There are various factors that have an influence on the health of mothers and infants, and the access to quality, timely, and affordable health care coverage during pregnancy is an important. Regardless of the need for health care, one and six women of reproductive age is uninsured, and women with incomes that fall below the Federal Poverty Level (FPL), one in four are uninsured (Guttmacher Institute, 2014).
Prenatal care, an issue that takes national precedence as discussed in the Healthy People 2020 and other great policy initiatives, is predicted on the access to coverage for women of reproductive age. The objectives, related to pregnancy, of the program include increasing the percentage of women who receive prenatal care, starting in the first trimester, and increasing the percentage of pregnant women who receive early, sufficient prenatal care. According to the baseline data reported by Healthy People 2020, approximately 70 percent of women received early, sufficient prenatal care beginning in the first trimester. This suggests that there still exist barriers for women to obtain adequate prenatal care (Healthy People 2020).
Prenatal care is essential in minimizing the risk of pregnancy-related complications for both mother and infant. It allows health care professionals to observe and oversee the health of the mother and infant and subsequently identify any medical conditions that may arise, such as preeclampsia and placenta previa, and treat them in time. Women who do not receive any prenatal care are three to four times more likely to die from complications than those who do receive care. With high-risk pregnancies, the probability increases (Coeytaux, F., Bingham, D., & Strauss, N., 2011). Infants whose mothers that do not receive prenatal care are three times more likely to have a low birth weight and five times more likely to die in infancy than those born to mothers who do receive care (Office on Women’s Health, 2012). Additional complications can arise in infants with low birth weights such as gastrointestinal problems and increased risk of sudden infant death (SIDS) (Stanford Children’s Health). Moreover, the risk of preterm birth is increased in women who lack prenatal care. Preterm infants have an increased mortality rate, and those who do survive may be subject to health complications throughout their lives (HHS Office and Public Affairs, 2017)
Pregnancy Coverage in an Era of Health Reform
Before the approval of the Patient Protection and Affordable Care Act (ACA), many women were unable to obtain coverage. Pregnancy status was legally considered as a preexisting condition, therefore insurance companies could deny coverage. As a result, maternity care was not offered as a benefit in several programs (National Women’s Law Center, 2016). The cost for coverage could be increased based solely on pregnancy status, consequently leaving numerous women without sufficient coverage. Since ACA became law, however, various issues linked to coverage and access to health plans has been reformed. The law ended discrimination and denial of coverage due to gender and pregnancy (“Eligibility,” Medicaid). ACA is crucial to improving access of health care for all women in their reproductive years before and during pregnancy.
Coverage Options for Pregnant Women
The ACA has built pathways for women to obtain prenatal care at almost no cost to them by broadening coverage and decreasing cost barriers; however, there are many gaps that persist in this complex system. In order to close these gaps, public, private and safety net program offer a myriad of options to pregnant women.
Medicaid has been historically instrumental in providing coverage to low-income women, especially pregnant women. It is financed by both states and the federal government, and distributed by states (“Benefits,” Medicaid”). The law mandates the minimum standards and eligible groups, however states do have the option to broaden coverage to more groups and eligibility levels.
Traditional Medicaid: Many groups fall into obligatory eligibility categories for Medicaid, these include low-income pregnant women, low-income infants and children, and individuals with disabilities (Centers for Medicare and Medicaid Services, 2014). Federal guidelines explaining the services that have to be offered to pregnant women must be followed by states that provide Medicaid coverage to pregnant women (“Financial Management,” Medicaid). Although the type, quantity, extent, and range of these services are regulated by the states, they must follow federal guidelines.
Pregnancy-Related Medicaid: States can choose to provide coverage to pregnant women beyond 138 percent of the FPL by Medicaid or the Children’s Health Insurance Program (CHIP). This includes multiple benefits such as labor, delivery, and postpartum care (Kaiser Family Foundation, 2014). They also have the choice to give pregnant women with higher incomes full Medicaid coverage or to put a cap on their coverage to pregnancy-related services, though a great number of states choose to offer all of the benefits to the pregnant women (Center for Medicare and Medicaid Services, 2014).
Children’s Health Insurance Program (CHIP): This program offers health care coverage by way of Medicaid or CHIP programs within states. CHIP can provide care four different ways:
A Section 1115 waiver to cover uninsured women
State plan option to cover the unborn child
State plan option to cover low-income pregnant women
State plan option to cover lawfully-residing immigrant pregnant women (20)
Figure 1, produced by the Kaiser Family Foundation, identifies income eligibility levels by state for pregnancy- related coverage in Medicaid/CHIP (Kaiser Family Foundation, 2016).
