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Almost all of the pregnant women Dr. Joshua Splinter sees at his rural East Texas practice are on Medicaid. For years, he would treat these patients during pregnancy, deliver their babies and then start the mad dash to squeeze in a follow-up visit before they lost insurance just eight weeks after giving birth.
This just didn’t work for him or his patients. He’d get someone on a treatment plan for a chronic condition, but then the hormone and weight changes after childbirth would require different interventions. He’d see early signs of postpartum depression or partner violence, and then lose contact with the patient once she lost insurance.
“These aren’t things where I start a medication and we’re done,” he said. “This requires close follow-up with continued treatment and non-medical intervention, and we can’t get that done in two months.”
So when the Texas Legislature voted to extend postpartum Medicaid to a full year in 2023, Splinter was ecstatic. This was going to be a “game changer” for his patients, he said.
But almost two years later, many of his patients and those like them across the state are still struggling to get the full range of health care they were promised. It took almost a year for the extended coverage to go into effect, leaving many of his patients in limbo, and even now, they’re still often falling through the cracks in Texas’ health care system.
The number of pregnant and postpartum Texans enrolled in Medicaid has almost doubled since before the pandemic, to more than 265,000. But many patients are unaware that they are still covered for an additional 10 months, according to a survey from Texans Care for Children, a health advocacy group. New moms report being unable to access the physical and mental health services covered by Medicaid, and doctors say changes are needed to ensure the workforce, reimbursement rates and coverage can keep up with a full year of need.
As the Legislature returns, Diana Forester, health policy director with Texans Care for Children, said there’s still much work to be done, such as increasing provider awareness and patient access, to ensure new moms are fully benefiting from this extended coverage.
“You can’t just turn on this extended coverage and expect that to be the end,” Forester said. “We as a state need to figure out what postpartum care looks like in Texas … Our leaders have an opportunity to make that work better for families, but it’s not there yet.”
How we got here
When Gov. Greg Abbott signed House Bill 12 into law in May 2023, Texas became the 41st state to extend postpartum Medicaid to 12 months. It was a victory years in the making, after several sessions of advocacy from health care providers, maternal health experts and moms themselves.
The state almost passed it in 2021, after the federal COVID relief package eased the way for states to get this extended coverage approved, but the Legislature instead passed a six-month extension that the federal government deemed “not approvable.”
But when the Legislature returned in 2023, Roe v. Wade had been overturned, abortion was virtually banned in Texas, and there was new momentum around bills to support pregnant women and families.
Sen. Lois Kolkhorst, a Republican from Brenham, carried the bill on the Senate side, and said at a hearing that extending coverage was about making sure “women who give birth to children in this pro-life environment are cared for … You cannot raise a child without being healthy.”
The bill passed with overwhelming bipartisan support, and Abbott signed it into law in May 2023. HHSC submitted the waiver request to the federal government, which approved it last January. The state began offering extended coverage March 1, 2024.
Awareness among doctors
After all that back and forth, half-steps and setbacks, many doctors were unaware that the extended coverage was actually in effect, Texans Care for Children found in its survey. Some doctors found out for the first time through their billing departments. Several said they wanted more outreach from the state health agency and the managed care organizations, like a flyer or training for doctors.
“The state could do a lot more in that area,” said Helen Kent Davis, a senior policy advisor to the Texas Academy of Family Physicians. “They’ve tried, to the extent that there’s funding for outreach, to get the word out, but there’s more to be done, for sure.”
In a statement, a spokesperson for Texas’ Health and Human Services Commission said they used a variety of approaches to inform the public about these changes, including calls and webinars, provider notices, posting information to their websites and working with managed care organizations to get the word out.
But knowledge gaps remain, Kent Davis said. As an example, she said pediatricians have not been educated on this change the way OB/GYNs and family physicians have. Since they’re seeing the baby regularly, these doctors could be a key ally in making sure the mom knows she still has coverage.
Doctors also report confusion about who is responsible for overseeing this year of health care. Texas Medicaid changed its policy to allow an OB/GYN to serve as a patient’s doctor for the whole year, but the survey found many doctors across specialties were not aware of that and, when asked, said they would prefer patients be handed off to a primary care provider.
