Access to health insurance is critical for keeping new parents and children healthy, especially during the first year of a baby’s life. But Washington’s Apple Health for Pregnant Women program cuts off health coverage at around 60 days postpartum, leaving over 10,000 low-income women and birthing parents* without health insurance during a critical and precarious time. Extending Postpartum Medicaid coverage will save lives, improve health outcomes, advance gender, and racial equity, save hundreds of millions of dollars over the long term, and help Washington recover more quickly from the COVID-19 pandemic.

Washington Women are in Crisis

The maternal mortality rate in the United States is more than double the rate in other high-income countries – and has been increasing steadily since 2000.[1] Most of these deaths are preventable.

• Washington’s Maternal Mortality Review Panel found that treatable behavioral health conditions like depression andanxiety are the leading cause of pregnancy-related deaths in Washington. These deaths occur on average five months after giving birth, far beyond the 60-day Medicaid cut-off.[2]
• Stark racial disparities continue to haunt our communities. Nationwide, rates of postpartum depression are higher among women of Color and low-income women. Black women in particular die of pregnancy-related causes at two to three times the rate of white women.[3] In Washington, Native American/Alaska Native women are six to seven times more likely to die from a pregnancy-related cause than white women.[4]

What’s at Stake

Maternal and infant mortality are only the tip of the iceberg. Women without adequate health coverage are more likely to suffer from untreated pregnancy-related complications, including high blood pressure, diabetes, and infection, which can lead to poor lifelong health outcomes.[5] Mothers with untreated mental and physical health conditions are also less able to provide the nurturing, and consistent care newborn babies need to thrive. Infants of moms with untreated mental health conditions are more likely to develop behavioral issues of their own.[6]

New research on the impacts of the COVID-19 pandemic has revealed significantly higher levels of depression (36%), generalized anxiety (23%), and post-traumatic stress disorder (10%) in pregnant and postpartum women.[7] The disparate impact of the pandemic on communities of Color, particularly on Black communities, is likely to exacerbate existing maternal and infant health and mortality disparities between Black women and their white counterparts.[8]

A recent report found that the total societal cost of untreated Perinatal Mood and Anxiety Disorders (PMADs) was $304 million in Washington State in 2017. These costs include a loss in maternal productivity, greater use of public and social services, and higher health care costs due to poor maternal and child health.[9]

Expanding Access to Care

In Washington State, if you are low-income and pregnant, you qualify for the Apple Health for Pregnant Women program. This covers women up to 198 percent of the federal poverty level ($43,500 per year for a family of three) during pregnancy, regardless of immigration status. However, this coverage ends two months after giving birth if you earn above 138 percent of the federal poverty level ($30,500 for a family of three).[10] Very low-income women who meet immigration qualifications can transition to the Adult Medicaid program, but too many women are falling through the cracks at a critical time.

The Washington State Board of Health found strong evidence that extending access to health insurance during the postpartum period would:

• Improve health outcomes for women by filling gaps in care after pregnancy;
• Increase the use of healthcare services due to improved affordability, access, and stable coverage;
• Decrease health inequities by geography, immigration status, socioeconomic status, and race/ethnicity;
• Increase access to health insurance for individuals who are undocumented.[11]

The Washington State Legislature passed the Postpartum Medicaid Expansion Bill with nearly unanimous support in 2020, but it was vetoed by Governor Inslee due to the budget crisis.

In 2021, Legislators again have the opportunity to address our state’s maternal health crisis, advance and racial equity, and help Washington recover from the pandemic faster by passing the Postpartum Medicaid Expansion Bill (SB 5068).

Expanding Apple Health for Pregnant Women to one year postpartum (SB 5068) would:

• Extend coverage from sixty days postpartum to one year postpartum for individuals who are receiving coverage on or after the expiration date of the federal public health emergency related to COVID-19.
• Require Washington’s Health Care Authority to provide one-year of postpartum coverage for individuals who are Washington residents with countable income up to 193% FPL by June 1, 2022.

As we emerge from the COVID-19 pandemic, we must rebuild a healthier, more resilient Washington. Ensuring all new moms can access health coverage by extending postpartum Medicaid coverage is a crucial step in the right direction.

