Mississippi cleared a big hurdle after lawmakers extended postpartum Medicaid coverage this session, guaranteeing low-income women a year of health care coverage after having a baby.

Now experts say that Mississippi needs to turn its attention to what happens before these women give birth. Early prenatal care is vital to healthy moms, babies and pregnancies, but because of the state Division of Medicaid's policies, it's unknown if the majority of pregnant Mississippians are getting that care.

The division, which funds more than two-thirds of births in Mississippi, doesn't monitor when people go to their first prenatal visit. And the absence of presumptive eligibility in Mississippi creates major delays for people seeking prenatal care.

Pregnancy presumptive eligibility allows people to receive care when they're pregnant, even if they're not on Medicaid. It's presumed that they qualify, so their providers enroll them and start billing Medicaid, which reimburses providers immediately.

That means fewer delays when it comes to receiving care. They're able to go to doctor's offices and get the care they need quickly, without having to pay out of pocket.

The agency is hoping to eventually track when recipients go to prenatal visits, but Communications Officer Matt Westerfield could not provide a timeline for when that data might be available. And Medicaid Executive Director Drew Snyder has said he won't take steps to make it easier for expecting mothers to get on Medicaid without legislative action.

Mississippi is one of the most dangerous states in the country to give birth in, and early intervention is key to successful pregnancies, according to Dr. Anita Henderson, former president of the Mississippi Chapter of the American Academy of Pediatrics.

The state's dismal maternal mortality rate is getting worse, especially for Black people, and Mississippi has the highest infant mortality, preterm birth and low birthweight rates in the nation.

But as rural health care collapses and hospital closures loom, it's getting harder to access health care for expecting Mississippians. Neonatal ICUs and labor and delivery units are closing, and county health departments stopped enrolling new maternity patients in 2016.

It's a dangerous mix following the U.S. Supreme Court's decision last summer to overturn abortion rights, which means the state is expecting thousands more pregnancies.

Care during the first trimester is crucial to a healthy pregnancy and healthy babies, especially for people with conditions that need to be managed like high blood pressure or diabetes.

“I think given the level of health concerns in our population that exists before pregnancy, we know too many people are going to start prenatal care with medical conditions that make that pregnancy high risk,” said Dr. Charlene Collier, an OB-GYN based in Mississippi. “The consequences are always snowballing when a person enters pregnancy with an untreated or complicated medical history.”

When people who are expecting can't make it to a prenatal visit in a timely manner, the consequences can be deadly — and, often, preventable.

Collier cited the prevalence of congenital syphilis in Mississippi, which is at an all time high, to stress the importance of early care. She said there's a limited time frame to prevent complications from syphilis.

Last month, the state health department implemented an emergency order requiring doctors to test pregnant patients for syphilis. Previously, Mississippi was one of six states in the country not to require the testing.

“Now that we're seeing a rise in congenital syphilis, it's even more important that people are in prenatal care, getting their blood work done and getting treatment so that infections like syphilis, which is easily treatable with penicillin, can be identified and treated early,” she said. “Any delays increase the chance of a really detrimental infection in a pregnancy.”

Another barrier to timely prenatal care is that it's complicated to get pregnancy Medicaid coverage.

According to the Kaiser Family Foundation, Mississippi is one of 21 states as of January 2020 that doesn't offer presumptive eligibility for pregnant people, which has significant benefits.

According to a study commissioned with the University of Mississippi Center for Population Studies by the Center for Mississippi Health Policy, preterm births are less likely for low-income people when they live in a state with presumptive eligibility and expanded Medicaid.

Mississippi is one of only three states in the country that has neither expanded Medicaid nor provides pregnancy presumptive eligibility.

And it takes the Mississippi Division of Medicaid about 24 days to approve pregnancy applications, Westerfield said in November. Until then, uninsured people who are expecting must foot the bills themselves, if a doctor sees them at all.

It's a tedious process that even top officials in Mississippi are confused by.