“Patients have been seeing their obstetrician this whole time and the health care system is not good at handing them back to a primary care physician for the rest of that period,” Kent Davis said. “This is a significant culture shift for patients and providers.”
And with a shortage of primary care physicians, especially in rural areas, more coverage doesn’t automatically translate into more health care. One new mother in Mineral Wells told Texans Care for Children she would have to travel almost an hour to Fort Worth to see a primary care provider.
“Every day, I get really bad headaches… very bad headaches,” she said. “And it’s getting more consistent. I just deal with it.”
Awareness among patients
In a state where almost half of all pregnant women typically lost insurance two months after giving birth, convincing new moms that they can continue engaging with the health care system has been an uphill battle. Home-visiting nurses, community health workers and others who work closely with new moms report significant confusion and resistance from patients.
“They really had to talk their patients into accessing care, essentially, because they’re so used to not having coverage and so worried about the cost and having to absorb that personally,” Forester said.
It didn’t help matters that this extended coverage finally went into effect amid a historic fracture to the state’s Medicaid system. For three years during the pandemic, states kept everyone enrolled in Medicaid, but in spring 2023, were allowed to move people off their rolls.
Texas removed more people, including postpartum women, faster than any other state, against federal guidelines, The Texas Tribune and ProPublica found. The state required almost everyone to resubmit documents proving their eligibility, rather than relying on automatic approvals like other states. More than a million people lost coverage for bureaucratic reasons like failing to return a form. The state has acknowledged some errors, which they later fixed.
Amid this upheaval, Texas implemented the extended coverage, including reinstating women who lost Medicaid at two months but were still in their one-year postpartum period.
“It was really confusing for members who were like, ‘you terminated my Medicaid a month ago, I have the notice,’ and then they’re told that it’s being turned back on for a few more months,” Forester said. “And it’s really hard for a doctor to be able to educate their patients when it’s totally dependent on where they are in the postpartum period.”
Splinter said he’s had at least a dozen patients over the last year who had to call their managed care organization to get their coverage reinstated.
“I’m having to act a little like a social worker and educate the patient on who they need to call and what they need to say,” he said. As a family physician trained in high-risk pregnancies practicing in an underserved area, Splinter said, “there’s only so much of me to go around, especially if I have to spend more time on non-doctor work like this.”
A spokesperson for the state’s health agency said everyone who was enrolled in Medicaid or CHIP during their pregnancy were automatically reinstated for the remainder of their postpartum period. While some of this is naturally sorting itself out the longer the policy is in effect, Splinter said he was surprised at the work his patients had to do to get the coverage they qualified for.
“You’re leaving pregnant patients and new moms to fight up the chain and solve it themselves from the bottom” he said. “That just isn’t the right way to be doing this.”
More work to be done
As more new moms are able to take advantage of this extended coverage, doctors and advocates hope the health care system is able to meet their needs. In the short term, Splinter said, he’s hopeful that the state can proactively go back through its records and ensure women who qualify for this coverage are actually getting it.
In the long term, the state needs to address long-standing structural problems facing its health care system, like significant shortages in primary care and mental health providers. Advocates are pushing for increased reimbursement rates and reforms to the bureaucracy that providers must go through to accept Medicaid, to ensure doctors are willing to see these patients.
They also want Medicaid coverage to catch up to the extended time period women can receive these benefits.
For example, Texas Medicaid covers one postpartum depression screening, even though national groups recommend at least four, Kent Davis said. With an extra ten months of coverage, that’s a lot more touch points for doctors to be screening patients for mental health needs. She’d also like to see Medicaid cover lactation support among other needs that can emerge in the first 12 months postpartum.
“It takes a comprehensive strategy,” Kent Davis said. “Obviously the coverage issue was one part to address and, and we’re so happy that we were able to pass House Bill 12. But now that we have this coverage, what do we do to make sure women can get it?”
Disclosure: Texans Care for Children has been a financial supporter of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune’s journalism. Find a complete list of them here.
