Being a new mother in Mississippi is almost as dangerous as it gets in the developed world. The Magnolia State ranks sixth among the states in terms of maternal mortality, with 33.2 deaths per 100,000 births. That’s double the U.S. average, which is the worst among peer countries. For mothers on Medicaid, who account for 65 percent of births in the economically stagnant state, insurance provides only two months of postpartum coverage, which is too little to prevent the suicides, overdoses, strokes, infections, and other fatal complications known to take place in the year after giving birth.
The situation is particularly dire in the Deep South and the Southwest, but the U.S. as a whole has been struggling to keep new mothers alive, especially during the pandemic. That’s why, in the 2021 American Rescue Plan Act, Congress temporarily extended Medicaid benefits for mothers from two months to a full year, massively increasing protection for women likely to fall through the cracks. That extension became permanent in the omnibus budget bill in December, seemingly offering a lasting fix. The only problem: Congress did not make the program mandatory.
As a result, Mississippi has, until just recently, declined to expand benefits for mothers, along with 13 other states, nearly all controlled by Republicans. Governors and legislative leaders in those states, many of which are among the deadliest for new mothers, have argued that there isn’t evidence the coverage will help and that they can’t afford it. Neither is true—health experts in Mississippi, for instance, say 12-month care will forestall postpartum complications, which are costlier for the system than preventive treatment—and even many GOP lawmakers have come to recognize it.
The standoff over postpartum coverage mirrors the partisan divide that saw many of the same Republican-led states (including Mississippi) refuse to expand Medicaid after the Affordable Care Act was enacted in 2010. Until recently, Mississippi’s governor, Tate Reeves, and state House speaker, Philip Gunn, have opposed both policies, nixing three separate attempts by the Republican-controlled state Senate to pass 12-month postpartum bills. “I just don’t have taxpayers calling, saying, ‘We want you to raise taxes so we can expand Medicaid,’” Gunn said in 2021. That is, until March 16, when Reeves and Gunn capitulated to pressure from their own party to endorse the expansion.
Just as in the Obamacare debate, Democrats are arguing for government-provided postpartum coverage, while Republicans reply that the payoff doesn’t outweigh the costs. Unfortunately, this partisan gamesmanship is taking place in a post-Roe world, with states like Mississippi, which has a near-total abortion ban, likely to welcome many more babies whose mothers can’t effectively care for them. Many of those mothers will need care themselves. But if recent developments in Jackson, the state capital, are any indication, the health benefits and potential taxpayer savings may prove too obvious for critics to ignore.
The sorry state of maternal health is among the less-examined tragedies of American healthcare. The U.S. has by far the worst maternal mortality rate of high-income countries, at 17.3 deaths per 100,000 live births in 2018, compared to 8.7 in the next highest country, France, and 6.5 in the United Kingdom. According to an analysis from the Commonwealth Fund, the problem stems from a lack of maternity care providers, a shortage of midwives relative to OB/GYN doctors, and no guarantee of provider home visits or paid parental leave. Medicaid has long provided vital care for mothers, covering 42 percent of births in the U.S., and giving access to services like mental health and substance use treatment. But Medicaid’s 60 days of coverage is notoriously inadequate: About a third of pregnancy-related deaths occur more than two months after birth, most often stemming from cardiomyopathy, embolisms, and other cardiovascular conditions exacerbated by the stress of childbirth.
In 2021, the dismal trend of maternal health throughout the pandemic, along with the work of many advocacy groups and members of Congress, finally drove Washington to act. As part of the $1.9 trillion American Rescue Plan Act, lawmakers allowed states to extend postpartum Medicaid coverage from 60 days to 12 months. ARPA was a critical, overdue win for advocates. Maggie Clark, a state health policy analyst at Georgetown University’s Center for Children and Families, told me she saw coverage expansion as “a once-in-a-generation change.”
Initially, the 12-month extension under ARPA would have expired in 2027. But in the omnibus spending bill passed in December 2022, Congress made permanent the option for states to extend postpartum coverage. But despite what the nonpartisan Medicaid and CHIP Payment and Access Commission recommended, Congress failed to make the extension mandatory. Along with Mississippi, 13 states have not taken the option: Alaska, Arkansas, Idaho, Iowa, Missouri, Montana, Nebraska, Nevada, New Hampshire, South Dakota, Texas, Utah, and Wisconsin. Many of those states already have among the worst stats in the nation. And indeed, geographic disparities have long been a grim fact of maternal health in America: Outcomes are historically far worse in Southern and Southwestern states, where most maternity care deserts—counties with no obstetric hospitals, birth centers, or obstetric providers—are located. The disparity is racial, too—Black and Indigenous women die from pregnancy-related ailments at two to three times the rate of white women. If the coin toss of someone’s life circumstances has always determined their health care fate, this decision by those 13 states further decreases the odds of survival for mothers who have given birth.
