NR 555 Week 8 Health Equity Brief Example

Equity Brief: A 16-Point Gap in Postpartum Visits Between Black and White Medicaid Enrollees, the Scheduling Arrangement Behind Part of It, and What the State and Its Health Plans Should Do This Year

Student Name

College of Nursing, Chamberlain University

NR 555: Health Policy: Advancing Health Equity & Outcomes

Instructor Name

Month Day, Year

Equity Brief: A 16-Point Gap in Postpartum Visits Between Black and White Medicaid Enrollees, the Scheduling Arrangement Behind Part of It, and What the State and Its Health Plans Should Do This Year

The Finding

Black women covered by our state's Medicaid program are 16 percentage points less likely than white women to be seen for postpartum care within 12 weeks of giving birth: 58% compared with 74% last year. The true gap is probably larger, because the state's measure excludes people who lose or change coverage around the birth, and they are disproportionately Black. Postpartum visits are when serious complications, including high blood pressure, heart problems and depression, are most often detected, and Black women in the United States face a far higher risk of pregnancy-related death than white women (Petersen et al., 2019). Missing postpartum care means missing protection.

What a Reader Needs to Know First

The measure counts a postpartum visit from day 7 to day 84 following a live birth among Medicaid enrollees continuously enrolled around the delivery. It covered 15,000 births last year. The overall rate, 67%, is the figure usually reported; it hides the gap. Hispanic enrollees fall between Black and white enrollees at 66%.

One Mechanism

At the hospitals that deliver most Medicaid births, new parents are usually expected to call the clinic after going home to schedule their postpartum visit. That arrangement shifts the work of scheduling onto people in the first weeks after birth, and it falls hardest on those with unreliable phones, inflexible jobs and long trips to the clinic. Those burdens fall more heavily on Black enrollees in our state. A local pilot that booked visits before discharge raised attendance overall but operated only on weekdays, missing weekend discharges and possibly widening the gap. The scheduling arrangement is one of several causes; others include coverage loss, which the state's 12-month postpartum extension now addresses, clinic closures in majority-Black neighborhoods and experiences of disrespect in maternity care (Bailey et al., 2017). It is the one that local institutions can change fastest.

What Should Be Done

The state's managed care plans should fund postpartum schedulers at the three main delivery hospitals, seven days a week, so that every Medicaid-covered birth leaves with a booked visit near home. A registered nurse should call each new parent at about two weeks to check on recovery, confirm the appointment and arrange a ride through the existing Medicaid transport benefit if needed. The estimated cost is about $340,000 a year across the three hospitals.

The state should tell every enrollee, at delivery, that coverage now lasts 12 months. Many were told during pregnancy that it ends at 60 days.

The state should report the gap, not only the average. Postpartum visit rates should be published by race, ethnicity and eligibility category every year, along with the number of births excluded from the measure, so that progress on the gap is visible.

How to Know It Worked

The goal is to cut the gap between Black and white enrollees from 16 points to no more than 8 points inside a year and a half. An increase in the overall rate that leaves the gap unchanged would not be success. The groups, the measure and the target are fixed now, before the program starts, so that results cannot be selected afterward. Guidance on equity-focused evaluation recommends exactly this kind of advance specification (Welch et al., 2012).

Why This Matters Now

Two changes make this the right year to act. Stretching postpartum Medicaid to a full year removes one of the main reasons enrollees lost access to care after birth, so remaining barriers such as scheduling are now a larger share of the problem. And the state has begun reporting postpartum care by race, which means progress on the gap can be measured for the first time. A program started now can be evaluated against a clean baseline; one started in three years will be harder to separate from other changes.

Who Needs to Act

The state Medicaid agency needs to require plans to report the gap and to notify enrollees of the extension. The managed care plans need to fund the scheduling and nurse call program, which also improves their quality scores. The three hospitals need to host schedulers and change discharge routines so that no one leaves without a booked visit. Clinics need to hold open appointments for postpartum patients within the recommended windows. None of these steps requires legislation, and each actor has a reason to take part.

Questions a Reader May Ask

Will this help white enrollees too? Yes, and that is fine, but the test of success is whether the gap narrows, not whether everyone improves by the same amount.

Why not start with respectful care? Because the state has no data on it yet. The brief recommends collecting that data now so the next step can be designed with evidence.

What if it does not work? The evaluation is designed to show that plainly. If the gap does not narrow, resources should shift to the next mechanism, and the state will have learned something it could not have known without trying.

What This Brief Does Not Claim

The brief does not claim that scheduling explains the whole gap. Coverage, clinic location and respectful care all matter, and a scheduling program will not fix experiences of disrespect. The brief also does not claim that the program will work; the local pilot's design flaw is a reminder that interventions can miss the people who most need them. What it claims is that the scheduling arrangement is one clear, changeable cause, that fixing it is within the power of the state and its plans this year, and that the evaluation is designed to show honestly whether the gap narrows. Whitehead (1992) defined inequities as differences that are avoidable and unjust; this gap is both, and this brief sets out one step toward closing it.

In short, the gap is measurable, part of its cause is known and changeable, and the actors who can change it have reasons to do so this year. The request is modest in cost and clear in how it will be judged.

The data needed to judge the result already exist in the state's quality reporting, and the first report on the program could be ready within two years of the decision.

References

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

Petersen, E. E., Davis, N. L., Goodman, D., Cox, S., Syverson, C., Seed, K., Shapiro-Mendoza, C., Callaghan, W. M., & Barfield, W. (2019). Racial/ethnic disparities in pregnancy-related deaths: United States, 2007-2016. MMWR. Morbidity and Mortality Weekly Report, 68(35), 762-765. https://doi.org/10.15585/mmwr.mm6835a3

Welch, V., Petticrew, M., Tugwell, P., Moher, D., O'Neill, J., Waters, E., & White, H. (2012). PRISMA-Equity 2012 extension: Reporting guidelines for systematic reviews with a focus on health equity. PLoS Medicine, 9(10), Article e1001333. https://doi.org/10.1371/journal.pmed.1001333

Whitehead, M. (1992). The concepts and principles of equity and health. International Journal of Health Services, 22(3), 429-445. https://doi.org/10.2190/986L-LHQ6-2VTE-YRRN