Mississippi moms and babies suffer disproportionately. Medicaid expansion could help.

by Isabelle Taft, Mississippi Today
November 21, 2022

Note: This article is part of Mississippi Today's ongoing Mississippi Health Care Crisis project.Read more about the project by clicking here.

During her 14 years working as an OB-GYN in Greenville, Dr. Lakeisha Richardson has seen five patients diagnosed with breast cancer during their pregnancies.

Most of them did not have health insurance prior to pregnancy, so going to the doctor for annual checkups was neither affordable nor routine. They missed out on clinical screenings and the chance to learn whether they were at higher risk of breast cancer.

Pregnancy does not cause breast cancer, but it can make it grow and spread more quickly, and breast cancer associated with pregnancy has a lower survival rate. For Richardson's patients without health insurance, pregnancy brought Medicaid coverage that allowed them to go to the doctor for prenatal visits, and that was when their cancer was diagnosed.

One of Richardson's patients died from breast cancer a few weeks after giving birth.

“Legislators think, women are healthy, they're going to have a baby, and they can come off Medicaid,” Richardson said. “They don't think that other illnesses and disease processes can exist in pregnant women.”

Mississippi doctors like Richardson see thousands of patients every year who have no health insurance, and thus limited access to affordable health care, until they become pregnant and qualify for Medicaid. If the patient has a chronic condition like diabetes or hypertension, getting treatment during pregnancy is critical – but not necessarily sufficient to prevent problems like preterm delivery, low birth weight, birth defects, and even stillbirth.

Access to routine care prior to conception increases the chance a person can have a healthy pregnancy and delivery. But in Mississippi, where one in six women of reproductive age is uninsured, preconception health care is far from universal. Under current Medicaid eligibility policy, adult women can get coverage only when they are pregnant or have kids at home and very low household income.

“If they have a preexisting disease like diabetes or hypertension, if they're uninsured they've probably been off their meds for a while, so they'll come in with elevated blood pressure, elevated glucose that have been uncontrolled for months or years,” Richardson said. “If it takes them a while to get their Medicaid and they're already late to prenatal care, they have growth restrictions for the baby.”

It's no secret that Mississippi is a sick state. More than one in seven Mississippians are living with diabetes, a higher rate than almost any other state. More than 700,000 Mississippians have hypertension, and the state has the country's highest rate of deaths due to high blood pressure, as well as the country's highest adult obesity rate, at just under 40%.

But perhaps nowhere are the consequences of sickness – sickness that is largely preventable – more evident than in the unnecessary suffering of Mississippi's mothers and babies.

The state has the country's highest percentage of babies born at a low weight. It has the highest percentage of preterm deliveries, which can result in costly NICU stays and long-term health consequences. Mississippi has the country's highest rate of stillbirth. And more babies here die before their first birthday than anywhere else in the U.S.

Nationally, the leading cause of infant mortality is birth defects. But in Mississippi, the causes are more preventable: premature birth and pregnancy or delivery complications as well as sudden infant death syndrome (SIDS).

Within each of these statistics, Black women and babies suffer much more than their white counterparts.

Expanding Medicaid would not on its own solve Mississippi's maternal and infant health crisis, which State Health Officer Dr. Daniel P. Edney has identified as a top priority. Health insurance is not the same as access to health care, and access to health care alone is not enough to ensure all Mississippians have healthy food, opportunities to exercise, and safe neighborhoods.

But OB-GYNs interviewed across the state said that lack of access to health care prior to conception is a problem they see every day. They may see a patient get her diabetes or hypertension under control when she has Medicaid coverage during her pregnancy, only to lose coverage and return to self-managing her conditions. They won't see her again unless she gets pregnant again, and then the process of treating her chronic condition must start all over again.

“We work really hard and optimize their diabetes during pregnancy, and then they'll be a gap in care between and patients come back for the next pregnancy and it's like we're starting from square one again,” said Dr. Sarah Novotny, a maternal-fetal medicine specialist at the University of Mississippi Medical Center.

