A recent study ranked Texas 50th among all states in access to high-quality prenatal and maternal care, and one of the main reasons is the difficulties women face in getting health care coverage both before and after their hospital stay to give birth, says Houston obstetrician-gynecologist Rakhi Dimino, MD, chair of the Texas Medical Association’s Committee on Reproductive, Women’s and Perinatal Health.
The study by ValuePenguin, a research group that specializes in providing consumers with data for comparison shopping, evaluated states based on six metrics tied to access and quality, but two criteria in particular accounted for Texas’ low ranking: The Lone Star State is last among the 50 states in the percentage of women 18 to 44 years of age who have health insurance (73.6%) and who have a primary care physician (57%).
The lack of coverage among women of child-bearing age reflects the larger lack of coverage statewide. Texas has the highest rate of people without health insurance, at 17.3%, according to U.S. Census data. That is twice the national rate of 8.7% and three percentage points higher than the next state, Oklahoma.
Texas women lack comprehensive coverage before they get pregnant, says Helen Kent Davis, TMA’s associate vice president of governmental affairs. Currently, in the 38 states that have expanded Medicaid coverage under the Affordable Care Act, pregnant women are covered before, during, and after pregnancy. That means any chronic conditions identified before pregnancy can be better managed, she says. For example, complications such as preeclampsia are higher in women with poorly managed or unmanaged diabetes.
Also, low-income pregnant women in Texas without coverage are often eligible for Medicaid, but they frequently struggle with enrollment, Dr. Dimino says.
“Many of these women end up not getting prenatal care – not because they didn’t try, but because they had too many barriers in the way to get there,” Dr. Dimino said. “And a large part of that is the way Medicaid coverage happens.”
She added: “That [Medicaid application] process can take over 30 days from the time you figure out you’re pregnant. Then, you have to call different [physician] offices and hope they take your specific Medicaid plan. If you don’t find out that you’re pregnant until after eight weeks, which is often normal, then you’re already 12 weeks [pregnant] by the time you get approved by Medicaid – and that’s if everything went smoothly, which is usually not the case.”
The upshot is that many pregnant women first see a physician at 20 weeks into their pregnancy, Dr. Dimino says. Many of them face additional barriers, like lack of transportation to and from the physician’s office.
“You’re missing half the pregnancy in terms of being able to optimize medical challenges,” she says. “And many doctor’s offices start turning you away at 20 weeks, saying you’re too far along to take you in our clinic.”
Texas has made strides in helping women while they are at the hospital and giving birth, Dr. Dimino says. In 2018, Texas launched TexasAIM, patterning it after a California initiative credited with lowering that state’s maternal death rate.
AIM, which stands for Alliance for Innovation in Maternal Health, uses “bundles” of best practices to educate hospital staff and clinicians in dealing with potentially deadly maternal complications, such as hemorrhage and hypertension.
TexasAIM works in 98% of the state’s hospitals offering delivery services to implement those bundles, says Dr. Dimino, who trains hospital staff for TexasAIM. Unfortunately, many women face the biggest threat from hypertension in the days after delivery.
“Traditionally, we see all postpartum women at six weeks after delivery, but the challenge is that the peak in blood pressure usually occurs about five to seven days after delivery,” Dr. Dimino said. “The mom is already home, on her own, when she is potentially in the most danger.”
Women face a range of other health threats postpartum, including depression and domestic violence, Dr. Dimino says. In 2021, the Texas Legislature, with TMA’s support, approved House Bill 133, which increased postpartum Medicaid coverage from two months to six months. TMA continues to push for a full year of Medicaid coverage, which is the standard called for by the Texas Maternal Mortality and Morbidity Review Committee (MMMRC).
Lack of access to health care is a leading cause of maternal death and illness, according to the MMMRC’s 2020 biennial report.
During the COVID-19 public health emergency, Texas women have had 12 months of postpartum Medicaid coverage, Ms. Davis says. But that coverage is set to expire when the Biden administration declares the emergency over, which will likely happen later this year.
The Texas House of Representatives is studying possible access-to-care improvements for consideration during the legislative session that will begin in January 2023.