Extending postpartum Medicaid coverage is key to bolstering maternal health care in Iowa, advocates say

As a growing number of states have moved to expand coverage for new moms under Medicaid to 12 months in the last three years, Iowa lags behind as one of only a handful of states that does not offer the extended coverage.

Around 40 percent of births in Iowa are covered by Medicaid, and eligibility limits are higher for pregnant women. But many new mothers lose Medicaid coverage for their post-pregnancy health needs as soon as two months after giving birth.

Women's health advocates are hoping Iowa lawmakers will pass legislation this year to extend that coverage from the 60 days currently required by law to 12 months, an option made available to states under the 2021 American Rescue Plan Act.

Iowa is now one of only three states — alongside Idaho and Arkansas — that have not passed a full 12-month extension, plan to implement the extension or have a proposed limited extension, according to KFF.

Supporters say the extension is vital to keeping new mothers healthy in the months after their pregnancy, when a number of health problems — including heart issues, mental health issues and substance abuse — may crop up as a result of the pregnancy.

Emily Boevers, a practicing obstetrician and gynecologist in Waverly, said extending coverage can help doctors address health problems that may persist or appear months after a pregnancy, as well as monitor mental health issues and cases of domestic abuse.

Providing the care could also help address Iowa’s maternal mortality rate, which has risen over the last two decades, Boevers said.

“You may have opportunities to make a significant difference in people's health, in that one year period after a delivery, because people's mentality and people's situations do change a lot in that time,” she said.

According to a report by the U.S. Department of Health and Human Services, extending Medicaid postpartum coverage would result in 6,000 additional mothers each year being covered for a year after their Medicaid-covered birth in Iowa.

Expanding the program would cost the state around $14 million over four years, according to bills proposed during the last legislative session, while the federal government would cover around 60 percent of the program’s cost.

Extending that coverage is one of several policies around maternal health care and women's health care that lawmakers may consider during the upcoming legislative session, which begins on Monday.

Republicans, who hold a majority in both the House and the Senate, have yet to unify around a proposal to extend postpartum Medicaid coverage, though some have been supportive of the move. House Speaker Pat Grassley and Senate Majority Leader Jack Whitver did not commit to passing the measure this year.

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In an interview, Grassley said while implementing the extension may be in consideration from some House Republicans, it is not a priority of the whole caucus.

“I think all types of ideas like this are going to get more and more conversation,” he said. “Whether each individual one has the support to pass in one session, or if it's part of a multi-step approach in what we look at.”

But Grassley said House Republicans do want to address care after birth and for new families as lawmakers move forward from a six-week abortion ban they passed during a special session last year.

He said his priorities include increasing financial accountability for fathers in cases of unwanted pregnancies, and expanding adoption services.

“We need to be willing to also be there after birth,” Grassley said. “It doesn't just end at that point in time … I think too long the conversation has just been about, we want to advocate for life, but then there's the next steps in life.”

Senate Republicans passed a bill that would have extended postpartum medicaid coverage in 2022, but it did not pass in the House. Whitver pointed to that past support and said it would be “part of the conversation” this year.

“If you're only the last state to do something, or only a couple left, that obviously plays into that decision making,” he said. “If you're one of the last three, it's definitely something to look at.”

Republican Rep. Devon Wood, the vice chair of the House Health and Human Services Committee, said she would like to work on legislation to pass the expansion, though she does not know if it will draw support from the full caucus.

Democrats put forward legislation last year to expand the coverage. House Minority Leader Jennifer Konfrst, a Democrat from Windsor Heights, said she is hopeful that Republicans will come together to support the legislation.

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"We've been supportive of that for a long time, and we're happy to provide (Republicans) language," she said. "But this is a critical need. If we're going to make sure that kiddos get their best start, we want to make sure that moms are able to get their best start. And that makes sure that they're not worried about health care for their kids or their family right after they have a baby."

