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Texas lawmakers extend Medicaid access after birth to improve health outcomes for new parents

Krystal Brown, a certified nurse midwife, walks through Lovers Lane Birth Center in Richardson.
Yfat Yossifor
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KERA
Krystal Brown, a certified nurse midwife, walks through Lovers Lane Birth Center in Richardson.

Texas lawmakers committed to better health coverage for pregnant and postpartum people in the 2023 legislative session. It’s one way they’re tackling the state’s maternal health crisis.

House Bill 12, authored by Rep. Toni Rose, extends postpartum Medicaid coverage from two months to 12 months. It's currently awaiting Gov. Greg Abbott's signature, and if signed into law, would go into effect Sept. 1. Advocates and the state’s Maternal Mortality and Morbidity Review Committee (MMMRC) have said for years that a longer coverage window will help address high maternal death rates.

“I feel like this is one of my most fulfilling pieces of legislation, because it saves lives,” Rose said. “I’m very honored to get it to the governor’s desk.”

Rose said better access to care will help reduce hospital costs and improve access to comprehensive medical care.

“It will enable [parents] to better manage medical and mental health issues before the issues worsen,” Rose said. “I’m just really excited about it.”

Diana Forester, the director of health policy for Texans Care for Children, has seen the momentum build for extended coverage.

“It’s an issue that we’ve been working on for at least three sessions,” she said. “It feels like a monumental relief that [it] was accomplished this session.”

The latest report from the MMMRC, which reviewed data on maternal deaths from 2019, identified that 90% of these deaths were preventable. The top reasons for these deaths were obstetric hemorrhage, or bleeding, mental health conditions, and blood clots that can lead to strokes.

“It really surprised me that the deaths were preventable,” Rose said. “They just didn’t have health care, and so they were not seeking help.”

Brown examines Cherish Sims lies down as Krystal Brown, Certified Nurse Midwife, examines her during a prenatal visit Tuesday, Feb. 21, 2023, at Lovers Lane Birth Center in Richardson.
Yfat Yossifor
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KERA
Brown examines Cherish Sims during a prenatal visit at Lovers Lane Birth Center.

Continuous health coverage means better outcomes for pregnant people

Patrice Lott, who testified in favor of the bill in March, said when she had a miscarriage, Medicaid paid for her surgery and recovery afterwards. She was able to access a therapist and support groups for other people who also had miscarriages. But her healthcare ended two months later.

“I pretty much lost my Medicaid until I became pregnant again,” Lott said. “And I had a high-risk pregnancy. So, I had to have a lot of specialists that needed to see me, and I ended up carrying my baby to full term. Being able to be on Medicaid, I was again allowed to be seen.”

If people don’t have continuous insurance coverage, Forester of Texans Care for Children said, they don’t have access to care that could intervene when health issues arise.

“It took nine months to build that baby, and it's going to take your body a little bit longer than two months to recover from all of that,” she said. “It’s a very intense process. It puts a lot of strain on your body.”

For the past few years, losing healthcare coverage hasn’t been an issue for pregnant Texans because of the federal public health emergency related to COVID. It ensured that no one lost coverage, so people were re-enrolled on Medicaid until it expired at the end of March. Since 2020, instead of losing health insurance two months after giving birth, people had coverage to address chronic conditions and get routine check-ups without having to worry about the out-of-pocket costs.

“One of the things I just heard over and over again, from all these moms, is it was the first time in my life as an adult that I had health insurance for a long period of time,” Forester said. “And I was able to get this diagnosis, I was able to get on treatment for this, and like it totally changes their life.”

She said the extended coverage under the public health emergency showed the future impact of HB 12.

“The healthier you come into your next pregnancy, the healthier outcomes you're going to have with that pregnancy,” Forester said. “It’s giving you time to recover and it's also investing in your health if you want to have a kid again in the future.”

Midwife Becky Hines uses a doppler on Jessica Gamboa’s stomach to listens to the baby as the children watch Monday, March 27, 2023, at their home in Forney. Jessica wanted her children to see birth as natural and involved them in the birth of their brother.
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KERA
Midwife Becky Hines examines Jessica Gamboa as her children watch at their Forney home in March. Gamboa wanted her children to see birth as natural.

Advocating for structural changes in maternal health care

Parkland Health in Dallas, which facilitates about 11,000 births a year, supported HB 12 at the legislature. Katherine Yoder, the vice president of government relations for the hospital system, said issues like substance-use disorders or postpartum depression need treatment over time.

“It can last a lot longer than 60 days,” Yoder said. “It doesn’t turn off at 60 days.”

She said having 12 months of coverage will mean better access, but there’s still work to be done to address disparities in maternal mortality and morbidity. Nationally, Black people are 2.6 times as likely to die from a pregnancy-related cause than their white counterparts, according to data from the U.S. Centers for Disease Control and Prevention (CDC). Racism, bias and access to quality healthcare all contribute to these outcomes.

In addition, according to a March of Dimes report from 2022, close to 50% of counties in Texas are maternity health care deserts. That means there’s “no hospitals or birth centers offering obstetric care and no obstetric providers.”