_{*“Birthing parents” is an inclusive term that refers to Transgender and gender-nonconforming parents who are pregnant and/or have given birth. We use the term women most often because it is most easily understood by the legislative community.}

Notes

[1] Tikkanen, Roosa, Munira Z. Gunja, Molly Fitzgerald, and Laurie Zephyrin. 2020. “Maternal Mortality and Maternity Care in the United States Compared to 10 Other Developed Countries.” The Commonwealth Fund. https://www.commonwealthfund.org/publications/issue-briefs/2020/nov/maternal-mortality-maternity-care-us-compared-10-countries#:~:text=In%202018%2C%20there%20were%2017,%2C%20Norway%2C%20and%20New%20Zealand

[2] Prevention and Community Health Division. 2019. Report to the Legislature: Washington State Maternal Mortality Review Panel: Maternal Deaths 2014-2016. Washington State Department of Health. https://www.doh.wa.gov/Portals/1/Documents/Pubs/141-010-MMRPMaternalDeathReport2014-2016.pdf

[3] Robles-Fradet, Alexis and Abbi Coursolle. 2020. “Maternal Mental Health Care is Critical to Reducing Racial Disparities. National Health Law Program” https://healthlaw.org/maternal-mental-health-care-is-critical-to-reducing-racial-disparities/; Centers for Disease Control and Prevention. “Racial and Ethnic Disparities Continue in Pregnancy-Related Deaths: Black, American Indian/Alaska Native women most affected”. 2019. https://www.cdc.gov/media/releases/2019/p0905-racial-ethnic-disparities-pregnancy-deaths.html

[4] Prevention and Community Health Division. 2019. Report to the Legislature: Washington State Maternal Mortality Review Panel: Maternal Deaths 2014-2016. Washington State Department of Health. https://www.doh.wa.gov/Portals/1/Documents/Pubs/141-010-MMRPMaternalDeathReport2014-2016.pdf; Taylor, Jamila and Christy M. Gamble. “Suffering in Silence: Mood Disorders Among Pregnant and Postpartum Women of Color”. 2017. Center for American Progress.  https://www.americanprogress.org/issues/women/reports/2017/11/17/443051/suffering-in-silence/

[5] Prevention and Community Health Division. 2019. Report to the Legislature: Washington State Maternal Mortality Review Panel: Maternal Deaths 2014-2016. Washington State Department of Health. https://www.doh.wa.gov/Portals/1/Documents/Pubs/141-010-MMRPMaternalDeathReport2014-2016.pdf

[6] Paediatrics & Child Health. 2004. “Depression in pregnant women and mothers: How children are affected”. Paediatrics & Child Health, 9(8), 584–601. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2724170/

[7] Liu, Cindy H, Carmina Erdei, and Leena Mittal. 2021. “Risk factors for depression, anxiety, and PTSD symptoms in perinatal women during the COVID-19 Pandemic”. Psychiatry Research, Vol. 295. https://www.sciencedirect.com/science/article/pii/S0165178120332133?via%3Dihub

[8] Harvard School of Public Health. 2020. “COVID-19 May Increase Maternal Mortality Disparities in U.S.”. www.hsph.harvard.edu/news/hsph-in-the-news/covid-19-may-increase-maternal-mortality-disparities-in-u-s/

[9] Luca, Dara Lee, Nellie Garlow and Colleen Staatz. 2019. “Societal Costs of Untreated Perinatal Mood and Anxiety Disorders in Washington”. Mathematica Policy Research. https://www.mathematica.org/our-publications-and-findings/publications/societal-costs-of-untreated-perinatal-mood-and-anxiety-disorders-in-washington

[10] Washington State Health Care Authority. 2021. “Pregnant Individuals”. www.hca.wa.gov/health-care-services-and-supports/apple-health-medicaid-coverage/pregnant-individuals

[11] Herendeen, Lindsay. 2021. “Health Impact Review of SB 5068: Improving maternal health outcomes by extending coverage during the postpartum period (2021 Legislative Session)”. Washington State Board of Health. https://sboh.wa.gov/Portals/7/Doc/HealthImpactReviews/HIR-2021-01-SB5068.pdf