After Roe: Options for Addressing Maternal and Child Health Medicaid Coverage Policy

Overturning the decision of the Supreme Court Roe v. Wade shined a spotlight on state abortion policies and the health and economic well-being of women and children in the states. With Medicaid covering 42% of births in the US, it’s a key part of the equation when it comes to maternal and child health.

Although federal legislation has been passed to encourage states to improve maternal and child health, address health care disparities, and expand Medicaid coverage, there is variation in states’ adoption of these options. For example, while the American Rescue Plan Act (ARPA) included a new option for states to adopt 12 months of postpartum coverage and new incentives for states to adopt a new Medicaid expansion, a number of states have not yet adopted these options. The Build Back Better Act (BBBA), passed by the House of Representatives in November 2021, includes a number of provisions to expand Medicaid coverage by closing the Medicaid coverage gap and requiring states to extend postpartum coverage to 12 months and to provide 12-month continuous coverage for children along with other maternal health provisions. There are active discussions in the Senate about the shape of the budget reconciliation bill, which is expected to include very limited provisions on health care spending.

The result of the recent reversal of the judgment Roe v. Wade re-raises the implications and importance of coverage policies that affect low-income women and children. While expanding Medicaid coverage for low-income parents and stabilizing coverage for their children is not a substitute for access to abortion, a path to stable coverage can expand access to care for those who might be affected by abortion bans. This policy watch examines the intersection of these Medicaid coverage policies with state actions to ban abortion.

Medicaid is the primary source of coverage for low-income pregnant women and children. In 2020, Medicaid covered 16% of non-adult women in the United States, but Medicaid coverage rates were higher among certain groups, including women in good or poor health, women of color, single mothers, low-income women, and women , who have incomplete secondary education. They’re also similar to the demographics of women getting abortions in the U.S.: 75% have a household income below 200% of the federal poverty level, 61% are women of color, 72% are under 30, and 59% have had a previous birth. Medicaid currently pays for 42% of births in the US, and in a number of states the share is 50% or more. With abortion bans in a number of states, this proportion may increase, as low-income women are less likely to have the ability to travel to other states to obtain an abortion because they cannot afford to travel or have jobs with limited flexibility or time off and limited childcare options.

Research showed that Medicaid expansion helped improve maternal and infant health, postpartum insurance coverage, and access to contraception. In addition, research shows that Medicaid expansion is associated with reduced disparities in health outcomes for black and Hispanic individuals, particularly on measures of maternal and infant health. Under current law, the federal government pays 90 percent of the expansion’s costs, but the American Rescue Plan Act (ARPA) included an additional temporary fiscal stimulus for states that recently adopted Medicaid expansion. The House-passed budget reconciliation bill would create a federal provision to close the coverage gap by allowing people living in states that have not expanded Medicaid to purchase temporarily subsidized coverage on the ACA Marketplace. Of the 12 states that did not pass the Medicaid expansion, seven had abortion bans in place (AL, MS, SD, TN, TX, WI, and WY) (Figure 1). Most of these states have parental Medicaid eligibility levels below 50% of the federal poverty level ($11,515 per year for a family of three in 2022), so many could become uninsured at the end of the 60-day period of postpartum coverage. In Texas and Alabama, the eligibility threshold for parents is below 20% of the poverty level.

Passing the postpartum Medicaid coverage expansion could help improve maternal health and coverage stability and help addressing racial disparities in maternal health. A provision in ARPA gives states a new option to extend postpartum Medicaid coverage for up to 12 months, with the federal government and states sharing the cost. While this new option goes into effect on April 1, 2022 and has been available to states for five years, 17 states have not adopted (or have no plans to) the 12-month postpartum coverage extension. Texas and Wisconsin have proposed limited expansions of coverage after delivery, and Missouri has indicated to CMS that it will not implement its approved but limited extension for six months after delivery – those states are included in the 17 states. Eleven of these 17 states have enacted abortion bans (Figure 1). The House-passed budget reconciliation bill would require 12 months of postpartum coverage in all states, at a federal cost of $1.2 billion over a decade.

While states have the option to provide 12 months of continuous coverage for children in Medicaid and CHIP, many have not. As of January 2022, 32 states have elected to provide 12-month continuous eligibility for all children in Medicaid and/or CHIP. The continuous coverage policy for children is more common in CHIP, with 24 of 34 individual CHIP programs providing a full year of coverage compared to 24 of 51 Medicaid programs that have adopted the option. Continuous eligibility eliminates gaps in coverage due to fluctuations in income, which are often temporary, and is mentioned in recent CMS guidance as a strategy to promote continuous coverage for eligible individuals and reduce attrition when individuals switch on and off from the program. Of the 18 states and the District of Columbia that have not adopted 12-month continuous coverage for children, six have abortion bans in place (Figure 1). The House-passed budget reconciliation bill did not have a separate cost estimate for the provision requiring 12 months of continuous coverage for children.

State bans would further limit access to abortion or even make it effectively impossible for low-income women living in most states in the South and Midwest. Many of the very states that have banned abortions have not taken advantage of current federal opportunities to strengthen health coverage for their state residents, especially for women who give birth and have children. The recent court decision to be overturned Roe v. Wade renews focus and attention on maternal and child health as states implement abortion bans.

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