“Even with this extension of Medicaid, there's not always enough doctors that are willing to see women for maternal care,” Yoder said. “In the rural areas, that has become more and more difficult. We've got to figure out a better way to make sure that no matter where you live in Texas, you can receive equal access.”

Midwife Becky Hines and Nikki Knowles deliver baby Ransom and place him on Jessica Gamboa’s chest for bonding Tuesday, March 28, 2023, at their home in Forney.
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KERA
Hines and midwife Nikki Knowles place baby Ransom on Gamboa's chest after she gives birth.

Postpartum Medicaid extension is “damage control” after abortion bans

Kelenne Blake, the executive director of Black Mamas ATX, said she was optimistic that HB 12 would pass. Black Mamas ATX provides “culturally aligned” birthing and mental health services to pregnant people in Central Texas.

“I’m glad it worked out,” Blake said. “Other [bills] I had no expectations for, if I’m being honest, because this is Texas. You just don’t know what issues are going to rile up the loudest people.”

It’s also a complicated win, she said, because extended postpartum coverage comes at a time when there are less pregnancy options for Texans since abortion is banned.

“This extension of postpartum care through Medicaid is a given, but I don’t feel like it would offset what has been taken and the effects on maternal health in the state,” Blake said. “But it is something — it is a little bit of damage control.”

A recent study from the Texas Policy Evaluation Project out of UT Austin showed that pregnant people in Texas received worse care in the months after the Dobbs decision last summer, which overturned Roe v. Wade and removed the federal protections for abortion access. The study found that doctors who had patients with ectopic pregnancies and miscarriages often were afraid that providing care would go against the law.

“It’s a strange situation where the people making policies that affect women’s health and reproductive health are not doing so based on the best healthcare and medical standards available,” Blake said.

Pro-choice protesters gathered outside Dallas City Hall June 24 after a Supreme Court ruling overturned Roe v. Wade, the landmark abortion rights decision.
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KERA News
Protesters s gather outside Dallas City Hall after the Supreme Court overturns Roe v. Wade last June.

HB 12 did seem to have more momentum with Republican lawmakers this session, Rose said, because of Texas’s abortion ban.

“You can’t have a law that outlaws abortions and then want [people] to have babies but not make sure that they have the healthcare that they need,” she said. “A lot of them understood that.”

But the bill was not without some controversy. Anti-abortion groups, like Texas Right to Life, were worried that HB 12 would allow people who traveled outside of Texas for an abortion to come back and receive post-abortion care. Lawmakers went back and forth on the bill’s language at the end of the session. Their concerns surprised Rose.

“I was taken aback,” she said. “It was really so unrealistic.”

The version of the bill sent to the governor includes a “legislative purpose” section at the top, which reads, “Out of the state’s profound respect for the lives of mothers and unborn children, Medicaid coverage is extended for mothers whose pregnancies end in the delivery of the child or end in the natural loss of the child.”

Rose “didn’t have an issue with the language being in the bill,” since abortions are banned in Texas. “I don’t think it’ll harm what we’re trying to do with extending our Medicaid services.”

Midwife Becky Hines checks baby Ramsom after birth to mother Jessica Gamboa as the siblings watch Tuesday, March 28, 2023, at their home in Forney. The family wanted the children to learn about birth and involved them in the whole process.
Yfat Yossifor
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KERA
Hines checks on baby Ramsom as his siblings watch.

Other maternal health bills in the 2023 Texas legislative session

Other bills, Blake said, have been a bit of a mixed bag. HB 852 set out to change the makeup of the Texas Maternal Mortality and Morbidity Review Committee. The bill’s original text included positions for community advocates, but the version of the bill sent to the governor specifies community advocates “with experience in a relevant health care field, including a field involving the analysis of health care data.”

“The issue here is that the expertise of lived experience can provide really important insight on that committee,” Blake said. “And if they are gatekeeping, then they are still not working with lived experience. They are working with healthcare and data expertise. That is not a community position. So, I think it might have potentially made it a little worse.”

Another bill, HB 465, would have created a pilot program to have doulas covered under Medicaid. It ended up passing in the House but failed to advance in the Senate.

While Blake is focused on the community work that Black Mamas ATX does with doulas, mental health support and education, she understands the impact that policy can have on the unequal structures in the healthcare system.

“Providing these services and support, sometimes I call it survival work,” Blake said. “And sometimes I call it damage control. These systematic environments and situations that we are living in, that is what has created the disparities. That is why our lives are in danger. That is why there are disparities that Black [people] experience just through getting pregnant and giving birth.”

But she’s hopeful that every year increases awareness of issues impacting health outcomes and movement toward change.

“The intention is getting things to change in a way that we all thrive,” Blake said. The system being inequitable “is the water we swim in. But on the day to day, I am thinking of the work we do to mitigate the effects of the polluted water we are swimming in.”

Got a tip? Email Elena Rivera at erivera@kera.org. You can follow Elena on Twitter @elenaiswriting.

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Elena Rivera
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