Maternal health care advocates applaud Medicaid extension, but say it doesn't go far enough

AUSTIN, Texas -- Mere moments after enduring a cesarean section and delivering her third child, Kalani, on Dec. 15, Tambra Morrison knew that something was wrong when she started to get an excruciating headache.

"I instantly felt like my head was about to pop off," said Morrison, 32, who lives outside of Dallas. "This was my third cesarean [delivery]. I had never had this feeling."

Morrison remained in the hospital for a week, where she said doctors were slow to address her pain. She was eventually released but was later readmitted due to complications. After being treated, she was sent home again - despite having high blood pressure. But within a day, Morrison was taken to the emergency room, where a different doctor determined she suffered from aggressive postpartum preeclampsia, a leading cause of pregnancy-related death.

Note: The video above is from a previous report on nationwide pregnancy-related deaths.

"By the time I got [there] I didn't think I was going to be going home to my kids," Morrison said. "... He was like, 'A lot of women don't know the signs, so a lot of women [die].'"

In some ways, Morrison was lucky. The number of reported maternal deaths has increased nationwide in recent decades, according to the Centers for Disease Control and Prevention. In Texas, which had a maternal mortality rate slightly higher than the national average in 2018, some of the leading causes of pregnancy-related death include cardiovascular-related issues, mental disorders, hemorrhaging and preeclampsia, characterized by extremely high blood pressure.

But many low-income women in Texas, the state with the highest uninsured rate in the nation, don't have access to the kind of comprehensive postpartum care experts say is essential to mitigate these deaths and complications that disproportionately affect women of color.

A new state law, set to go into effect Sept. 1, hopes to address that by extending the government-subsidized Medicaid coverage many new mothers in Texas rely on. Coverage will jump from 60 days after a baby is born to six months. Experts, though, worry that still isn't long enough for women to be adequately covered for the myriad health issues that can arise months after giving birth.

It's been more than six months since Morrison gave birth, but she has yet to shake the trauma from its aftereffects as she balances work with taking care of Kalani and her two other kids, Kynnedi, 12, and Kayden, 7. Morrison is still covered by Medicaid thanks to a federal public health emergency order in place because of the pandemic that requires states to keep Medicaid recipients enrolled. She worries, though, what happens once that protection is expected to end after 2021.

"I wish [the state] knew we needed time," she said.

State Rep. Toni Rose, D-Dallas, was the lead author of House Bill 133, which extends postpartum Medicaid coverage. She successfully got a majority of her colleagues in the Texas House to approve a version of the bill that would extend Medicaid for qualifying mothers to one year after they give birth. Rose said she lobbied Republican lawmakers and Gov. Greg Abbott, pitching the legislation as a pro-life bill. But the Senate lowered the extension to six months.

She said getting new Texas mothers six months of coverage instead of just two was still a win.

"So, as it is with all other legislation, sometimes you have to start somewhere and then hopefully we'll build on it," she said.

Filling in the gaps

According to a 2020 state report that looked at pregnancy-related deaths in Texas for 2013, about a third of deaths occurred 43 days or more after pregnancy. Black women died at almost two times the rate of white women in 2012, according to the Texas Department of State Health Services. From 2011 to 2018, Black mothers and Hispanic mothers in Texas also experienced higher rates of severe maternal morbidity - pregnancy complications that harm a woman's health - compared to white women.

Texas has one of the country's strictest income eligibility limits for Medicaid, according to the Kaiser Family Foundation. For example, a single parent with three kids, like Morrison, has to earn $277 a month or less to be covered. But that threshold changes during pregnancy, where a woman in a family of four can earn up to $4,373 and still receive Medicaid coverage.

More than 380,000 babies were born in Texas in 2018, with almost half of them born to mothers on Medicaid, according to the Medicaid and CHIP Payment and Access Commission. Under the new state law - and once the federal order to keep Medicaid recipients covered during the pandemic ends - mothers will get dropped six months after their baby's birth if they don't meet the stricter income threshold for their own health coverage.

That's because Texas is among states that have not expanded Medicaid to cover more low-income residents, contributing to the state's uninsured population.

As chair of the state's Maternal Mortality and Morbidity Review Committee, Dr. Lisa Hollier sees extending Medicaid coverage to a full year as a way to address some of the leading causes of maternal mortality and health issues that can go easily unseen in the first months after a woman gives birth. According to the review committee, out of 54 pregnancy-related deaths that occurred in Texas in 2013, about 90% of them were preventable at some level - signaling the importance of extended comprehensive care, Hollier said.

"Women can continue to have access to see specialists, they can continue to see psychiatrists, receive the full range of medications that they might need for postpartum depression and [receive] hospitalization if that is what's necessary for them," Hollier said.

Denishea Williams said she knows all too well the need for postpartum care. After having her son, Tommie, in 2009 while attending the University of Texas at Arlington, Williams noticed a change in her mood that she later recognized as symptoms of postpartum depression. However, when she decided to address her symptoms, her post-pregnancy Medicaid coverage had already been cut off and there was little she could do.

"I realized there was an issue that I was facing, something that I couldn't put my finger on," Williams said. "And by the time I put my finger on it, I didn't have the support ... there was no coming back to the doctor to talk about postpartum depression."

