Letter to the Hon. Mitch McConnell, Majority Leader and the Hon. Chuck Schumer, Minority Leader - Booker, Gillibrand, Harris, Smith Press Senate Leaders for Maternal Health Policies in Next COVID-19 Package

Letter

Dear Majority Leader McConnell and Minority Leader Schumer:
As the Senate continues to work on the next legislative package to address COVID-19, we write
to urge you to include policies that will improve maternal health. While this should be a constant
priority for Congress, it is especially important now as we work to respond to COVID-19.
As you know, the maternal mortality rate in the United States exceeds that of almost all of its
peer countries, and in fact, the U.S. is one of only a few countries in the world that experienced
an increase in maternal mortality between 2000 and 2014.1 Each year about 700 people in the
United States die from pregnancy-related complications, and a majority of these deaths are
preventable.2 Troubling racial and geographic disparities plague maternal health. American
Indian and Alaska Native (Indigenous) people and black people are more than two and three
times likely to die, respectively, than white people due to pregnancy-related complications.3
Additionally, pregnant people in rural areas are more likely to die or experience severe
complications around the time of childbirth.4
The same communities that are at greatest risk for maternal death and illness are
disproportionately affected by COVID-19. It is clear that this pandemic is placing further strain
on our nation's maternal care system and on pregnant people. For instance, there have been
reports of expectant mothers forced to delay or forego check-ups and other needed care due to
fears that they might contract COVID-19, which is particularly troubling for people of color,
rural residents, and other medically underserved individuals who already face barriers to care.
Many pregnant people are also having to give birth without their full support system, including
family members and doulas, due to the social distancing measures that hospitals have
implemented.7 Other pregnant people are looking for alternatives to giving birth in a hospital but
are burdened by restirctions. In addition, pregnant and postpartum individuals are dealing with
significant stressors related to the COVID-19 pandemic, including those related to employment,
health, income, and housing.
8 Furthermore, preliminary data indicates that Black and Indigenous
people make up a disproportionate amount of those who are contracting and dying from
COVID-19 across the country, and rural residents are increasingly affected. This, intersected
with their already higher rates of maternal mortality, may put pregnant Black and Indigenous
people, especially those in rural areas, at particular risk of experiencing poor health outcomes
during this pandemic.
To support and address the needs of pregnant people, particularly during this time, we encourage
you to include the following policies in the next legislative package Congress considers:
Postpartum Medicaid
Medicaid is a primary payer of maternity care in the United States, covering 43 percent of births
nationwide.9 One in three women experience a disruption in insurance coverage before, during,
or after pregnancy, and nearly 60 percent of these perinatal insurance disruptions include a
period of uninsurance.
10 Under current law, many pregnant people who are covered by Medicaid
as a result of their pregnancy are only guaranteed coverage for up to 60 days postpartum. This
abrupt cut-off during the postpartum period is harmful for new mothers, particularly as one-third
of pregnancy-related deaths occur between one week and one year after delivery.11 12 Deaths
from cardiovascular disease, including cardiomyopathy, and other preventable causes, including
overdose and suicide, occur more frequently during this 12-month postpartum period, than
before.
13 Ensuring continous Medicaid coverage for postpartum individuals can save lives and
reduce disparities; for example, Medicaid expansion has helped lead to 1.6 fewer maternal deaths
per 100,000 women, and racial disparities in states that have expanded Medicaid are smaller than
in those that have not.
14 As the nation continues to respond to the COVID-19 pandemic, it is
particularly important that postpartum patients have continuous health coverage. We urge you to
extend pregnancy-related Medicaid coverage for all postpartum beneficiaries to one full year
post-birth.
Full-Scope Medicaid Coverage and Increased Reimbursement
In addition to ensuring that pregnant Medicaid beneficiaries may remain covered for at least a
year postpartum, it is also critically important that coverage is comprehensive. Currently, many
Medicaid beneficiaries are restricted to coverage for "pregnancy-related" services only. This
restriction may prohibit individuals from receiving care for other health conditions and
comorbidities that impact maternal health, including those related to COVID-19. We urge you to
ensure that all pregnant and postpartum beneficiaries have full-scope Medicaid coverage, which
includes coverage for critical services like oral health care as well. In addition, even before the
COVID-19 pandemic, Medicaid reimbursement rates for maternal health and other services were
very low. Maternal health providers, like all medical providers, are suffering deep losses due to
the pandemic and have received limited federal funding. Upcoming legislation should also
include a reimbursement rate increase for maternal and childbirth services, including parity with
Medicare rates as appropriate.
