Washington State Increases Postpartum Coverage Under Medicaid, Saving Lives

by Sally James and Emerald Staff

A new parent in poverty has more health protection in Washington because of a bill signed on April 16 by Gov. Jay Inslee. Senate Bill 5068 extends coverage to new mothers for an entire year after their child's birth if they are covered by the state's Medicaid program, known as Apple Health.

The bill covers a gap in Medicaid coverage that will impact about 10,000 people in Washington state who lose coverage 60—90 days postpartum. People who were on Medicaid prior to being pregnant, and who qualify for Medicaid based on an income level about 300% of the federal poverty line are not affected and will continue to be covered. Those in the range of between 193% and 300% of the federal poverty level will now receive postpartum coverage thanks to the bill.

At least one physician, Lillian Wu, M.D., told the Emerald in an email that her patient's face lit up with relief when she heard about the bill's passage. The patient has a condition, which will now be covered for longer. Wu is the president of the Washington Academy of Family Physicians and practices in Renton.

Before the bill became law, a new mother (or technically, in the bill, a "postpartum person" to include people who might not identify as a mother or a cis woman) would lose health coverage on day 61 after the baby was born — if they were between 193% and 300% of the federal poverty line. Before, this person received no health coverage for any problems that turned up later than the cutoff — for instance, if complications related to surgery developed if they delivered their baby by Cesarean section. New mothers also received no coverage for serious mental health issues, including postpartum depression or postpartum anxiety. This will change when the law — which is designed to save lives by improving access to health care of all sorts in that critical first year — takes effect in 2022. SB 5068 extends one-year postpartum Medicaid coverage for those in the gap in Washington state beyond the COVID-19 pandemic. In the American Rescue Plan Act of 2021, postpartum Medicaid coverage was temporarily extended to 12 months.

The prime sponsor of the bill was Senator Emily Randall, who represents the 26th Legislative District in Kitsap County. She testified during a committee meeting in this legislative session that maternal deaths were too high, especially for birthing People of Color.

"Nearly one-third of (postpartum) deaths happen more than six weeks postpartum," Randall testified in video archived online of the committee meeting. She added that the bill could be lifesaving, especially for families who are Black, Indigenous, or living in rural areas. Randall identifies as Chicana and gay and is a member of the Members of Color Caucus as well as the LGBQT Caucus.

Molly Firth, who works as a consultant and advocate on maternal health issues and also teaches at the University of Washington School of Public Health, was one advocate for this bill, in part because she almost died in childbirth five years ago. Firth talked to the Emerald about advocating for the bill, which she began working on more than a year ago.

The United States has the highest rate of maternal mortality of the top ten industrialized countries. In addition, perinatal mental health disorders are another factor, sometimes leading to suicide. And while the early days or hours following a difficult delivery are certainly high-risk, it's not the only time a mother's life can be in jeopardy. Medical conditions that can also seriously threaten a new mother's health include gestational diabetes and preeclampsia, a serious complication that involves high blood pressure and damage to internal organs such as the kidneys and liver. Both require follow-up for more than 60 days.

Firth notes that a State study published in Oct. 2019 found the average number of days between a baby's birth and their mother's death from behavioral problems was 157 days. "I think it was very surprising to people … I don't think people understood these behavioral health conditions and how they played a role [in maternal deaths]," Firth said. The new law could prevent those deaths, she said.

Though Firth was not on Medicaid when she had her difficult birth experience five years ago, the experience informed her decision to work to improve care for mothers who do depend on state aid.

Rokea Jones, who is a doula and a mother herself, testified at the legislature in favor of the bill. Jones works with birth parents through Open Arms Perinatal Services, a nonprofit that provides low-income families with a variety of services. A majority of those families are People of Color. As a doula, Jones provides education and advice to families about birth and sometimes accompanies them to a hospital or birthing place to provide support during labor and delivery. Jones, who has a 5-year-old daughter, is also getting her master's degree in public administration.