Texas does have a 12-month service under its Healthy Texas Women program that women can transition into after their Medicaid coverage expires. There is also the state's Family Planning Program and coverage for before and after birth through Texas Children's Health Insurance Program.

Although some of those programs cover things such as treatment for diabetes, high blood pressure and substance use, they do not provide the full range of coverage a woman receives while on Medicaid, said Erika Ramirez, policy and advocacy director of the Texas Women's Healthcare Coalition.

"It is a limited package," Ramirez said about the Healthy Texas Women program. "So it's not as comprehensive like Medicaid. Continuing Medicaid coverage would be the No. 1, best situation but short of that there are some benefits women can get."

Michelle Anderson, a policy associate with the Afiya Center, a reproductive justice organization based in North Texas, said once Medicaid coverage runs out, many women turn to emergency rooms to seek health care if they have complications.

Starla Simmons, interim director of the Austin organization Black Mamas ATX, said she has seen mothers scrambling to find postpartum care and having to lean on local organizations to help guide them through the patchwork of resources available to them. The group offers holistic support services such as doula assistance, support groups and case management assistance.

"We've been seeing that need," Simmons said of mothers searching for postpartum health coverage. "Once Medicaid [coverage] is over, we're making referrals for all sorts of things to fill the gaps for what they could have gotten through Medicaid ... it's very frustrating to be in this position to have to constantly be struggling year after year to help some of our moms get what they need and what they deserve."

Changes in the Senate

While presenting the Senate version of House Bill 133 to her colleagues in the upper chamber, state Sen. Lois Kolkhorst, R-Brenham, defended the shortened extension.

"The media has portrayed our version of this, as cutting it from 12 [months] to six," said Kolkhorst, who also sponsored the bill. "I want to make sure that we clarify that we are adding four months, and we will become one of the first states in the nation to extend it beyond two months."

Aside from extended postpartum care, provisions the Senate added to HB 133 include transitioning case management services for children and pregnant women on Medicaid and in the Healthy Texas Women program to managed care. The state plans to move away from a fee-for-service model to contracting with managed care organizations that work with a certain network of providers.

Ramirez said that could mean better service for women experiencing postpartum issues, but the real impact of the change remains to be seen. That's especially true for traditional family planning providers that may not have much experience working with managed care organizations.

Adriana Kohler, a policy director with the children's policy nonprofit Texans Care for Children, said that although HB 133 is set to go into effect on Sept. 1, it could still take a while to see the actual benefits play out because it will take time for state and federal officials to secure funding.

Once the state gets necessary federal approval to use Medicaid funds for six-month postpartum coverage, women enrolled in Medicaid coverage on and after Sept. 1, 2022, would be eligible to receive extended coverage, according to the state's Legislative Budget Board.

That means there could be a gap between when the federal pandemic order expires and when Texas' extension of Medicaid for mothers kicks in.

"The women that are going to lose out are the ones who give birth next spring and summer," Kohler said.

A recent pandemic relief bill passed in Congress presents a pathway for states to extend postpartum coverage up to a year without enduring the lengthy approval process for Medicaid funds they normally have to go through. It's an enticing option some would've liked the state to take advantage of, said Kohler.

"Unfortunately, we did not go that route because Texas only extended [Medicaid coverage] for six months postpartum," Kohler said. "This means we have to kind of do a longer process."

"Mixed emotions"

Rep. Shawn Thierry, D-Houston, who was a co-author of HB 133, said "there's very mixed emotions" in her district about the state's extension to six months.

"I think there were those who switched it to six months thinking that it was saving the state money, but in fact, it could end up costing us more if these women end up getting sick, have prolonged hospital stays, or they don't go to the hospital till much later and they have severe complications," Thierry said.

For Thierry, who has made maternal health a priority during her time in office and has been open about her own struggles with childbirth, the passage of HB 133 is a win, albeit a small one in the fight against systematic disparities in maternal health care.

"We've got to look at this as a comprehensive solution and not just doing what we seem to be: putting Band-Aids on a hemorrhage," Thierry said. "So while this is a step in the [right] direction, it's not going to get us across the finish line."

Morrison said she's been struggling with going to her postpartum checkups to monitor her preeclampsia and hasn't really been to the doctor outside of checking on her incision from her C-section. She's also not satisfied with the options she has under Medicaid.

"When I look to go find a good doctor, a lot of them are like clinics where the doctors are in and out, you may see a doctor this month but next month you see somebody else, and it's a lot of doctors that you don't have access to," Morrison said.

Currently, Morrison works from home processing medical claims and earns about $19 an hour, or a little under $40,000 a year - too much to qualify for Medicaid in Texas as a parent once her pregnancy coverage expires. Her job does offer health insurance, but she said it comes with a high deductible and doesn't cover many of the services she required while pregnant.

Right now, with her Medicaid coverage temporarily in place, she continues searching for a doctor she feels truly meets her postpartum needs.

"I don't want to go to somebody that just tries to patch me up," Morrison said.

Disclosure: Texans Care for Children, Afiya Center and the University of Texas-Arlington have been financial supporters of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune's journalism. Find a complete list of them here.

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