States Miss Key Opportunities in Medicaid Maternal Health Coverage

October 2, 2024

Recently, a report from the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) has highlighted missed opportunities by states to improve maternal health access through Medicaid managed care organizations (MCOs). The report points out significant gaps in insurance coverage provided by MCOs for various essential maternal health providers across 41 states. The findings are especially worrisome considering Medicaid’s role as the primary payer for pregnant beneficiaries in the U.S., covering 40% of all births. These disparities impact maternal health outcomes and exacerbate healthcare inequalities, particularly among marginalized communities.

Disparities in Mandatory Coverage

Uneven Coverage for Key Providers

The report underscores a troubling inconsistency in mandatory coverage for maternal health providers. While all states analyzed require coverage for OB-GYNs and hospital births, the inclusion of other essential providers like midwives, maternal-fetal medicine specialists, doulas, lactation consultants, and community health workers varies widely. Notably, one in five states does not mandate coverage for midwives, and more than half omit maternal-fetal medicine specialists. The situation is even more dire for doulas, lactation consultants, and community health workers, with many states not mandating their coverage at all.

These coverage gaps are critical given that diverse types of maternal health providers play a significant role in comprehensive maternal care. Midwives, for instance, offer personalized and lower-intervention care that can significantly benefit low-risk pregnancies. Doulas provide emotional and physical support during labor and postpartum periods, while lactation consultants ensure successful breastfeeding, which has long-term health benefits for both mother and child. Community health workers often serve as bridges between healthcare providers and underserved communities, enhancing reach and efficiency. The lack of coverage for these providers limits the options available to pregnant women, potentially leading to poorer health outcomes and increased stress during an already critical period.

Impact of Policy Flexibility on Maternal Health

Federal regulations require states to cover certain maternal health services but leave the choice of providers largely to state discretion. This flexibility results in considerable variability in who gets covered, directly impacting the quality and accessibility of maternal healthcare. Deputy Regional Inspector General Laura Kordish noted that states have not fully utilized available options to broaden the scope of covered providers, thereby missing opportunities for improvement. Given Medicaid’s extensive reach, the lack of uniform provider coverage undermines efforts to ensure high-quality maternal healthcare for all pregnant beneficiaries.

The federal government’s push for more inclusive policies thus becomes crucial for addressing these disparities. As states have the capability to tailor their Medicaid programs to their unique demographic and geographic needs, a more standardized approach could ensure that essential maternal health providers are universally accessible. This disparity in coverage also highlights the importance of ongoing policy review and adaptation to meet current healthcare demands. States that proactively utilize their policy flexibility to expand provider coverage can significantly improve maternal health outcomes and contribute to reducing the nation’s alarming maternal mortality rates.

Adverse Implications

The Toll on Marginalized Communities

The report’s findings are particularly concerning due to their implications for marginalized communities. The U.S. has the highest maternal death rate among high-income nations, and poor maternal health outcomes disproportionately affect Black women, American Indian, Alaska Native women, and women in rural regions. These groups stand to benefit significantly from a wider range of maternal health professionals, yet they are often the ones most adversely affected by limited provider coverage. In such demographics, access to midwives, doulas, and community health workers could bridge the healthcare gaps, offering more personalized and culturally competent care.

The adverse implications of inadequate coverage are profound, contributing to an ongoing cycle of disparity and poor health outcomes. The Centers for Disease Control and Prevention (CDC) data reveal that Black women are three to four times more likely to die from pregnancy-related causes than white women. American Indian and Alaska Native women face similarly dire statistics. These alarming figures underscore the need for comprehensive and equitable maternal health care. Ensuring these communities have access to a full spectrum of maternal health providers could mitigate risks and pave the way for healthier pregnancies and births. Moreover, enhanced coverage could also alleviate the financial burden on these families, making necessary healthcare services more accessible and affordable.

Federal and State Response Needed

To address these gaps, HHS is urging the Centers for Medicare & Medicaid Services (CMS) to ensure states cover required maternal health services from a diverse set of providers and to enhance guidance on OB-GYN network adequacy standards. Typically, MCOs build provider networks for maternal care services and must cover out-of-network care if such services are unavailable, often requiring prior authorization. However, this practice is not scalable and does not address root causes of provider inadequacy. Comprehensive approaches at both federal and state levels are necessary to ensure all beneficiaries receive consistent, high-quality care throughout the prenatal to postpartum continuum.

Enhanced federal guidance and oversight could drive states toward more uniform standards and practices in maternal health coverage. By systematically addressing the gaps, CMS can support states in developing robust provider networks that include midwives, doulas, lactation consultants, and other essential professionals. These measures would not only meet immediate healthcare needs but also foster long-term, sustainable improvements in maternal health outcomes. Federal actions should be complemented by state-level initiatives tailored to address local challenges and promote health equity among diverse populations. By working in tandem, state and federal entities can create an integrated system that delivers on the promise of comprehensive maternal healthcare for all.

Network Adequacy Standards

Defining Adequate Networks

HHS defines network adequacy standards to ensure sufficient provider availability in MCO networks, based on factors like time and distance requirements, appointment wait times, and provider-enrollee ratio standards. Despite most states enforcing time and distance standards, these are often insufficient on their own. A majority of states have not reported improvements in access to maternal healthcare even after implementing these standards. Adequacy is not merely about spatial or temporal proximity but also involves ensuring the qualitative availability of various types of maternal health professionals.

Minnesota stands as a notable exception, being the only state to mandate MCO coverage for all types of maternal health providers examined in the report. This approach likely improves access to diverse maternal care services and could serve as a model for other states. By encompassing a full array of maternal health providers, Minnesota sets an example in achieving comprehensive care coverage. This holistic model, if adopted broadly, could significantly improve the quality and accessibility of maternal healthcare across the nation. Other states are encouraged to evaluate Minnesota’s successful policies and consider implementing similar measures tailored to their specific populations.

States with Limited Coverage

A recent report by the U.S. Department of Health and Human Services’ Office of Inspector General has brought to light missed opportunities by states to enhance maternal health access through Medicaid managed care organizations (MCOs). The study reveals notable shortcomings in the insurance coverage offered by MCOs for critical maternal health services across 41 states. This issue is troubling, given that Medicaid serves as the primary payer for pregnant individuals in the U.S., underwriting 40% of all births. These coverage gaps significantly affect maternal health outcomes and worsen healthcare inequities, particularly in marginalized communities.

Medicaid’s effectiveness in providing comprehensive maternal health services is crucial for ensuring better health outcomes for both mothers and babies. In many cases, MCOs fail to offer sufficient access to essential maternal care providers, such as obstetricians, midwives, and mental health specialists, all of which are vital for a healthy pregnancy and childbirth experience. Addressing these disparities could lead to improved health equity and reduce the risks associated with pregnancy and childbirth for underserved populations.

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