NR 555 Week 6 Health Equity Policy Analysis Example

Policy Analysis: A State's 12-Month Postpartum Medicaid Extension, Read From Its Own Terms, the Groups It Writes Out, and the Steps Between Qualifying and Actually Receiving a Postpartum Visit

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College of Nursing, Chamberlain University

NR 555: Health Policy: Advancing Health Equity & Outcomes

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Month Day, Year

Policy Analysis: A State's 12-Month Postpartum Medicaid Extension, Read From Its Own Terms, the Groups It Writes Out, and the Steps Between Qualifying and Actually Receiving a Postpartum Visit

The Rule Itself

Federal law enacted in 2021 gave states a new option, beginning April 1, 2022, to extend Medicaid and Children's Health Insurance Program coverage for pregnant enrollees from about 60 days postpartum to 12 months postpartum through a state plan amendment. Most states have since adopted the option. Our state's amendment, effective last year, provides that an individual who was eligible for and enrolled in Medicaid while pregnant remains eligible for full Medicaid benefits through the last day of the month in which the 12-month postpartum period ends, regardless of changes in income during that period. The analysis below works from the state's amendment and its eligibility manual, dated last year, rather than from news summaries, because summaries often describe the extension as covering "all new mothers," which the text does not say.

Why the Policy Matters to the Gap

The disparity analysis found a 16-point difference in postpartum visits, Black versus white Medicaid enrollees, and the determinants write-up identified coverage ending at about 60 days as one candidate cause. Coverage changes around childbirth are common (Daw et al., 2017), and broader Medicaid eligibility has been associated with increased postpartum coverage and outpatient care (Gordon et al., 2020). The extension directly targets that mechanism. Whether it narrows the gap depends on who it reaches.

Written Out

The text excludes several groups, some by name and some through its conditions.

People not enrolled while pregnant. Eligibility for the extension requires enrollment in Medicaid during pregnancy. A person who was uninsured during pregnancy, or covered by a private plan that lapsed after birth, gains nothing from the extension.

People covered only for the delivery through emergency Medicaid. Some immigrants who do not meet federal eligibility rules, including many recent lawful permanent residents during a five-year waiting period and undocumented immigrants, may have labor and delivery covered as an emergency service but are not enrolled in full Medicaid and are not covered for postpartum care. The extension does not change that. In our state, these enrollees are disproportionately Hispanic.

People with incomes just above the pregnancy threshold. Those with incomes above the state's limit for pregnancy coverage were never enrolled and are outside the extension.

Each exclusion is produced by a condition in the text, not by an explicit statement that a group is excluded. That is typical: policies rarely name the people they leave out.

Written In but Not Arriving

For those the text covers, a sequence of steps stands between eligibility and a postpartum visit, and each step has a cost.

Staying enrolled. The extension removes income changes as a reason to lose coverage, but enrollees can still be disenrolled if the state cannot confirm their address, for example when mail is returned. People who move after a birth, more common among renters and those in unstable housing, are at higher risk.

Knowing coverage continues. Many enrollees were told during pregnancy that coverage ends at 60 days. If no one tells them it now lasts a year, they may not seek care they believe they must pay for.

Getting an appointment. The extension provides coverage, not appointments. Enrollees still need a clinic that accepts their plan, has openings and is reachable, the scheduling and location barriers described earlier.

Being treated well. Coverage does not address experiences of disrespect that make a return visit less likely.

Each step is priced in time, paperwork and travel, and the burdens fall unevenly. American College of Obstetricians and Gynecologists (2018) guidance frames postpartum care as an ongoing process beginning within three weeks of birth, which requires more contact than a single visit and makes each step matter more.

Expected Effect on the Gap

The extension should reduce one mechanism, coverage loss, that falls more heavily on Black enrollees, and so should narrow the gap somewhat. It will not reach people written out of the text, who are disproportionately Hispanic immigrants, and it may not reach enrollees who never learn that coverage continues or who face scheduling, distance and respect barriers. The gap between Black and white enrollees may therefore narrow while the gap for immigrant enrollees widens relative to others. Measuring the extension's effect requires reporting postpartum visits by race and ethnicity, and by eligibility category, before and after it took effect.

Implementation Questions for the State

Four questions will decide how much of the extension's promise is realized. First, how will the state identify enrollees entitled to the extension when their pregnancy coverage was recorded in different eligibility categories? Errors here could end coverage at 60 days by default. Second, how will the state handle renewals during the 12 months? If an enrollee's annual renewal falls within the postpartum year, the state should make sure the extension protects them from disenrollment for income. Third, will managed care plans be required to tell members about the extension and to maintain postpartum care coordination through the year? Fourth, how will the state measure the extension's effect on the gap, rather than only on overall enrollment?

Each question has an owner within the state Medicaid agency. The analysis recommends that the agency publish its answers, because advocates and plans can only help enrollees keep coverage if they know how the rules are being applied.

Recommendations

Three recommendations follow. First, the state should notify every enrollee in writing and by text at delivery that coverage lasts 12 months. Second, the state should report postpartum visits and coverage retention by race, ethnicity and eligibility category annually. Third, the state should consider using state funds to provide postpartum coverage to people whose delivery was covered only by emergency Medicaid, as some states have done, since they are entirely outside the extension. Bailey and colleagues argued that addressing structural inequity requires changing the rules that produce it (Bailey et al., 2017); the extension changes one rule and leaves others in place.

The extension is therefore a necessary step rather than a complete one. Its effect on the gap should be judged after the first full year of data, with the implementation questions above answered in public, and the analysis repeated once the state reports visits by eligibility category.

Advocates can help by checking each answer.

References

American College of Obstetricians and Gynecologists. (2018). ACOG Committee Opinion No. 736: Optimizing postpartum care. Obstetrics & Gynecology, 131(5), e140-e150. https://doi.org/10.1097/AOG.0000000000002633

Bailey, Z. D., Krieger, N., Agénor, M., Graves, J., Linos, N., & Bassett, M. T. (2017). Structural racism and health inequities in the USA: Evidence and interventions. The Lancet, 389(10077), 1453-1463. https://doi.org/10.1016/S0140-6736(17)30569-X

Daw, J. R., Hatfield, L. A., Swartz, K., & Sommers, B. D. (2017). Women in the United States experience high rates of coverage "churn" in months before and after childbirth. Health Affairs, 36(4), 598-606. https://doi.org/10.1377/hlthaff.2016.1241

Gordon, S. H., Sommers, B. D., Wilson, I. B., & Trivedi, A. N. (2020). Effects of Medicaid expansion on postpartum coverage and outpatient utilization. Health Affairs, 39(1), 77-84. https://doi.org/10.1377/hlthaff.2019.00547