At a recent press conference about Mississippi's commitment to its “culture of life” following the overturning of abortion rights, Republican Gov. Tate Reeves said that the state has presumptive eligibility. But he was referring to hospital presumptive eligibility, which allows hospitals to assume patients' Medicaid eligibility to provide care. It is not the same thing as presumptive eligibility for pregnant people, which allows them to get care at doctor's offices just as they would if they were insured.

Reeves' spokesperson Shelby Wilcher responded that pregnant women in Mississippi have presumptive eligibility at hospitals. After Mississippi Today clarified hospital presumptive eligibility was not the same thing as presumptive eligibility for pregnant women, Wilcher suggested further questions be directed to the Division of Medicaid.

She did not respond to a question asking if the governor would support establishing presumptive eligibility for pregnant women.

“Presumptive eligibility is, intentionally, a very loosely used umbrella term,” said John Dillon Harris, a health care systems and policy consultant at the Center for Mississippi Health Policy. “The question is who is presumed eligible and for what?”

At the last Medical Care Advisory Committee Meeting on Feb 24, Snyder said that the Division of Medicaid wouldn't utilize pregnancy presumptive eligibility unless directed to by the Legislature.

Westerfield said in an email that position is to prevent the DOM from paying “providers for services for women who subsequently would not qualify for Medicaid.”

Rep. Missy McGee, R-Hattiesburg, introduced a bill this past session to establish presumptive eligibility for pregnant women, but it died after being referred to the Medicaid committee, which met just once last legislative session and only advanced two bills out of committee.

Collier said she recently had a patient who applied for Medicaid but hadn't yet been approved. The patient delayed getting ultrasounds and other labs out of fear of running up a higher bill even though all her bills would be back-paid once she got on Medicaid.

“I do think the lack of insurance preceding pregnancy is a major barrier to initiating early prenatal care, particularly getting bloodwork done in a timely manner,” Collier said.

It's a paradox — a confirmatory pregnancy test is required to qualify for Medicaid, but many doctor's offices don't provide care to people who are uninsured.

County health departments still offer these confirmatory tests for free, said Liz Sharlot, communications director at the Mississippi Department of Health.

“In fact, that is the most common reason women come in for the pregnancy tests is to confirm that pregnancy test and receive the confirmation letter to bring to the Regional Medicaid Offices in order to apply for Medicaid benefits during pregnancy,” she said.

Clinics that specifically serve uninsured and underserved populations such as the Hinds Comprehensive Health Center, where Dr. Jaleen Sims works as an OB-GYN, also provide these confirmatory pregnancy tests at low cost.

It's not clear how many people are aware these services are offered at low or no cost at places other than primary care doctor's offices. And if they are aware, transportation can be another issue.

“The patients who live in these areas need a ride or they have to take off work for a full day to drive to Jackson or their closest areas, spend time in the waiting room, have their visit and then drive back,” she said. “By the time you finish with that you've missed … a full day of work for the most part.”

According to a report from the March of Dimes, more than half the counties in Mississippi are considered maternity care deserts, with no OB-GYNs, certified midwives or hospitals providing obstetric care.

It also continues to be a challenge to recruit doctors, especially OB-GYNs, to Mississippi and keep them here. Of the five people who graduated from UMMC's OB-GYN program in 2019, Sims was the only one to stay in Mississippi.

For the doctors who stay, their patient waitlists are long.

One of the nurses Sims works with had to use her health care connections to get into a doctor's office. She had just missed her period and called to schedule an appointment, only to be told she had to wait four months.

“I'll never judge a person again on coming late to prenatal care,” Sims said the nurse told her.

It's hard work being pregnant in Mississippi, Sims said.

“It's almost like you have this feeling of being defeated,” she said. “It's like, ‘I'm trying everything that I can to take care of me and to take care of my baby. But I have all these barriers and hoops that I have to jump through just to get to that point.'”

Reporter Isabelle Taft contributed to this story.

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