Research Report Advancing Maternal Health Equity in Southern States
What Are Medicaid Programs Doing and What More Could They Do?
Jennifer M. Haley, Sofia Hinojosa, Leandra Lacy, Carla Willis
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The US is facing a severe maternal morbidity and mortality crisis, and Black women and other women of color are at particularly high risk. Maternal mortality is also higher in the South than in other regions. Given evidence that abortion restrictions are associated with higher maternal mortality, such risks could grow under the recent Supreme Court ruling overturning Roe v. Wade, especially in the South, where in many states abortion is now severely restricted. With more than 40 percent of all births nationally, 65 percent of births among Black women, and 59 percent of births among Hispanic women covered by Medicaid, state Medicaid policies and practices have the potential to improve maternal health and reduce racial and ethnic inequities in maternal health outcomes.

What We Did

For this study on Medicaid and maternal health, we conducted interviews with national experts, a national policy scan, and case studies in three Southern states (Georgia, Louisiana, and Texas) that are using various approaches to promote improvements in maternal health care for their Medicaid populations. We sought to identify facilitators of and barriers to maternal health equity and promising programs and policy levers that could advance maternal health equity to inform approaches in other Southern states.

What We Found

  • A growing number of Medicaid programs has adopted policy changes that could improve maternal outcomes, but whether existing Medicaid policy changes can close racial and ethnic equity gaps is unclear. Many states, both nationally and in the South, are adopting Medicaid policy changes aimed at improving maternal health care, including care delivery transformation, data and oversight initiatives, and postpartum coverage extensions. But the extent to which these initiatives will reduce disparities is unclear given a lack of data and evidence.
  • Support for improving maternal coverage and care is broad and bipartisan, but not all initiatives are designed to address disparities. Though stakeholders in our three study states described several promising Medicaid initiatives and broad support for strengthening maternal coverage and care, these initiatives were not consistently designed to address racial and ethnic inequities in maternal health outcomes.
  • Some barriers inhibit promoting maternal health equity in Medicaid, but opportunities exist to address inequities. Stakeholders shared barriers like political sensitivities in some states and data limitations. But they said the following strategies could encourage state policymakers to support addressing racial and ethnic inequities in Medicaid:
    • taking advantage of lower political hurdles for improving pregnant women’s and new mothers’ coverage and care relative to other Medicaid populations
    • broadening the framing of disparities from racial and ethnic to include income and geographic (rural versus urban) disparities
    • considering whether policymakers would be more motivated by cost-based or emotion-based reasoning
    • considering whether and how to place maternal health equity goals within a larger reproductive health and reproductive justice context
    • educating policymakers about the benefits of a wider array of perinatal health providers such as doulas
    • identifying leaders to champion policy changes
  • Driving support for improving maternal health equity in Medicaid will likely require a broader set of stakeholders and collaboration across groups and sectors. More than just the state Medicaid agency and state legislators have roles to play, according to our informants. Managed-care organizations (MCOs); state perinatal quality collaboratives; other state agencies; maternal mortality review committees; maternal health coalitions, professional groups, advocates, and community-based organizations; providers and hospitals; academics, philanthropists, and researchers; and community members are also needed.
  • Several federal policy actions could support states’ progress on advancing maternal health equity. According to key informants, these include better incentivizing the adoption of optional policy changes (like postpartum Medicaid extension or diversification of the maternal health workforce), supporting efforts to improve the extent and quality of data collection, and supporting evaluations of how maternal health initiatives affect racial and ethnic disparities.
  • Many existing state-level policy levers could support maternal health equity. When larger-scale policy changes such as adoption of full Medicaid expansion are unlikely, some initiatives that may face fewer political hurdles could still potentially advance maternal health equity, including pilots to test the efficacy and impacts of new benefits and services, hospital-level investments and interventions, and the use of MCO procurement and contracting mechanisms to incentivize reductions in disparities.

Though many Southern states are already adopting Medicaid policies that could improve maternal health outcomes broadly, whether those policies explicitly focus on closing racial and ethnic gaps is more varied. Both data and intentional evaluation will be needed for tracking the impact of program and policy changes on maternal health outcomes and assessing whether equity gaps are closing. Though broader changes in other sectors will also be needed to address the many factors that contribute to racial and ethnic inequities, Medicaid programs have numerous tools that could be used more fully and effectively to improve maternal health care and address unjust differences in maternal outcomes.

Research Areas Health and health care Race and equity
Tags Health care delivery and payment Health equity Medicaid and the Children’s Health Insurance Program  Maternal, child, and reproductive health
Policy Centers Health Policy Center
Research Methods Qualitative data analysis