This past summer, Victoria Ferrell Ortiz welcomed her first child into the world. The Dallas native was nearing the end of her AmeriCorps term with a local nonprofit, where she had earned a modest stipend but had been denied health insurance. To ensure she had health insurance throughout her pregnancy, she applied for Medicaid.
“It was a time of a lot of learning, turnaround, and pivoting for me, because we weren’t necessarily expecting that kind of life change,” she says. However, there was no user guide included with the Medicaid application process. Countless forms flooded her inbox. She devoted entire days to calling insurance companies to find out what was covered and where she could go for treatment.
The process was time-consuming, and the representative she spoke with often lacked the information necessary to help her. I’d have to sit tight and cross my fingers that they get back to me.
At the moment, more than 471,000 pregnant Texans are trying to find their way through that disjointed, bureaucratic system. Nearly half of all births in the state are covered by Medicaid, but the benefits are so minimal that many mothers lose eligibility soon after giving birth.
Roughly half of Texas babies are born into Medicaid-eligible families. Pregnant women who have Medicaid coverage are able to get the care they need, from doctor’s visits to prenatal vitamins.
However, Medicaid coverage for pregnancy-related expenses ends only two months after delivery, and advocates and researchers say this short period of time contributes to the high rates of maternal mortality and morbidity in the state. They are in favor of a bill being considered in the current legislative session that would extend Medicaid coverage for pregnant women for a full 12 months after giving birth.
Result Of Texas’ Refusal To Implement Medicaid Expansion
Despite the fact that the federal government would pay 90% of the cost, Texas is one of 11 states that has decided not to expand Medicaid to cover its uninsured adult population under the Affordable Care Act.
As a result, more than 770,000 Texans are uninsured because they do not have access to affordable health insurance through their employers or the federal insurance marketplace, HealthCare.gov. Twenty-three percent of Texas’ female population aged 19 to 64 had no health insurance in 2022.
Ian Bremmer posted a Tweet about uninsured women. You can see the Tweet below
A state that criminalizes abortion but ranks 50th in uninsured women, 46th in child hunger, 44th in clinical care for infants, 41st in maternal mortality and 38th in school funding per child doesn’t care about children. #Texas
— ian bremmer (@ianbremmer) September 6, 2021
Medicaid coverage during pregnancy helps bridge the gap temporarily. Nearly half a million Texans are participating right now. The vast bulk is young Latinas (and Latinx women) between the ages of 19 and 29.
Citizens of other countries and those who are illegally in the country are not eligible, but they can get alternative coverage that ends as soon as the baby is born.
All adults with incomes at or below 138% of the federal poverty level are eligible for coverage in states that have opted to adopt the Medicaid expansion. That works out to an annual income of $34,307 for a family of three.
However, in Texas, adults without dependent children are ineligible for Medicaid coverage. When caring for a Medicaid-enrolled child, parents may qualify for Medicaid benefits themselves, but only if their own income falls below certain thresholds. A family of three (two parents and one child) can’t afford to spend more than $251 per month.
Texans with monthly incomes of $2,243 or less are eligible for Medicaid coverage related to pregnancy. Prenatal care and postpartum care are both included for a full two months after delivery.
The Medicaid-accepting hospitals and clinics in Ferrell Ortiz’s Dallas neighborhood left her feeling “uncomfortable, uninviting…and a space that wasn’t meant for me,” she explains. But she learned that if she gave birth at a birthing center that accepted Medicaid, the government program would cover her expenses.
I gave birth at the Lovers Lane Birth Center in Richardson,” she explains. I’m so relieved that I found them; they helped me get in touch with additional resources that the Medicaid office hadn’t known about.
Ferrell Ortiz felt fortunate to have found such a warm and encouraging group of midwives and doctors to help her give birth. However, Medicaid coverage ended only two months after her daughter was born. She found the unexpected loss of health insurance concerning at a time when her infant was still very young.
“The two-month window just adds more pressure on women to wrap things up in a messy and not always beneficial way.”
Medicaid coverage for pregnant women was expanded by Governor Greg Abbott from two to six months after the end of the 2021 legislative session.
According to The Texas Tribune, some lawmakers think the application was rejected “because of language that could be construed to exclude pregnant women who have abortions, including medically necessary abortions.” The federal government denied the extension in the fall of 2022.
