For months now, advocates and experts have been encouraging Governor Sarah Huckabee Sanders to expand Medicaid coverage for new moms to twelve months after they give birth. Governor Sanders has refused to do so, calling the idea “duplicative” with other options for new moms and derisively saying it’s a “headline-grabbing policy.”
But Arkansas, bottom of the barrel in infant and maternal mortality, is the only state in the nation to resist this expansion. Despite some of her advisors asking for this policy, Sanders still shakes her head.
However, her own party is starting to push back. Rep. Aaron Pilkington gave the idea a go in the last general legislative session, but the bill died in committee.
Now he’s getting ready to try again, having presented the idea to the Public Health, Welfare, and Labor Joint Subcommittee in late September. His colleagues didn’t have any questions for him in the meeting, so it’s possible he’s done the behind the scenes work to get this over the hump next year. Whether it survives a possible Sanders veto, we can’t say yet.
So today, we thought we’d dive in. How would the expansion work? How does it help to reduce maternal and infant mortality? Finally, what’s Sanders’ resistance to the idea?
How Postpartum Medicaid Expansion Works
Federal law requires that states cover pregnancy-related issues through Medicaid through 60 days after the baby is born. In 2022, the American Rescue Plan Act (ARPA) let states extend that coverage to 12 months after the kiddo makes their appearance. As of this writing, every state but Arkansas has expanded postpartum Medicaid coverage.
The process of expanding Medicaid for moms is, uh, shockingly simple. We just pass a law! This could be done through what’s called a Section 1115 waiver, which lets states use federal Medicaid money in a way that it’s not normally used. If the state didn’t want to fully expand Medicaid to cover all eligible women and any postpartum condition, then it could still expand for certain common conditions associated with higher rates of maternal mortality and for certain high-risk populations.
Another way is to amend the state’s plan itself through a state plan amendment (SPA), which is a bit more complicated. One key difference is that SPAs don’t expire; the only way to change coverage would be to pass another SPA. Section 1115 waivers usually last for 5 years, with one 3-5 year extension afterward. After that, a new Section 1115 waiver has to be approved by the federal government. This is why most states that have chosen to expand Medicaid for new moms have done so via the SPA process.
Either way, with some basic legislation we could get this done and give new moms the security they need as they navigate what should be a joyous time in their life.
How Does it Reduce Maternal Mortality?
Like many healthcare questions, the exact answer isn’t known, but what we do know can be summed up quite simply: people who have insurance are far less likely to die.
When fully expanded, postpartum Medicaid coverage covers care for one year after birth. This often includes things like mental healthcare, treatment for any post-partum complications, advice on caring for a newborn child, and more. This is the part that’s honestly really simple, and it’s quite baffling Sanders is showing such resistance. News moms are insured, full stop.
Beyond medical care, it also helps by providing peace of mind and bureaucratic simplicity.
As we stated above, current federal law requires Medicaid coverage to 60 days postpartum. The 60 day mark is important; studies increasingly show that a large percentage of maternal deaths happen after that 60-day mark, especially in communities of color. Of course, insurance coverage is only one factor here, but if the mom knows she has insurance she’s much more likely to take herself (and her baby!) to the doctor, so issues that crop up are far more likely to be found and treated promptly.
Coverage disruptions also play a part here. Some states (we’ll get to Arkansas down below) used to essentially provide vouchers to women at that 60-day cutoff to buy private health insurance. This is… fine; better they’re insured than not.
But a “coverage disruption” costs time and money for both the woman and the state. A woman may not know about the program; the process of switching is complicated; and paperwork takes time and energy to do and process.
New moms famously have tons of time and energy to fill out insurance paperwork, talk on the phone for a long time, and find new doctors under new insurance plans.
It should be noted that postpartum Medicaid coverage is particularly important for Black and Asian women, especially those experiencing poverty. Arkansas has high numbers of both populations, so again, if Sanders wants to be a Governor for all Arkansans – and especially moms – this is a no-brainer to bring down the maternal mortality rate.
Finally, it’s also important to say that this isn’t just about maternal mortality. One that that became clear in the conversation surrounding the Arkansas Abortion Amendment was that keeping women from dying is a relatively small part – though, obviously, an essential part – of the puzzle. We don’t just want moms alive, we want them healthy.
Postpartum Medicaid care encourages moms to come to the doctor where issues can be spotted quickly and treated sooner rather than later. It helps them recover quickly from a traumatic physical ordeal. It helps educate them about caring for their new baby in its first year of life, which is also when the majority of infant deaths occur. This last point is why Sanders’ comments about “duplicative” programs don’t make a lot of sense.
Why Doesn’t Sanders Do the Obvious?
Hard to say for sure.
Above, we quoted her saying she thinks the idea is “duplicative” of other programs. The program she seems to be referring to is the voucher program; after the federally required 60 day postpartum coverage runs out, moms can apply for vouchers for private insurance. Here’s where the “coverage disruption” issue comes into play. That’s a lot of paperwork, and for a new mom who may be single or may be going back to work quickly, that’s a huge time sink. Paperwork is easy to mess up, it can be hard to navigate, and lots of folks simply give up.
The other part of Sanders’ quote indicates she doesn’t think expanded coverage gets more women to the doctor. This is partly true, but not for the reasons she thinks. It’s because Arkansas has a huge doctor and postpartum healthcare worker shortage, which, admittedly, wouldn’t be solved by expanded Medicaid. It’s mostly false, though; again, when people know they’re fully insured, they tend to use it.
It could be as simple as a desire to performatively rely less on the federal government. This didn’t stop her from using American Rescue Plan Act funds to beef up her security, or federal infrastructure dollars to repair Arkansas’s failing roads. This really doesn’t pass the smell test; again, Arkansas is the only state not to propose some kind of expansion. Even Mississippi and Idaho have done this. While the data are still coming in, it seems clear it’s a simple, powerful way to begin reducing maternal mortality rates (though it’s important to say this wouldn’t be a silver bullet).
It really is baffling, though. Sanders took the time to start a maternal health working group. Many folks who sit around that table support Medicaid expansion. Members of her own party support expansion. The data clearly support its efficacy.
Alexa Henning, Sanders’ former communications director, said that “The data indicates that most women have continuous coverage, they just need to access it. But if we identify gaps, the governor is open to all options to help moms and babies.”
This strikes us as a profoundly backwards way of looking at the issue. Giving birth and learning to be a parent – or adding a child on top of one you already have – is incredibly stressful and hard. Sanders believes on top of that, moms should have to navigate complex paperwork mazes, if they even know the voucher options exist.
Instead, the state should be proactive. Simply insure new moms, full stop. Then the mom can focus on what really matters: her family. When states actively choose to support their citizens, the state flourishes. Sanders doesn’t think so, despite literally everyone else in the nation disagreeing.
We bring this up now because maternal health has been a big topic this year, and with elections coming up, we think Arkansans should pay attention at the ballot box to which candidates are saying what about this issue.