Maternal Morbidity and Mortality Review Committees (MMRCs)
Most, but not all, states have maternal mortality review committees that regularly review
maternal death data. It is essential that MMRCs be universally established and equitably
resourced; establish consistency in data collection and reporting; and include people who have
been most affected by maternal mortality.15 Federal guidelines and resources for reporting
maternal deaths should be equitably provided across states. Additionally, federal leadership can
ensure consistency in how deaths are identified, defined, systematically collected, managed and
how to report on subpopulations at greatest risk (including different racial and ethnic groups,
rural populations, and people experiencing domestic violence.) Committee representation should
include people who have given birth, family members of those lost to maternal mortality, and
those who are disproportionately affected by maternal morbidity and mortality -- including
Black, Indigenous, and rural people.
Expanding Telehealth and Related Equipment
Telehealth may play an important role in providing maternal health care, particularly as many
Americans continue to observe social distancing. The Centers for Medicare and Medicaid
Services (CMS) recently published a toolkit to assist states in increasing the use of telehealth
services through Medicaid and CHIP.16 We urge you to provide additional support and resources
to help states implement telehealth services for maternity care, particularly for Medicaid, which
covers almost half of all births in the United States. This should include covering equipment and
devices that are necessary for providing maternal health services via telehealth, such as blood
pressure cuffs. Currently, many women enrolled in Medicaid do not have access to the
equipment that is required for remote patient monitoring services. Allowing clinicians to write
prescriptions for at-home equipment will ensure equitable access to evidence-based telehealth
services for pregnant and postpartum women, as well as reduce their risk of exposure to COVID19. Congress should also do all it can to ensure that a range of providers are able to provide
telehealth services and receive reimbursement for such services, including midwives.
Additionally, similar guidance, requirements and resources should be applied to private insurers
to ensure their patients have the ability to appropriately access critical maternity care services
through telehealth at this time.
Access to Doula and Other Perinatal Support Services
physical, and informational support before, during, and after birth. Doula support has been linked
to improved perinatal outcomes, particularly for people of color.17 Doula support also plays an
important role in helping expectant or new mothers relieve stress, which is particularly important
now. Other perinatal support services like lactation counselors and childbirth educators can also
aid expectant and new mothers by providing support and helping to navigate resources and
systems during this time. In the next COVID-19 package, Congress should require CMS - in
coordination with patients and perinatal support workers, including community-based doulas - to
provide guidance and additional support to states to reimburse and better facilitate access to
doula and other support services, including through telehealth, for Medicaid and CHIP
beneficiaries throughout the country.
Access to Midwifery Care
Midwifery care is associated with fewer unnecessary interventions, increased positive experience
of care and patient satisfaction, and lower health care costs. However, restrictive regulations and
insufficient Medicaid and commercial insurance reimbursement rates make midwives
inaccessible for many, particularly people of color and people enrolled in Medicaid. We urge you
to provide funding for midwifery education programs in order to grow, strengthen, and diversify
the midwifery workforce, especially for midwives of color and those working in health
professional shortage areas. Specfically, a funding stream should be established within the
Health Resources and Services Administration's (HRSA) Title VIII and Title VII programs
specific to Advanced Midwifery Education Grants, to support university-based accredited
schools of midwifery and to establish programs for increasing the number of midwife preceptors
across the country. In addition, certified-nurse widwives should be eligible for reimbursement
under Medicare's Graduate Medical Education program, in order to ensure that midwives who
work in obstetrical training and teaching facilities can be explicitly reimbursed for performing
those services. Midwives should be reimbursed at 100 percent of physician rates for identical
services under Medicaid and guaranteed inclusion in Medicaid managed care plans and equity
and inclusion within private insurance plans. We also urge HHS to work with states to ensure
that midwives are being allowed and supported to practice to the full scope of their certification
in all states.
Funding to Help Hospitals Prevent and Respond to Pregnancy Complications
States and hospitals need dedicated funding to purchase supplies, train staff, and fully implement
standardized best practices to help reduce maternal deaths, and prevent and respond to
complications arising from pregnancy and childbirth. The next COVID-19 relief package should
include dedicated funding to support emergency responses at hospitals to protect women before,
during, and after childbirth.
Funding to Support Birth Centers
Freestanding birth centers are evidence-based, safe alternatives to in-hospital birth, which
can help relieve pressure on the physician workforce, minimize COVID-19 transmission, and
direct health system resources more effectively as the country continues to respond to the
We urge you to improve access to
freestanding birth center services for people with low-risk pregnancies, especially those enrolled
in Medicaid, by funding a Medicaid demonstration program to develop and advance innovative
payment models for birth center care. CMS should also publish guidance for states to implement
payment for birth center facility fees and birth attendant provider fees. Additionally, in response
to the COVID-19 pandemic, regulations and financial support must facilitate the rapid opening
and expansion of birth centers and auxiliary maternity units to meet the increasing demand for
out-of-hospital birth, following guidelines from national birth center accreditation organizations.
These options require adequate reimbursement rates and facility fees to sustain their operations
and serve patients enrolled in Medicaid.
Thank you for your consideration of our request. We look forward to continuing to work with
you on policies that will help all Americans as our nation continues to respond to the COVID-19
pandemic.