JACKSON, Miss. — Like low-income pregnant women around the country, nearly every patient at the Sisters in Birth clinic here 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 pre-eclampsia — 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.”
President 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.”
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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 Mr. Reeves has proposed — including promoting adoption and offering tax credits for businesses that donate to pregnancy resource centers, which are usually run by abortion opponents — 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 percent of the expense. They include Mr. 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,” Mr. Gunn said in April, adding, “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 percent 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 says that she was left out of Mr. Reeves’s plan to promote pregnancy resource centers because she is not in the anti-abortion movement, and is irritated at her congressman, Representative 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, Mr. 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.”
The walls of Sisters in Birth, which is in an industrial park, are lined with pictures of female luminaries: Maya Angelou, the poet; Gloria Steinem, the feminist; Dolores Huerta, the labor leader. Its couch pillows are covered in Kente cloth — traditionally worn by West African royalty to signify power and prestige.
The clinic partners with doctors at a nearby hospital and employs a nurse-midwife, Audreanna Lewis-Sholes, who provides routine obstetrics and gynecology care. It also offers nutritional counseling and childbirth, education and fitness classes (there is a Pilates machine on the floor) as well as doula training for fathers and postpartum and breastfeeding support, led by a community health worker.
Medicaid covers about 60 percent of births in Mississippi; Ms. Israel said that means most pregnant women have access to an obstetrician.
“But the outcomes are still horrible,” she said. “So we need to do more than just give access to an exam or an ultrasound.”
Some red states, even those that refuse to expand Medicaid more broadly, have embraced the option to extend it for new mothers. Texas has taken a half step, extending postpartum coverage for six months after birth instead of a year.
Tennessee adopted a full 12-month extension after the deputy director of the state’s Medicaid program used a report on maternal mortality to press lawmakers to do so.
In Alabama, Gov. Kay Ivey signed a budget bill in April that included $4 million to extend postpartum Medicaid coverage for a year — both because of the advocacy of a female Republican lawmaker, and because other Republicans viewed it as a step toward racial justice, said Robyn Hyden, executive director of the advocacy group Alabama Arise.
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.
“For us, it’s a very common-sense issue,” Ms. Boyd said. “We have a high maternal death rate in the state — one of the highest in the country — and we know that good postpartum care will greatly reduce that. We know that we have a significant portion of children born to Medicaid mothers. We know that preventive health care is cost-effective, and we know that making sure these mothers have health care a year after they deliver is absolutely essential.”
After the Dobbs decision, Mr. Gunn, the House speaker, announced he would form a commission to recommend “Next Steps for Life” legislation for lawmakers to take up when they reconvene in January. The lieutenant governor, Delbert Hosemann, who favored extending Medicaid for new mothers, created his own committee and put Ms. Boyd in charge. The committee will hold hearings in the fall.
Ms. Boyd and Ms. 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. Ms. Boyd said afterward that she welcomed Ms. Israel’s tough talk, adding, “We know we are going to have more babies being born, and those babies will require more services.”
Ms. 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.”