Statewide reports on maternal mortality and morbidity causes and prevention efforts are the responsibility of each state’s Maternal Mortality and Morbidity Review Committee. The committee members, advocates, and legislators all want to see Medicaid coverage for pregnant women and their newborns extended by 12 months during the current legislative session.
Pregnant women in Texas had poorer outcomes because they lacked access to affordable health care.
Associate professor at the University of Texas at Austin Kari White says pregnant Texans on Medicaid frequently face bureaucratic obstacles like those faced by Ferrell Ortiz.
White, who is also the lead investigator for the Texas Policy Evaluation Project, describes maternal health care and Pregnancy Medicaid coverage in the Lone Star State as “a big patchwork with some big missing holes in the quilt” (TxPEP).
TxPEP investigates how different policies in Texas affect citizens’ ability to have healthy families. TxPEP conducted a survey in March 2022 among nearly 1,500 pregnant Texans with public insurance. Poorer health outcomes and barriers to postpartum care were linked to “insurance churn,” or the practice of people losing health insurance in the months following childbirth.
To avoid paying out of pocket, “people are either having to wait until their condition worsens,” White says. “There are people dying after pregnancy for reasons that are related to having been pregnant, and almost all of them are preventable.”
According to the most recent report from the Texas Maternal Mortality and Morbidity Review Committee, for instance, chronic disease was a factor in nearly 20% of obstetrical deaths in 2019. (MMMRC). High blood pressure and diabetes are examples of chronic diseases.
At least 52 pregnancy-related deaths occurred in the state of Texas in 2019, according to the report. Among the leading causes of death were severe bleeding (obstetric hemorrhage) and mental health issues. A lack of health care has “one of the more extreme consequences,” White says.
There has been no change in the MMMRC’s finding that black Texans, who account for nearly 20% of pregnant Medicaid recipients, are more than twice as likely to die from a pregnancy-related cause as their white counterparts over the past decade.
Lack of diversity among healthcare providers; socioeconomic barriers for Black women such as cost, transportation, a lack of childcare, and poor communication with providers; and even shortcomings in medical education and providers’ own implicit biases — which can “impact clinicians’ ability to listen to Black people’s experiences and treat them as equal partners in decision-making about their own care” — are all potential causes of such glaring disparities.
Legislation pertaining to maternal health set to advance in 2023 Legislative session in Texas
The director of health policy for Texans Care for Children, Diana Forester, has called Medicaid coverage during pregnancy a “golden window” for accessing medical help.
It’s the opportunity to get medical care for problems that have been lingering for a while, the kind that, if left untreated, could lead to the need for surgery or other invasive procedures down the road. As the author puts it, “That just seems like it ought to be something that everyone can get their hands on when they need it.”
She argues that giving more women access to healthcare during pregnancy is “the difference between having a healthy pregnancy or not.”
According to a report by the Kaiser Family Foundation, 29 states have adopted a 12-month postpartum coverage extension as of February, with another 7 states planning to implement this extension in the future. Forester says, “We’re behind” in reference to Texas. “We’ve fallen so far behind at this point.”
“I Feel Like The Momentum Is There”
House Bill 56 and Senate Bill 73 are just two of many bills introduced this year that would increase Medicaid coverage during pregnancy to 12 months. According to Forester, she has “cautious optimism.” Some legislative “landmines” may remain, she says. However, “the momentum is there,” as far as I can tell.
It’s Ferrell Ortiz’s daughter’s fifth birthday this year. Amelie is eloquent in expressing her opinions, has a keen mind, and displays her creativity. Ortiz reflects on the year she spent pregnant, remembering how difficult it was but also how much she grew as a person.
“Giving birth was the hardest experience my body has physically ever gone through,” she says. “Knowing that I could get through that time and that it could even be enjoyable was a really profound moment in my health history, and obviously so special because look what the world has for it.”
She fervently hopes that one day, everyone, especially pregnant women of color, will have access to the medical care they require in a time of great need.
“If I could talk to people in the legislature about expanding Medicaid coverage, I would say to do that,” she says. It’s a great idea to put money into the hands of those who will be responsible for raising our children.
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