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State Policies to Improve Maternal Health Outcomes
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Background
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Recent data show that U.S. maternal mortality rates are rising. But Black, American Indian, and Alaska Native (AI/AN) people giving birth are two to four times more likely to die from pregnancy-related complications as their white counterparts are.1 As the health insurer for 45 percent of births in the United States2 and 66 percent of all births to Black mothers,3 state Medicaid agencies have a critical leadership role in implementing policy changes that support clinical improvements, enhanced services, and community investments necessary to reduce racial disparities in maternal health outcomes.

State Medicaid agencies and public health departments have numerous levers for crafting such policies and programs. They include:
• extending postpartum coverage
• enhancing benefits to cover evidence-based models such as home visiting programs, group prenatal visits, and doulas
• developing value-based payments that reward improved health outcomes and equity
• conducting quality improvement initiatives
• enhancing surveillance and data collection on maternal mortality and morbidity
• creating statewide maternal mortality review committees for greater oversight.
To advance uptake of comprehensive approaches to improving maternal health outcomes and reducing disparities, national and state policymakers, health care and public health researchers, patient advocates, and health care providers must first understand the state policy landscape and identify what is supporting or hindering this important work.

To support effective policymaking, research, and care delivery improvements, the Center for Health Care Strategies (CHCS), in partnership with the Institute for Medicaid Innovation and with support from the Commonwealth Fund, compiled this database and accompanying interactive maps of state maternal health policies that support high-value care. The policies are organized in three areas: 1) coverage and benefits; 2) care delivery transformation; and 3) data and oversight.

In March 2020, the Medicaid and CHIP Payment and Access Commission (MACPAC) released a state-level inventory of Medicaid policies, programs, and initiatives to improve maternity care and outcomes. This database supplements MACPAC's inventory with additional Medicaid and non-Medicaid state-led initiatives, including COVID-19 related benefits, postpartum coverage expansion efforts, freestanding birth centers, and midwifery services, among others.
The U.S. policy maps accompanying the database show where all 50 states and the District of Columbia stand in their use of different policy levers. A state-by-state comparison chart is also available for download.


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Methodology
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CHCS developed a policy framework categorizing information under three overarching levers, including: (1) coverage and benefits; (2) care delivery transformation; and (3) data and oversight. CHCS used publicly available data sources to collect information on existing state Medicaid and public health policies that align with the maternal health equity policy framework. Information was scanned from sources, such as state Medicaid agency websites, the National Conference of State Legislatures, and the National Academy for State Health Policy, among many others. Extensive policy information was also acquired from MACPAC's Inventory of State-Level Medicaid Policies, Programs, and Initiatives to Improve Maternity Care and Outcomes and the Institute for Medicaid Innovation's Improving Maternal Health Access, Coverage, and Outcomes inMedicaid. CHCS interviewed two states, Nevada and New Jersey, to verify information and gain additional insight and perspectives on the approach to maternity care improvement. Findings will be included in the accompanying issue brief. Data collection occurred from May through August 2020 and included only active policies.
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Considerations for Policy Review
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A key consideration in reviewing these resources is that under certain policy areas implementation may appear to be extensive, but access for prenatal and postpartum people may be limited. As an example, the ACA requires that states provide Medicaid reimbursement for freestanding birth center facility service fees and the professional fees of a birthing attendant. However, the reality of “on-the-ground” factors, such as establishing formal collaborative and contractual agreements, financial pressures of low reimbursement rates for midwifery services, and high insurance liability rates present significant barriers to access. Because states have significant flexibility in how they structure benefits, providers, and payments, service gaps may continue to exist.

In this database, the information set for freestanding birth centers, substance use disorder programs, and mental health care includes contextual information on the complexity of issues related to implementation of these services. There are limitations to this project's approach in capturing access to services. Licensing and regulation information for midwifery services and freestanding birth centers is not included in this database. Substance use disorder programs and mental health services includes expanded services related to prenatal and postpartum care and does not capture mandated standard coverage for general enrollees.

For Postpartum Coverage Expansion, federal law requires Medicaid coverage until 60 days postpartum and does not currently have an option for extension beyond 60 days. No state is permitted to extend coverage beyond 60 days without a waiver mechanism.

Data for this project was collected during the COVID-19 public health emergency. The database includes information on telemedicine and emergency orders that were approved during states' public health emergency declarations. The publication of this information does not capture updates on funding and programs after August 2020.

This database is intended to be comprehensive, but it is possible that some policies were not captured, new policies have been adopted; or that policies exist outside the scope of the database. If you would like to correct any information, please contact pkhanal@chcs.org.
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References
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 1 CDC Morbidity and Mortality Weekly Report. (2019, September) Racial/Ethnic Disparities in Pregnancy-Related Deaths — United States, 2007–2016.
2 Women's Health Issues. (2013, December) Medicaid Covered Births, 2008 through 2010, In the Context of the Implementation of Health Reform.
3 MACPAC (2020, January). Medicaid's Role in Financing Maternity Care.
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