JACKSON, Miss. — Like low-income pregnant women around the country, nearly every patient at the Sisters in Birth clinic in Jackson, Mississippi, is covered by Medicaid, the public health insurance program for the poor. But they face the prospect of losing the coverage two months after their babies are born, when they are still at high risk of complications that could lead to serious illness — or even death.
Last year, Democrats put a potential solution in their pandemic relief bill: a streamlined way to extend new mothers’ Medicaid coverage for a full year after they give birth. Most states have pursued the option, but Mississippi is among 17, largely led by Republicans, that have not. Most of those, including Mississippi, have also banned abortion or will soon.
In the wake of the Supreme Court’s decision to overturn Roe v. Wade, Republican lawmakers who welcomed it are under pressure to commit to policies that will support women and children. But the conversations have barely begun, and many states are ignoring obvious possibilities. Even some conservatives say that not taking up the limited Medicaid expansion is a mistake.
“If you are a state looking for options to address the health care needs of women, this is a clear, easy win,” said Seema Verma, who oversaw Medicaid and Medicare during the Trump administration. “From my perspective, this has strong potential to improve health outcomes for women.”
Mississippi — whose maternal mortality rate is nearly twice the national average — already had a spirited political discussion about extending Medicaid coverage for new mothers; a measure to do so passed the state Senate, with support from a number of Republicans, earlier this year. But it was blocked by the Republican speaker of the House, who cited financial concerns and said of Medicaid enrollment at the time, “We need to look for ways to keep people off, not put them on.”
For the patients at Sisters in Birth, the stakes could hardly feel higher. Many have seen friends and families suffer or even die during or after childbirth. Julia Kirkland, 27, her 2-year-old cuddled against her bulging belly, told the clinic’s nurse-midwife one recent day that she was worried about postpartum bleeding; she had heard so many stories.
D’Asia Newton, a 21-year-old child care worker, has a friend whose doctors misdiagnosed her preeclampsia — a pregnancy-related condition that can be fatal — and had to be rushed back to the hospital after giving birth. Losing coverage soon after having her baby, she said, is “one of the things I’ve been stressing about.”
The United States has the highest rate of maternal deaths in the industrialized world; Black women are three times as likely as white women to die of pregnancy-related complications. One-third of those deaths happen weeks or months after delivery, when a significant share of women lose coverage. Researchers at the University of Colorado have estimated that rates of maternal deaths will rise now that Roe has been overturned.
President Joe Biden, who has vowed to reduce racial disparities in health, has put Vice President Kamala Harris in charge of addressing maternal mortality. In June, she issued a “Blueprint for Addressing the Maternal Health Crisis,” with the stated goal of turning the United States into the “best country in the world to have a baby.”
In Mississippi — the state that gave rise to Dobbs v. Jackson Women’s Health Organization, the case that overturned Roe — Gov. Tate Reeves, a Republican, called it “a joyous day” when Roe fell. He later wrote on Twitter that Mississippi was “leading the nation in a building a culture of life that serves mothers and children!”
His office did not respond to repeated interview requests. But critics say the solutions Reeves has proposed — including promoting adoption and offering tax credits for businesses that donate to pregnancy resource centers, which are usually run by opponents of abortion — do not take into account the stark reality that many American women of childbearing age lack access to basic health care.
Mississippi is one of 12 states that continue to block a broad expansion of Medicaid under the Affordable Care Act more than a decade after the law was passed. That has left tens of thousands of women of reproductive age — 43,000 in Mississippi alone — without access to routine medical care before they get pregnant that helps ensure healthy outcomes when they do. Many face barriers in accessing family-planning services to prevent unwanted pregnancies in the first place.
“We’re talking about 800,000 women of childbearing age, two-thirds of them women of color, who are falling between the cracks right now,” said Maya Wiley, president of the Leadership Conference on Civil and Human Rights in Washington. “And so many of these states are the same states trying to force them to have babies against their will.”
Republicans who oppose a broad expansion of Medicaid often cite cost concerns, although the law requires the federal government to cover 90% of the expense. They include Reeves and Philip Gunn, the House speaker, who blocked the extension of Medicaid for new mothers. Through their offices, both declined repeated requests to comment.
“I am not open to Medicaid expansion,” Gunn said in April. “I just don’t think the taxpayers can afford it.”
At the moment, new mothers with Medicaid can stay on it — but for many, only for as long as the national public health emergency for the coronavirus remains in effect. The American Rescue Plan streamlines the process for states to extend Medicaid coverage for 12 months after a woman gives birth on a permanent basis. Health advocates hope the demise of Roe will prompt Mississippi and other holdout states to do so.
“It really puts the rock in the pocket of policymakers who say they care about women,” said Michele Johnson, executive director of the Tennessee Justice Center, an advocacy group.
Along with Arkansas, Kentucky, Alabama, Tennessee and Louisiana, Mississippi has one of the highest maternal mortality rates in the nation, according to the Centers for Disease Control and Prevention. There were 136 pregnancy-associated deaths between 2013 and 2016, according to a report last year by the state’s Department of Health, which recommended extending Medicaid coverage for new mothers.
Many of those deaths happened after the two-month coverage period had ended. Black women, who tend to be poorer and have worse health care than white women, accounted for about 80% of maternal deaths associated with cardiac conditions.
The trends outrage Getty Israel, a population health expert who has studied poor birth outcomes in Mississippi. Concern about high rates of obesity, unnecessary cesarean sections and other problems that lead to poor birth outcomes drove her to establish Sisters in Birth in 2016, initially as a community health organization. The clinic opened last year.
She is fed up with Democrats and Republicans alike. She said she was left out of Reeves’ plan to promote pregnancy resource centers because she is not in the anti-abortion movement, and is irritated at her congressman, Rep. Bennie Thompson, a Democrat, for not securing federal dollars to fulfill her plan of turning Sisters in Birth into a full-fledged birthing center where women could deliver their babies. (In a statement, Thompson said he tries “to assist as many people as possible.”)
“I’m not getting help from Democrats or Republicans in Mississippi,” she said in an interview last month. “Republicans are aggressively taking away rights and undermining birth outcomes, and Democrats, realizing that they have a minority, throw their arms up in the air and say, ‘We can’t do anything.’”
In Mississippi, those who favor Medicaid for new mothers include two female lawmakers, both Republicans: Becky Currie, a registered nurse and member of the Mississippi House who wrote the anti-abortion law at issue in the Dobbs case; and Nicole Boyd, a lawyer and state senator who once ran a health care nonprofit.
After the Dobbs decision, Gunn announced he would form a commission to recommend “Next Steps for Life” legislation for lawmakers to take up when they reconvene in January. Lt. Gov. Delbert Hosemann, who favored extending Medicaid for new mothers, created his own committee and put Boyd in charge. The committee will hold hearings in the fall.
Boyd and Israel met for three hours last week, talking about a range of issues, including the low rates of long-acting birth control use among Black women and the role of community health workers. Boyd said afterward that she welcomed Israel’s tough talk, adding, “We know we are going to have more babies being born, and those babies will require more services.”
Israel came away hopeful. “This woman is on the right track. I salute her,” she said. “This is a ship we could start turning around.”