Lawmakers’ justifications for opposing expanded maternal care ring hollow. Governor Reeves’s initial argument against the policy is that the data on its effectiveness “is incomplete at best,” a claim contradicted by the positive effects of extended postpartum coverage in the 35 states where it’s been implemented. The 12-month option has led to a significant drop in insurance coverage gaps, a study by JAMA Health Forum found. Women with extended postpartum coverage are also more likely to seek preventive care. Since so many maternal deaths in the U.S. are preventable, encouraging a new mother to check out a nagging symptom or seek treatment for mental health often makes all the difference.
Another empty claim is that the option would be too costly, a concern raised by legislators in Wyoming and Mississippi. In Mississippi, House Speaker Gunn has long argued that Medicaid expansion under the Affordable Care Act is a financial burden his state cannot sustain. “I don’t see the advantage of doing the postpartum thing,” he told reporters in December after the legislature reopened the debate on an expansion. But neither general Medicaid expansion under the ACA nor the “postpartum thing”—the adoption of the 12-month postpartum extension—would require tax increases. In 2021, the state’s chief economist, Corey Miller, found that the state’s current savings could easily cover the 10 percent of Medicaid expansion costs that Mississippi would have to fund—the other 90 percent being federally funded. Miller also found that Medicaid expansion under the ACA would create 11,300 jobs a year from 2022 to 2027 and increase the state’s GDP by about $719 to $783 million annually, far outstripping the $186 to $207 million cost of expansion. Health experts say expanding only postpartum coverage would cost Mississippi a paltry $7 million a year.
But advocates and health policy experts believe the 13 states that have refused the 12-month expansion will come around as the political calculus shifts. Sara Rosenbaum, a health law and policy professor at George Washington University, told me she expects that the bad optics of postpartum women being thrown off Medicaid after Roe v. Wade’s overturning will force Republicans’ hand. Such was the case in Mississippi and recently in Wyoming, where Governor Mark Gordon, a Republican, celebrated the extension as pro-life legislation.
The trajectory of Obamacare is an encouraging roadmap for what this might look like. Many states yet to extend postpartum coverage were initially opposed to Medicaid expansion under ACA and eventually capitulated. In 2014, only 28 states had adopted the ACA expansion; today, 40 have. In the most recent three states to do so—Idaho, Nebraska, and South Dakota—expansion was achieved through citizen-led ballot measures, which suggests that mobilizing public support for a postpartum expansion referendum may be possible. Advocates are also encouraged that states are moving much more quickly to adopt 12-month postpartum coverage compared to general Medicaid expansion over the last decade.
Health experts have testified before Mississippi lawmakers, bringing a human face to the state’s paltry benefits. Dr. Anita Henderson, a pediatrician, described her heartbreaking inability to do much for new mothers with heart complications or mental health issues. “I know that those moms are suffering, and I know that those babies are likely to suffer as well,” she said this winter. “Babies need their mothers, and their mothers need health care.” By that point, budget-conscious Republicans had started to get on board. “This reminds me of that Midas commercial: ‘Pay me now, or pay me later,’” Senator Kevin Blackwell, chairman of the Medicaid Committee, said in a December hearing. He added, “The relatively minimal amount to provide this care compared to the cost later—it’s a no-brainer in my mind.”
In January, an overwhelming majority of the Mississippi Senate voted to extend postpartum coverage under Medicaid from 60 days to 12 months—for the fourth time. Finally, in February, Reeves caved to the pressure from the state’s medical and religious groups, along with his strong election opponent, Democrat Brandon Presley, who he will face later this year. Reeves, a former state treasurer, reluctantly embraced the policy. “In a post-Dobbs world—we may even have to be willing to do things that make us ‘philosophically uncomfortable,’” he wrote on social media, asking the House to pass the benefit extension. In March, he signed it, casting his flip-flop as “pro-life.” “This is one more thing we can do to tip the scales in favor of life,” the governor said in a statement.
Even in heavily Republican Mississippi, with an abysmal record in women’s health, lawmakers eventually recognized the human and economic necessity of extending postpartum Medicaid coverage. The turnaround offers hope that more Republican governors and state legislatures will backtrack on their stances. (In Utah, the Senate recently passed a 12-month extension bill that is pending in the House.) In an era where more children are being born to mothers who’ll struggle to provide for them and where the financial (not to mention moral) benefits of keeping those mothers alive clearly outweigh the costs, even conservative Republicans may be about to embrace a good old-fashioned government benefit.