In her testimony, Jones, who is Black, talked about how difficult the first year can be for any mother, and especially for a mother in financial need. She talked to the Emerald about the high risk of maternal death in Washington state for some mothers of color. A recent article in the Emerald told the story of a Black family's experience of racist treatment during the birth of a child.

Indigenous women are at the highest risk in Washington, according to a 2019 report. These new parents have six to seven times the risk of dying in the year after giving birth as white women, according to Abigail Echo-Hawk, who also testified in favor of the bill. Echo-Hawk, who works for the Seattle Indian Health Board, said she had suffered from postpartum depression in the past and received treatment. You can watch all the testimony on the bill on this TVW page.

Racism and attitudes about families of color within the system play a role in the quality of postpartum care for families. Jones explained that Women of Color who feel symptoms may be afraid to tell a pediatrician or other medical provider about their feelings because they worry about being judged, or even fear having a baby or child taken away by authorities from Child Protective Services.

"It is totally normal," Jones says, for a new mother or family to feel overwhelmed at times after bringing a baby home. Poverty and illness can make that worse. But if families are also afraid of being judged by the system, they may not report important symptoms of physical or mental health problems.

One of the benefits of the new Medicaid extension is help with transportation for new mothers. Babies typically receive medical checkups many times in the first weeks and months following birth, and each time a family has to travel for that appointment. Organizations such as the nonprofit Hopelink can now assist with providing that transportation for an entire year after a birth.

SB 5068's one-year extension of benefits will require a waiver from the federal government. The Department of Health and Human Services granted its first waiver request for a one-year extension of postpartum Medicaid benefits to Illinois in April of this year. In addition, to address the Black maternal health crisis, Congresswoman Lauren Underwood, Congresswoman Alma Adams, Senator Cory Booker, and members of the Black Maternal Health Caucus introduced the Black Maternal Health Momnibus Act in 2021.

In addition, another primary supporter of SB 5068 was Senator T'wina Nobles of the 28th Legislative District, who was joined by many other supporting senators. Organizations that were instrumental in helping pass the bill include American College of Nurse-Midwives, The American Indian Health Commission, Nurse Family Partnership, Washington Association for Community Health, Partners For Our Children, Perinatal Support Washington, WithinReach, Children's Alliance, The Maternal Coalition, and the Perigee Fund.

It's clear that the pandemic has made many birth parents' lives worse during pregnancy and after childbirth, according to testimony before the legislature. More women have reported increased stress and mental health problems than pre-pandemic.

Expanding this coverage has the potential to spare families from the grief of losing a parent. It's a grief that has lifelong echoes and consequences for the children of that parent.

Wu, who works for the nonprofit community health centers HealthPoint and has delivered babies and cared for mothers and children for more than 20 years, told the Emerald: "A mother unable to access care for her physical or mental health issues will have a hard time meeting her child's needs. … Children of birthing parents with mood and anxiety disorders have a higher risk of behavioral and developmental disorders. So extending medical coverage postpartum will definitely improve the health of new mothers and their families."

Editors' Note: Responding to input from Srilata Remala, founder and executive director of The Maternal Coalition, this article was substantially modified, expanded, and republished on May 25, 2021 to acknowledge SB 5068's primary sponsor, state Senator Emily Randall of the 26th District, who pushed this legislation for pregnant people for more than two years, as well as mentioning a host of organizations that were instrumental in passing the legislation. In addition, the article was corrected to note that the bill specifically refers to "birth parent" rather than "mother" to acknowledge that some new parents may not identify as mothers or cis women. The article was also revised to include more accurate information about the number of people added to coverage, details about the federal waiver that will be required for Washington to extend this coverage, as well as various other changes made to improve the article's clarity and accuracy. The Emerald regrets the errors and omissions and always works to be as transparent as possible when revising articles after their publication.

📸 Featured Image: Photo by Andrae Ricketts (under a public domain license via Unsplash).