State Efforts to Improve Perinatal Healthcare
Advancing quality of healthcare continues to be a focus for many states, even as they continue to tackle the impacts of the COVID-19 public health emergency and are faced with a myriad of other healthcare-related challenges. One of the recent focus areas of state quality efforts has been the delivery of perinatal care for Medicaid recipients. While states across the nation are targeting this important issue, their approaches vary due to the unique state policy landscapes.
New Jersey is a state leading the effort around quality perinatal healthcare within the Medicaid program. Nurture NJ, an initiative launched in 2019 by the state’s First Lady Tammy Murphy, aims to address the quality of care for maternal health patients during the prenatal, birthing, and postpartum periods. Sarah Adelman, Commissioner of New Jersey’s Department of Human Services, spoke about the initiative at the recent annual conference of the National Academy of State Health Policy (NASHP). The program’s goal is to reduce statewide infant and maternal mortality and morbidity and ensure equitable maternal and infant care in New Jersey. According to Commissioner Adelman, New Jersey currently has the fourth highest maternal morbidity rate among the 50 states, and black women in the state are seven times more likely to die from pregnancy compared to their white counterparts. The Nurture NJ team envisions that New Jersey will become the safest state in the nation to deliver and raise a baby for people of all races and ethnicities.
New Jersey has approached this issue by seeking a 1115 Medicaid Waiver to increase the number and types of providers and services covered under Medicaid. Services provided by licensed midwives and community-based doulas, for example, are now reimbursable under Medicaid in New Jersey. Moreover, the waiver has given New Jersey the ability to extend postpartum coverage under Medicaid from 60 to 365 days, making them the second state to do so, after Illinois.
The Wisconsin Department of Human Service (DHS) has sought to address birthing disparities using initiatives aimed at measuring prenatal and postpartum care and outcomes, and participating in projects with the goal of reducing disparities. Makalah Wagner from Wisconsin DHS also discussed the state’s efforts at the NASHP conference. Wisconsin developed the Obstetric Medical Home Initiative Model to improve the coordination of care for high-risk pregnant women. The state recognizes care coordination as a key component in addressing patient engagement in care. Wisconsin now offers this target population at least 10 prenatal visits, a home visit, a care plan, and a postpartum visit with details on transitioning to ongoing care.
Wagner shared that the Wisconsin DHS plans to invest in more sustainable approaches to close these disparities and adopt the best maternal health practices. However, the impact of its efforts is limited by the fact that the state has not expanded Medicaid, Therefore, their efforts through the Medicaid program reach a more limited population. Wagner noted specific areas as key focuses for these investments, including
- Social determinants of health, such as food security, affordable housing, employment, and social connections
- Mental well-being
- Building responsive and equitable health care systems (for example, training providers or health systems on the role of doulas and community health workers, training providers, or health systems)
- Perinatal workforce development (for example, training or reimbursement of doula services or community health workers)
- Connecting families to information and resources (targeted community outreach or education campaigns, related to the above priority topics)
- Wraparound support for perinatal populations in uncertain situations, such as those without housing or incarceration
Wisconsin hopes that the investments that DHS makes in the community will lead to better maternal health outcomes within the state.
Innovative work is also happening in California, where the Department of Health Care Services has increased their list of reimbursable preventative services under Medi-Cal, California’s Medicaid program. Deitre Epps, founder of RACE for Equity, discussed this work at the NASHP conference. Epps noted that pregnancy-related deaths for black people in California are three to six times higher than people of other racial demographics.
In an effort to close these disparities, the Department added doula services to the State’s list of preventative services covered under Medi-Cal—a similar approach to the methods of the Nurture NJ program. The American College of Obstetricians and Gynecologists refers to the services doulas and other support personnel offer as “one of the most effective tools to improve labor and delivery outcomes.” Doula services are now reimbursable at the same labor-and-delivery rate as physicians and midwives under Medicaid. This rate is more than double the amount that was initially proposed. The Newsome administration anticipates that the increased rate will be an incentive for more people to become certified doulas and to incentivize providers to accept Medi-Cal patients.
The United States experiences the highest rate of maternal morbidity among high-income countries. The initiatives these states are taking to reduce the disparities associated with this morbidity rate may help make strides towards a significant decrease in maternal morbidity and can serve as models for other states. Expanding Medicaid coverage and investing in families’ socioeconomic health help in creating sustainable changes to alleviate this problem.