion, and I love my son, I wanted my son. It was terrible timing, we were hoping to wait another six months because we would’ve been a lot more stable, but sometimes things happen when they’re supposed to happen,” Singer said. “If you’re going to take (abortion access) from us and you want us to have babies, I think you have to take care of the women and children.”
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