An analysis by the consulting firm Manatt found that expanded Medicaid eligibility to adults with incomes below 138% of the federal poverty line would likely cut enrollment in pregnancy Medicaid by about half – meaning that it would provide more consistent coverage and access to care for about 10,000 women each year who can currently have health insurance only during and right after their pregnancies.

Dr. Jaleen Sims has worked as an OB-GYN at Jackson-Hinds Comprehensive Health Center since 2019. The federally qualified health center offers services on a sliding scale, so it's affordable for people without insurance.

“I serve the underserved population that experiences the most suboptimal outcomes , the highest comorbidity rates, the highest mortality rates – those are my patients,” she said.

She estimates that more than half of her patients who are pregnant with their first child have not had health insurance as adults before getting pregnant.

Medicaid offers full coverage for pregnant women with incomes 194% of the federal poverty level, or $4,603 monthly for a family of four. That ensures that low-income and working-class women can get health care during their pregnancies. About 60% of births in Mississippi are covered by Medicaid, the second-highest percentage in the country, after only Louisiana.

Hinds County has both the state's largest number of Medicaid-covered births, at an average of 2,300 annually from 2016 to 2020, and one of the state's highest per capita rates of pregnancies covered by Medicaid. Some people with pregnancy Medicaid have another form of insurance, too, but generally the rate of Medicaid coverage during pregnancy gives an indication of how many people lacked insurance before they conceived.

Sims sees patients with hypertension, diabetes, obesity, lupus – “those chronic medical conditions that you really want to have under very, very good control before you get pregnant.”

Diabetes is a good example of a condition that can cause problems during pregnancy– but doesn't have to.

Sometimes Sims sees patients who got treatment for diabetes during a previous pregnancy, but stopped seeing going to the doctor when that coverage ended. Instead, they've tried to manage it on their own.

“Then before you know it, they're out of the medication, they're just kind of living,” she said. “They're like, ‘Well, I don't check my finger sticks, I don't have my insulin, I don't have my medicine. Now I don't really know where I am at this point.'”

During pregnancy, doctors try to keep blood sugar tightly controlled. That becomes harder to accomplish when the patient's condition isn't well managed when they arrive for their first prenatal visit.

If blood sugar is elevated during the first 10 weeks when the fetus's organs are developing, the risk of birth defects is higher, Novotny said, even if blood sugar is controlled later in the pregnancy.

“A lot of times women haven't been in care, they find out they're pregnant, sign up for Medicaid, and by the time they come to us, it's often the end of the first trimester, when damage may already be done,” she said.

Spina bifida and heart problems are the most common birth defects associated with diabetes. People with diabetes are also at risk for preterm delivery.

Dr. Emily Johnson, an OB-GYN in the Jackson area, said it's important for people to know that chronic conditions and risk factors during pregnancy can be managed with very good outcomes. Early communication between provider and patient is critical.

“I think them knowing that information helps them have a little autonomy that they can be responsible for their blood pressure and they know what they're supposed to call me for,” she said. “Communicating about the risk can help them take a little ownership of it and in some way provide some reassurance.”

For many uninsured women in Mississippi, getting signed up for Medicaid is one of the first rituals of pregnancy. But getting approved is a hurdle that for some people can delay their prenatal care by days or weeks.

Providers said they largely see patients get approved within a month or so. A mistake on the paperwork, however, can delay approval.

Matt Westerfield, spokesperson at the Division of Medicaid, told Mississippi Today that according to a recent analysis by the Office of Eligibility, the average approval time for pregnancy Medicaid from Aug. 2021 to Aug. 2022 was about 24 days. That's slightly higher than the average approval time in 2021 for all eligibility categories of 20 days, according to documents Mississippi Today obtained through a records request.

Even a delay of a few weeks can make a difference, given the importance of early prenatal care. Dr. Kushna Damallie, an OB-GYN at The Woman's Clinic in Clarksdale, said he would like to see a patient as soon as she misses a period. But that often doesn't happen.

“One of the biggest hurdles we have in our practice is late prenatal care, no prenatal care, or insufficient prenatal care,” Dumallie said.

