The Medicaid Challenge
Jessica Kahn, Director of the Data and Systems Group at the Center for Medicaid and CHIP Services explains the challenges of Medicaid in providing maternal healthcare.
Many of the women featured in our three-part film series, Giving Birth in America, are insured by Medicaid, the jointly funded, Federal-State public health insurance program that covers nearly 70 million Americans.
Watch the Giving Birth in America Trailer from Every Mother Counts. The full series will be available later this week on CNN.com.
Every Mother Counts: Medicaid covers almost half of all births in the U.S. yet maternal health outcomes vary all over the map. Why is that?
Jessica Kahn: Medicaid regulates, guides and funds health services on the federal level and the States administer and monitor them. Different states have different populations and healthcare needs. As of 2013 (most recent data), Medicaid financed 45% of all U.S. births. We expect that number to rise now as a result of the Affordable Care Act and Medicaid expansion. Looking at the states featured in Giving Birth in America, Medicaid covers 49% of births in Florida, 35% in Montana and 46% in New York. Percentages are even higher in states that have more poverty. For instance, Medicaid covers 67% of births In Arkansas and DC, 70% in Louisiana and 75% in New Mexico.
EMC: Is it coincidental that these states have some of the highest maternal mortality rates?
Jessica: You can’t show that it is causal but I wouldn’t be surprised if there wasn’t some association. Medicaid’s maternal health coverage serves a very vulnerable population.
EMC: What does Medicaid cover in terms of maternal healthcare?
Jessica: All prenatal visits, medications, acute care, tests, lab work and hospitalizations — whatever is necessary by current medical guidelines.
The type of providers and locations for services covered varies by state.
In some states, county health departments provide most of the prenatal care. States that don’t have that structure work with other federally qualified health centers or regular OB-Gyn providers. About 75% of Medicaid coverage is provided as managed care, just like the managed care I have with my Blue Cross/Blue Shield policy. Medicaid eligible women are given lists of providers in their network and they’re expected to make their own appointments. That’s where many may struggle. Even though they’re covered for prenatal care, they still may have challenges with access if they can’t find a provider who will take them as a patient. That’s called network inadequacy and each State’s Medicaid agency monitors that.
EMC: Can you explain more about network inadequacy?
Jessica: In order for a managed care plan to meet Medicaid qualifications, they have to demonstrate that their list of network providers is adequate for the number of people enrolled in that plan. That includes geographic adequacy and providers who are accepting new patients. For example, if you live in Los Angeles, it’s not OK if the only provider for the basic health services you need is in San Francisco.
EMC: Why don’t doctors want to accept Medicaid patients?
Jessica: Because Medicaid doesn’t always reimburse providers at rates that are comparable to private insurance. Some practices accept Medicaid patients but impose caps on how many they’ll take at a time. Some can’t afford to take too many because of the lower reimbursement rates.
EMC: Why is there so much variation between states in the types of maternal health services and providers Medicaid covers? For instance, in Oregon, Medicaid covers doula services but most states don’t.
Jessica: It’s largely up to the States to decide which services and providers they’ll cover and often, that decision mirrors how the state views those different professional roles. Some states will only reimburse Certified Nurse Midwives and others will reimburse midwives with other certifications. Some states reimburse for birth center deliveries and other states only cover hospital-based deliveries. We also have to recognize that not every provider wants to participate in Medicaid reimbursement. They have to have the administrative capabilities to bill Medicaid. They have to register with the state. They have to submit claims in specific ways. It’s great for Medicaid to cover services like midwifery or doula care, but if that doula doesn’t have the necessary administrative resources and she’s not going to be reimbursed at a rate she desires for her time, it might not be worth her while.
Kaiser Family Foundation provides a good summary of Medicaid midwifery benefits for each state.
EMC: Did any particular section of the documentary resonate with you?
Jessica: One of the issues that came up repeatedly was that having insurance coverage isn’t enough to improve health outcomes. I think the Montana story is a great example of that. You also have to have access to a provider and support services such transportation and/or childcare. Never mind whether there’s any kind of patient-provider rapport. Patients with Medicaid sometimes have to go with any provider who will accept them and is accessible to them. We know that lack of rapport can have an impact on all women’s healthcare participation and treatment adherence. States are working hard with Medicaid to improve beneficiary satisfaction and overall health outcomes.
EMC: How is Medicaid improving services for pregnant women?
Jessica: We’re doing some really strong work along with fellow Federal agencies. We’re wrapping Medicaid around other human and social service programs to provide a more holistic approach to overall wellness. We’re banding together with other state programs that look at childcare, transportation, food stamps, energy credits and other issues that impact a woman’s health and ability to take care of herself and her baby. About a third of states now have a multi-benefit application, which means when you apply for Medicaid, you can find out if you’re eligible for other social services as well. It’s a more streamlined customer experience we think will help more women. It’s not just about getting coverage. There also has to be quality of care and accessibility. Even the ability to choose when you become pregnant is empowered through access. Without access, you don’t have a choice.