Does Texas' maternal Medicaid extension improve access to healthcare?

AUSTIN (Nexstar) — Out of every 100,000 births in Texas, 28.1 result in the mother’s death. Now, the state is providing new moms with up to a year of Medicaid coverage in an effort to bring its maternal mortality rate down.

Nakeenya Wilson almost became part of the statistic. 

At age 35, Wilson said she faced multiple severe complications when giving birth to her second child. 

“I had an opportunity to survive what could have been a really abysmal outcome for me and my family,” Wilson said. 

The mom said she grew up receiving Medicaid, federally funded health insurance for low-income individuals, but lost coverage when she turned 18. 

Wilson said she considered entering the workforce, but chose to sacrifice healthcare access to be a first-generation college student at the University of Texas.

In her last year of undergrad, Wilson became pregnant and again qualified for Medicaid. 

“For the first time in four years, I was able to go to the dentist and go to the doctor and get eyeglasses,” she said.  

But her coverage ended soon after giving birth. 

“Because I chose to go for the long game to have a higher quality of life, then I spent several years without healthcare,” Wilson said, “and it did impact my health.” 

“Whenever I had private insurance at 35, and had my second child, I experienced a morbidity, several morbidities that could have cost me my life.” 

Wilson said she got the care she needed to survive, and she gave birth to her youngest child a few years later, making her a grateful mom of three. But Wilson said there's more to be done to improve maternity care in Texas.

“If you are low income and uninsured or underinsured as an adult, in this country, and in the state, you may go into a pregnancy without having optimal health to begin with,” Wilson continued. 

“That can increase your risk for heart disease, mental health conditions, things that can be dangerous for you.”

Texas’ Medicaid Extension

Texas has the highest rate of uninsured residents in the nation. The United States has the highest rate of maternal mortality among high-income countries. 

On March 1, mothers in Texas became eligible for Medicaid coverage for up to a year postpartum. The previous policy only covered the first two months. 

“There are a lot of health conditions that either are exacerbated during pregnancy, or that can arise after that six week postpartum visit, within that first year, that can increase chances of morbidity and mortality,” Wilson explained. 

“The reality that those moms who utilize pregnancy Medicaid have insurance to see other providers during that first year and get the support that they need is great.” 

Nearly two-thirds of pregnancy-related deaths occur in the postpartum period, and about 30% of those deaths occur 43 to 365 days postpartum.

Postpartum health care includes physical, social, and psychological well-being, infant care and feeding, sleep habits and chronic disease management, according to Medicaid’s website. 

“Over half of the births in Texas are paid for by Medicaid,” said state Rep. Donna Howard, who helped pass the extension last legislative session. 

“We know that a lot of folks can't afford to go to get the prenatal care and the postpartum care that they need without this coverage.”

Howard said there’s still much more to be done to ensure expecting women and mothers have access to healthcare. 

“Certainly the prenatal care, the delivery, the postpartum care, spacing their babies, all those things require that you have access to a provider,” she said. “Right now, when you don't have insurance, you don't have care.”

“It's a much broader issue than just what the postpartum extension will take care of.”

Disparities in Rural Communities

Although advocates say the extension is a step in the right direction, it’s unclear whether it will help those who struggle to physically obtain healthcare. 

“A large number of our rural hospitals have closed so that we don't even have access to labor and delivery and maternity care in many areas of Texas,” Howard said. 

March of Dimes found that 46.7% of Texas counties are considered “maternity deserts,” where women have low or no access to quality pregnancy care. 

Maternal deaths are almost twice as likely in the most rural counties than in metro areas. 

“There are times when a pregnant person or someone that's newly postpartum will drive an extended distance to an ER that does not have the proper resources or personnel to treat them,” Wilson said. “Sometimes it results in that person dying.”

During the COVID-19 pandemic, a Medicaid expansion provided higher reimbursement rates for hospitals. When the expansion expired, rural hospitals suffered from the drop in funding. 

Mental health is one of the leading causes of maternal death postpartum. While Medicaid may cover counseling and medication, Wilson says it can be hard for mothers to find a provider that accepts the insurance.

Howard said lower reimbursement means fewer physicians are willing to accept Medicaid. 

“The reimbursement rates are so low, it doesn't cover their costs,” she said. “We did put some money, this last legislative session, into our rural hospitals to give a little bit of an add on, give them more reimbursements if they do have maternity care.” 

“It remains to be seen whether that's going to be sufficient to help in some of those areas.”

There are also major disparities in access to care for Black and Hispanic individuals, people without higher education and those with chronic illnesses, according to Medicaid.gov. 

Next Steps

Now, Wilson provides resources for mothers through Black Mamas Village and The Village Place in Austin. 

She also serves on Texas’ Maternal Mortality and Morbidity Review Committee, which studies cases of pregnancy-related deaths and recommends ways to reduce maternal morbidity and preventable pregnancy-related deaths in the state. 

“It's very gratifying to know that I can take hard things and be a voice for people who otherwise would not have a voice,” Wilson said. 

Howard and Wilson agree that expansion means innovation, and the state needs to do more to “bolster” the healthcare workforce. 

Howard said the state needs to open up to reimbursing doulas, funding mobile clinics and encouraging advanced practice nurses to travel and reach areas in the state that lack quality care. 

“We've got to be thinking about all the different ways that we can address this because just one thing is not going to do it,” she said.  

“It would be great to see reimbursement and more support of midwifery care in the state of Texas,” Wilson added.

“I think there's a lot of emphasis in the state on babies,” she said, "but babies need mamas. And all of us deserve to have a good quality of life.”