Westerfield told Mississippi Today that the Division of Medicaid doesn't track when women go to their first prenatal visit or what percentage take place during the first trimester of pregnancy.

Richardson said early prenatal care is particularly important for women with a condition called an incompetent cervix, in which weak cervical tissue can cause very early delivery. Black women are more at risk for this condition. One treatment to help ensure a successful delivery is a cervical cerclage, in which providers stitch the cervix closed, usually around 12 to 14 weeks of pregnancy. If that doesn't happen in time, the risk of miscarriage is higher.

In August of this year, Richardson had a patient who was in the hospital because her water had broken well before viability. The patient had known she needed to get treatment for her incompetent cervix but had not been able to get an appointment early enough.

“She moved from another state, so she didn't have her Mississippi Medicaid and so she couldn't get in anywhere to be seen,” Richardson said.

OB/GYN Dr. Nina Ragunanthan poses for a portrait inside of Delta Health Center in Mound Bayou, Miss., Thursday, July 14, 2022.

While Medicaid expansion is a taboo topic among Republicans in the legislature, extending Medicaid coverage for postpartum women has bipartisan support. A measure to extend coverage from 60 days to 12 months postpartum passed the Senate resoundingly in the last session, before House Speaker Philip Gunn killed it.

Today, Mississippi is one of just two states that has neither expanded Medicaid eligibility nor extended postpartum coverage.

Senate Republicans including Sen. Kevin Blackwell, R-Southaven, who sponsored the measure, have vowed to reintroduce the measure in the next session, though Gunn still opposes it.

Gunn recently said he believed postpartum Medicaid extension would help only a few thousand women in Mississippi, referring to his calculation that only 60% of the 5,000 new births expected annually after the state's abortion ban would be covered by the program and dismissing the 21,000 people already covered by pregnancy Medicaid each year.

When discussing crisis pregnancy centers, which already get a $3.5 million tax credit from the state and which Gunn wants to expand to $10 million, he offered no information about the number of people they serve and how, probably because that data is not being collected by the state.

Providers largely say they'd welcome any opportunity to lengthen the amount of time their patients have health insurance. Novotny, the maternal-fetal medicine specialist, said 12 months of coverage postpartum would give her patients a chance to control their diabetes for a longer period before becoming pregnant again.

Some providers were not aware of continuous coverage provisions during the pandemic. But those who knew about it said their patients benefited from longer access to care.

“They've been able to continue the management of their chronic diseases so that when they're ready to get pregnant again, they are in a good place,” Sims said.

But postpartum Medicaid does nothing to improve access to health care before conception.

Some advocates are concerned that the conversation about postpartum Medicaid could distract from the need to address Mississippi's health care crisis more broadly.

Nakeitra Burse, a public health consultant and advocate focused on maternal health, said some of the discussion of postpartum Medicaid seems to reflect a belief that pregnancy can be separated from the rest of a life.

“A person's already experiencing obesity, diabetes, high blood pressure, and then you add pregnancy on top of that, then pregnancy also becomes a condition,” Burse said. “So you're trying to treat all these things at one time, when people don't even just have the opportunity to make the healthy decisions for themselves because they don't have access to care.”

When patients do get access to care during pregnancy, making it to a doctor's appointment isn't as easy as it sounds.

“A lot of that decision making means: Do I miss work to go to the doctor? Do I go to the doctor over my child? It's a lot of push and pull and give and take for the decision making that shouldn't have to happen, if we had opportunity or access to quality health care.”

Dr. Nina Ragunanthan, an OB/GYN in Mound Bayou, pointed out that the focus on pregnancy and postpartum coverage, rather than expanding access to health care for everyone, implies that women are more deserving of care if they are giving birth than if they are not.

“I think it's really important not to just pigeonhole a woman as a child bearing vessel,” she said. “Access to care for that woman as an autonomous, independent person, regardless of whether she plans to get pregnant or not, is very important.”

This article first appeared on Mississippi Today and is republished here under a Creative Commons license.