Iowa Gov. Kim Reynolds declined a request to be interviewed for this legislative preview series. Asked whether she would support a measure to extend postpartum Medicaid coverage, a governor’s spokesperson said she would lay out her legislative agenda during her Jan. 9 Condition of the State address.

Rural maternal care

Access to maternal health care is especially difficult in rural areas, as birthing centers have continued to close around the state. A 2023 report from the March of Dimes found that a third of Iowa's counties are "maternity care deserts," meaning they have no hospital birthing centers and no OB-GYN providers.

Lawmakers passed legislation last year funding family medicine obstetrics fellowships in rural areas and "Centers of Excellence" to encourage collaboration between health systems.

Boevers said her hospital benefited from the obstetrics fellowship, but there is still a need for more specialized physicians in rural areas of the state. Workforce shortages across the board are affecting hospitals' access to nurses, ultrasound technicians and other specialists.

State policies to address that include making Iowa a more attractive place for maternal health providers to work and increasing Medicaid and Medicare reimbursement rates for clinics and hospitals, Boevers said.

"Running a hospital in a rural area like mine, it just really requires a higher payment rate for the services so that we can keep our margin less negative than it has been," she said. "Many, many rural hospitals are consistently running in a negative margin and, and trying to rely on things like grants and little shortfalls to fill the gap when the ends are not meeting."

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Wood said she wants to meet with hospitals in the state to see what their needs are and craft legislation to support maternal health in rural areas. Wood and Grassley pointed to changing populations as a cause of rural access shrinking, as rural populations have also decreased in recent years.

"When you're looking at the rural maternal maternal health care, talk to your hospitals and figure out what do they need to be successful in that area, and how you can support them through that," Wood said.

Abortion access

Konfrst said allowing women access to abortion is key to any maternal health care solutions.

Republicans this year passed a bill to ban abortions after a heartbeat can be detected in a pregnancy, which could be as early as six weeks. The bill is being held up in court as the Iowa Supreme Court weighs its constitutionality.

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“It’s no exaggeration to say that women will die when this ban goes into effect,” Konfrst said. “The Republicans have put this ban forward and want to ban abortion in this state. Women’s lives will be at risk.”

House Democrats have proposed a constitutional amendment that would enshrine a constitutional right to an abortion and reproductive health care. Without a majority in the House the bill is very unlikely to see any action this year.

Grassley said Republicans are going to wait for a decision from the court before proposing any new bills dealing with abortion. Republicans gave first approval to a constitutional amendment in 2020 that would explicitly state there is no right to an abortion in the state of Iowa. It will need to be passed a second time and then pass a majority vote from the public on an election ballot before going into effect.

"At this point in time, I think we're focused on getting a positive ruling from the courts to get that to be the law," Grassley said.

Birth Control

Reynolds proposed a bill last year to allow pharmacists to dispense birth control without a prescription to Iowans 18 and older.

The proposal, Senate File 326, passed the Senate but stalled in the House, where Republicans amended it to require a patient to see a doctor within 15 months of receiving birth control from a pharmacist. Lawmakers ultimately could not reach a consensus and ended the session without passing legislation.

Grassley said he’s “supportive of us having that conversation,” but he’s not sure how his caucus would vote on the measure.

Democrats have long been supportive of proposals to remove those barriers to birth control access, Konfrst said. But she said Republicans have tried to reach a consensus within their party rather than work on bipartisan legislation to get it passed.

"Democrats are ready to have the conversation about how we can get this over the finish line if Republicans would just accept that we can do this in a bipartisan way," she said. "Right now, they're just waiting to get enough Republican votes. And we're here ready to vote for it."

Tom Barton of the Gazette Des Moines Bureau contributed to this report.

Legislative Previews

In the days leading up to Monday’s start of the 2024 Iowa Legislature session, The Gazette will preview topics of possible discussion by state lawmakers:

Dec. 31: Tax cuts and state budget

Monday: Social issues

Tuesday: Economic development

Wednesday: K-12 education

Thursday: Higher education

Friday: Government transparency

Saturday: Agriculture and environment

Today: Health care

Monday: Hot-button issues