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States’ Essential Health Benefits Coverage Could Advance Maternal Health Equity

An expectant mom waits in a hallway with her 1-year-old daughter in Loiza, Puerto Rico, on August  30, 2016.

The Affordable Care Act (ACA) greatly improved coverage of maternity health services. In particular, 20 million people have gained coverage, financial assistance has become available to purchase coverage, and the quality of coverage offered has been improved. But there are still significant differences among states in the prenatal, labor and delivery, and postpartum services covered. Specifically, the ACA requires small group and individual market plans to cover maternity and newborn care among the required essential health benefits (EHBs), but states are able to select a benchmark plan to define the specific services covered under each category. The state benchmark plan can set an important standard for plans offered in the state; unfortunately, however, the authors’ assessment of plans in every state and Washington, D.C., found that the maternity and newborn services offered frequently have limits that could impede birthing people’s access to care.

These differences can have severe consequences—particularly for Black and Indigenous women, who are around three times more likely than non-Hispanic white women to die from pregnancy-related complications and more likely to suffer severe maternal morbidity. Initial data suggest that the pandemic is only worsening these disparities. People of color are also more likely to be underinsured and to report not being able to afford to access health care services—a fact that the pandemic is exacerbating given that the current economic crisis has resulted in women losing 5.4 million jobs, nearly 1 million more job losses than men.

Before May 7, states have the opportunity to advance maternal health equity by updating their EHB benchmark plans for 2023. Beyond this deadline, state policymakers can ensure that plans provide the necessary and preventive services outlined below. Even still, the differences between states’ current benchmark plans illustrate why the federal government should establish a minimum maternity and newborn care benefit standard.

Prenatal and labor and delivery services

Maternity care should be consistent with the services medical experts recommend. Typically, a person has 10 to 15 prenatal visits, and this number may necessarily increase for complicated pregnancies. It is also important for plans to explicitly cover services regardless of pregnancy outcomes; several states explicitly mention covering postnatal services and services related to prenatal care, false labor, miscarriage, and delivery. Plans can also provide important access to health education services. Vermont’s benchmark—namely, the Better Beginnings program—notes that it will cover education classes related to “childbirth, siblings, parenting, breastfeeding, and CPR.” Similarly, benchmark plans in Alaska, Maryland, and Massachusetts cover childbirth and/or newborn education services.

These services should be covered without limits impeding access to critical and potentially life-saving care. New Hampshire’s benchmark plan provides that a pregnant person does not need a referral or precertification for obstetrical or gynecological care. Unfortunately, not every plan provides such coverage; benchmark plans in Arkansas and North Dakota cover only one and two ultrasounds, respectively, for prenatal care. Some health plans have limitations or exclusions which may be in violation of ACA requirements. For example, a number of states’ plans exclude pregnancy coverage for individuals claimed as dependents, including plans in Alabama, Idaho, Louisiana, and Mississippi.

Postpartum services, including home health visiting services

Postpartum people continue to need follow-up visits, maternal mental health services, and contraceptives, among other services. About one-third of maternal deaths occur between one week and one year postpartum. Washington state’s benchmark plan has no maximum length of stay postdelivery for a mother’s inpatient stay in a hospital. Additionally, pregnant people may want to receive a visit at home from a doula, lactation consultant, nurse, or other health care professional. Several states’ plans cover home health visiting. Lactation visits are also covered to varying degrees. Connecticut’s benchmark plan provides coverage for comprehensive lactation visits for two months after delivery.

Breastfeeding support and supplies

The ACA’s women’s preventive services benefit requires most plans to cover breastfeeding services and supplies without cost-sharing; however, states have flexibility on the specific breast pumps that must be covered. Plans should, at a minimum, cover the three main types of breast pumps: electric, manual, and battery-operated. However, many plans cover only one type. For example, Rhode Island, Tennessee, Texas, Iowa, and South Dakota limit coverage to only manual pumps. Although both breastfeeding equipment and counseling are required, multiple states’ benchmark plans only mention coverage of either a breast pump or breastfeeding support.

Midwives and doulas

Midwifery care and doula support are associated with improved maternal health outcomes and increased autonomy over the pregnancy and birthing experience. This is particularly important for people of color and LGBTQ people, who frequently experience bias and mistreatment when receiving health care, and specifically in traditional hospital settings. While most state benchmark plans include coverage for certified nurse midwives (CNMs), a limited number of benchmark plans extend coverage to other qualified midwives, including certified professional midwives. Florida, Alaska, New Mexico, and Rhode Island are among the states with more expansive midwifery coverage. Despite the benefits, many benchmark plans restrict coverage of midwives and doulas. Alabama, Arkansas, Illinois, and Maryland require midwives to have a collaborative agreement with a physician; these requirements restrict midwives’ ability to practice independently at the top of their licenses and limit access to midwifery. Other restrictions include explicit exclusion of midwives who are not CNMs, including in Georgia and Arkansas. Finally, no benchmark plan explicitly includes coverage for doula support, and Connecticut’s plan explicitly excludes doulas.

Home births and birth centers

Birthing people also need access to the full range of safe options for locations of birth and maternity care, including homes and birth centers. State benchmark plans that cover home births include Delaware, Missouri, Pennsylvania, South Dakota, and Virginia, among others. In addition, care at birth centers is explicitly covered in benchmark plans in more than one-third of states. However, Arizona, Massachusetts, and Minnesota, among other states, exclude coverage of elective home births, and Michigan excludes coverage for births at home and birth centers.

Conclusion

Through benchmark plans, states have an opportunity to set high standards for health plans offered in the state and, subsequently, the services that plan enrollees can meaningfully access. Ensuring coverage and access to high-quality maternity care is just one step states can take to meet the needs of all birthing people. Federal and state policymakers can learn from the practices of benchmark plans that contain robust maternal health coverage without harmful limitations. In particular, the federal government should pull from good state examples to establish a national standard for EHBs that includes maternity and newborn care. Improving insurance coverage alone cannot solve the maternal health crisis—but high-quality insurance coverage can advance equitable access to necessary and preventive services and culturally competent providers.

Nora Ellmann is a research associate for women’s health and rights at the Center for American Progress. Jamille Fields Allsbrook is the director for women’s health and rights at the Center.