Health Insurance Marketplaces play a major role in ACA implementation. Marketplaces will screen individuals in order to determine whether they are qualified for Medicaid and CHIP coverage. Maternity care and newborn are have to be covered on every plan sold on the Marketplace, and must provide preventative services. Marketplace plans also give one other option for health care access and coverage for low-to moderate-income pregnant women in order to receive prenatal care. A women’s pregnancy status at the time of enrollment in a Marketplace plan, does not affect future benefits. Pregnancy and related care will be covered by the plan if they become pregnant. During enrollment, women who are pregnant and qualified for Medicaid will be enrolled in said program for coverage (Association of Maternal and Child Health Programs, 2014).
Community Health Centers
Community health centers (CHCs) aid groups that are medically underserved by offering health services, by way of staff and assisting resources to the center or through contracts or cooperative arrangements. The company was established in 1965 by the Office of Economic Opportunity. Under Section 330 of the Public Health Service Act, CHCs must satisfy key requirements in order to receive federal funding. One requirement is to provide primary health care, which includes pregnancy and prenatal care, including health services related to obstetrics or gynecology (Office of the Law Revision Counsel, 2018).
Issues and Gaps in Coverage
The percentage of uninsured women of reproductive age decreased between 2013 and 2014 from 17.9 to 13.9 percent. The percentage of uninsured women of reproductive age with incomes below the FPL declined from 32.1 to 25.6 percent (Guttmacher Institute, 2018). The upgrade in coverage among all women of reproductive age are mainly caused by coverage expansions through the ACA, such as the establishment of the Marketplace and Medicaid expansion. The percentage of uninsured women of reproductive age has decreased, however, pregnant women continue to face barriers when accessing health care.
The changes in eligibility for Medicaid and federal subsidies throughout a woman’s pregnancy and postpartum period can cause pregnant women and new mothers to continuously transitioning from one health care plan to another, or they transition on and off of coverage. This process, known as “churning”, can disrupt the continuity of care, since it moves women to various health care networks with different providers. CMS realized that churn has many adverse effects for pregnant women and issued an article stating that women should have a choice in the kind of coverage they receive during their pregnancy and immediate postpartum period. The article also states that women who are receiving federal subsidies who become pregnant and at that time are income-eligible for pregnancy-related Medicaid that is known as MEC, can choose to stay in a QHP and continue to receive tax credits, or they may elect to switch to pregnancy-related Medicaid (Internal Revenue Service, 2014). It is important for MCH programs to be aware of this issue and understand what types of coverage can fill gaps for pregnant women.
The Title V Role in Improving Access to Care for Pregnant Women
The Title V Maternal and Child Health Services Block Grant of the Social Security Act (Title V) program has a , 80-year history of building comprehensive, integrated systems that safeguard the care of mothers and their children, and children with special needs and their families. Title V State programs guarantee access to adequate and timely prenatal care to women, specifically low-income and at-risk pregnant women. These programs engage with stakeholders from various levels, including providers, patients, payers and consumers, in order to increase the amount of women that can receive comprehensive prenatal care.
The reformed Title V Block Grant brings a new system that includes National Outcome Measures (NOMs), which depict the desired results of an activity or intervention and National Performance Measures (NPMs) that aim to boost outcomes relative to indicators of health status (i.e. NOMs). The NPM system is centered on elements of access to prenatal care, especially low-risk cesarean deliveries, and the percentage of women who smoke during pregnancy. Through its system, these NPM are to influence NOMs related to maternal mortality, low birth weight, infant mortality, preterm birth, or a combination of these (Health Resources and Services Administration)
Title V State programs regulate and associate with public programs with natural access points for educating women on how crucial prenatal care and assisting them in finding coverage. There are various natural access points such as prenatal care clinics and the Special Supplemental Food and Nutrition Program for Women, Infants and Children (WIC). Title V are required by statute to work with their state Medicaid program and provide expertise on access issues faced by women. Specifically services such as toll-free hotlines and assisting women who are eligible for Medicaid.
Outreach and Education
There are a large number of pregnant women that are uninformed on the different coverage opportunities available in their state. In situations where women are at risk for coverage disruptions during pregnancy or the postpartum period, there could be trained health care navigators and community health workers that could provide education and appropriate planning to reduce the stress that comes with disruptions in care for these women. Furthermore, staff at qualified organizations, such as WIC programs, Head Start and other public programs, could also provide education and support.
Conclusion
Access to timely and adequate prenatal care is an key part to improving health outcomes for women and infants. It reduces the risk of low birth weight, preterm birth and several other pregnancy-related complications. Title V programs recognize the importance of prenatal health care and are creating pathways to establish new ways of improving access to prenatal care. Moreover, Title V programs could act as a conduit, expert advisor and educator on these issues faced by women during pregnancy. Health reforms, including the ACA, give Title V programs new ways to create and improve access to prenatal care, and ultimately improve health and birth outcomes for women and infants in their states and communities.