NUR 8100 Module 4 Social Justice Policy Paper: Twelve Months of Postpartum Medicaid Example

Day 61: Postpartum Medicaid, Pregnancy-Related Deaths After the Sixth Week and a Social Justice Case for Twelve Months of Coverage

Student Name

Doctor of Nursing Practice, Thomas Edison State University

NUR-8100: Health, Healthcare Policy, and Politics

Mentor Name

Month Day, Year

Day 61: Postpartum Medicaid, Pregnancy-Related Deaths After the Sixth Week and a Social Justice Case for Twelve Months of Coverage

Introduction

Pregnancy has long been a pathway into Medicaid for low-income women. Eligibility limits during pregnancy are higher than for other adults in most states, and Medicaid pays for roughly four in ten births in the United States. Until recently, that coverage ended at the close of the month in which the 60th day after delivery fell. In states that had not expanded Medicaid, a mother whose income was above the limit for parents lost coverage at that point, often in the middle of recovering from birth, managing a new diagnosis such as hypertension or treating depression. This paper analyzes the policy that extended postpartum coverage to 12 months, using social justice as the lens.

Social Justice as a Lens

Social justice in health asks whether the benefits and burdens of a policy are distributed fairly and whether the policy addresses unfair differences in health that track race, income or place. A policy is judged not only by its average effect but by who gains and who is left out. Nursing's ethical commitments, including advocacy for vulnerable populations, make this lens part of the profession's own standards.

When Mothers Die

Petersen et al. (2019) analyzed national surveillance data on pregnancy-related deaths from 2011 to 2015. Across the country, 17.2 women died of pregnancy-related causes for every 100,000 babies born alive. Black women died at 42.8 per 100,000 and American Indian and Alaska Native women at 32.5, rates 3.3 and 2.5 times that of white women. Deaths were spread across the whole year: 31.3 percent occurred during pregnancy, 16.9 percent on the day of delivery, 18.6 percent in the first week, 21.4 percent between one and six weeks and 11.7 percent between six weeks and one year. Review panels in thirteen states decided that roughly 60 percent of these deaths could have been prevented.

The last figure is the one that bears on coverage. More than one in nine pregnancy-related deaths occurred after the six-week period that the 60-day coverage limit roughly matched, from causes such as cardiomyopathy, which often appears weeks to months after birth. A mother without coverage at that point has fewer chances to have breathlessness or swelling recognized as heart failure.

Coverage After Delivery Depends on Policy

Two studies show how state policy shaped coverage after birth before the extension. Gordon et al. (2020) compared Colorado, which expanded Medicaid, with Utah, which had not expanded at the time. After expansion, new mothers in Utah lost Medicaid more often in the six months after delivery and used fewer outpatient visits than mothers in Colorado, and the effect was largest among women who had serious complications at delivery, the very group most in need of follow-up. Daw et al. (2020) used national survey data on women before conception, at delivery and after birth and found that expansion reduced churning between insurance and uninsurance by about 10 percentage points, a 28 percent decrease, mainly by increasing the share of women who stayed continuously insured.

The Policy Response

A 2021 federal relief law let states stretch postpartum Medicaid and CHIP to a full year from April 2022 on, and Congress later made that choice permanent. Most states adopted it. New Jersey moved early to extend postpartum coverage to a full year, consistent with its broader maternal health agenda. The extension removes the 60-day cliff for every mother whose birth was covered by Medicaid, whether or not her state expanded coverage for other adults.

Stakeholders

The stakeholders largely align, which helps explain how quickly states adopted the option. Mothers and their advocates gain coverage. Obstetric and primary care clinicians gain the ability to treat conditions such as postpartum hypertension and depression without a break in payment. Hospitals and health systems gain fewer uninsured readmissions in the postpartum year. Managed care plans gain enrollees, though they must now build programs for the longer period. State budgets bear a share of the added cost, which was the main concern raised in legislatures that hesitated. The federal government shares costs at each state's usual matching rate, so the burden on any one state is partial.

Applying the Lens

On distribution, the extension directs benefits to low-income mothers and, because Black and Native mothers are more likely to have Medicaid-covered births and to die in the postpartum year, toward the groups with the greatest burden. On fairness, it treats the year after birth as the period of risk the evidence shows it to be, rather than an arbitrary 60 days. On its limits, coverage is necessary but not sufficient: the deaths reviewed in the national data had contributing factors at the community, facility, provider and system levels, and a mother with insurance still needs a clinic that will see her, transportation, child care and clinicians who take her symptoms seriously. Social justice requires attention to those barriers as well.

Recommendation for Implementation

For New Jersey clinics serving Medicaid patients, the extension creates an opportunity that must be used. Practically, that means a first check by three weeks after delivery and a fuller one by twelve, screening through the year for low mood, high blood pressure and a failing heart, a warm handoff to primary care before month twelve and a coverage check at every visit. Nurses in prenatal clinics can tell mothers before delivery that their coverage now lasts a year, since many still believe it ends at two months.

Conclusion

Pregnancy-related deaths continue well after the six-week visit, fall most heavily on Black and Native mothers and are often preventable. Coverage after delivery depended on state policy until the federal option allowed a full year. Judged by social justice, the extension directs help where the burden is greatest, and its promise depends on clinics and nurses making sure the added months of coverage turn into care.

References

Daw, J. R., Winkelman, T. N. A., Dalton, V. K., Kozhimannil, K. B., & Admon, L. K. (2020). Medicaid expansion improved perinatal insurance continuity for low-income women. Health Affairs, 39(9), 1531-1539. https://doi.org/10.1377/hlthaff.2019.01835

Gordon, S. H., Sommers, B. D., Wilson, I. B., & Trivedi, A. N. (2020). Effects of Medicaid expansion on postpartum coverage and outpatient utilization. Health Affairs, 39(1), 77-84. https://doi.org/10.1377/hlthaff.2019.00547

Petersen, E. E., Davis, N. L., Goodman, D., Cox, S., Mayes, N., Johnston, E., Syverson, C., Seed, K., Shapiro-Mendoza, C. K., Callaghan, W. M., & Barfield, W. (2019). Vital signs: Pregnancy-related deaths, United States, 2011-2015, and strategies for prevention, 13 states, 2013-2017. MMWR. Morbidity and Mortality Weekly Report, 68(18), 423-429. https://doi.org/10.15585/mmwr.mm6818e1