Colorado Medicaid focuses on community experiences to improve maternal health equity as reports reveal pandemic impacts on births – State of Reform

The Colorado Department of Health Care Policy and Financing (HCPF) held a webinar on Wednesday presenting maternal health data impacted by the COVID-19 pandemic. 

The webinar presented the state’s roadmap for maternal health equity through a series of scheduled stakeholder sessions this year, coordinating with the Maternity Advisory Committee (MAC) and community birthing partners who can center member experiences.

Comprised primarily of women of color with lived experience, MAC will guide HCPF on the strategic direction of maternal health programs.

Speaking to State of Reform, Erin Miller, vice president of health initiatives at Colorado Children’s Campaign (CCC), emphasized the importance of MAC’s community-informed guidance to ensure equity.

“If we can build a maternal healthcare system that centers their voices and works well for them, the system will work well for everyone,” Miller said. “That will be a system that we can all be in—that we can all thrive [in] … As you peel away the layers of the onion around all of these [maternal health and mental health issues], it really comes back to centering the voice—the needs, the experience of that birthing person—learning, helping our system trust birthing people, and helping really meet their needs as they see them.”

HCPF’s Maternal Health Equity Report released last week said the extension of postpartum coverage along with the rapid telehealth expansion helped Medicaid members overcome the barriers that resulted from the COVID-19 pandemic and access care in 2020, the first year Health First Colorado members received 12-month postpartum coverage. 

From 2019 to 2020, the state witnessed a 1.1% decrease in prenatal visits and a 0.7% increase in postpartum behavioral health visits for the Medicaid population.

Based on Medicaid claims and birth records data, the report found 24% of parents were not accessing prenatal care visits in 2020—those rates were higher for Pacific Islander (42.4%), Black (29.8%), and Indigenous (29.4%) populations. 

The report also noted that statewide mortality rates likely increased in 2020 based on preliminary data from the Maternal Mortality Review Committee and national data trends.

The CDC’s 2021 maternal mortality data that showed deaths rose 32% from the previous year to 32.9 per 100,000 live births. Mortality rates for Black women stood at 69.9 deaths per 100,000 live births—a 26% increase from 2020 and 2.6 times the rate of white women. 

During the webinar, HHS Region 8 Regional Director Lily Griego said the pandemic exacerbated workforce and access challenges, especially in rural parts of the country, that are contributing to disproportionate outcomes. 

“One of the other important steps that’s being taken [in Colorado] and through the governor’s office is enhancing the workforce so that we have representation—we see ourselves in our providers,” Griego said. “That’s a longer-term plan. And folks are asking us to address this now … [we’re] really looking to our community colleges and our higher [education] institutions here in Colorado to give us these incremental steps and break down the barrier of elite programs, to be in the field of addressing the maternal health crisis.”

President Biden recently outlined his fiscal year 2024 budget proposal, which would increase federal Medicaid and CHIP spending by $2.4 billion over 10 years and require all states to provide 12-month continuous postpartum coverage in those programs.

The budget also includes $471 million to improve maternal health by addressing mortality rates, rural health challenges, implicit bias among providers, and perinatal health disparities. 

Colorado will be working on the implementation of some key legislative reforms to improve maternal health and equity, which include last year’s expansion of Medicaid eligibility to individuals who were previously ineligible due to resident documentation status (which will take effect in 2025) and the addition of Medicaid reimbursement for doula services in this year’s state budget. 

Gretchen McGinnis, senior vice president of healthcare systems and accountable care at Colorado Access, the largest regional accountable entity (RAE) in Colorado Medicaid, told State of Reform that the report reinforces the evidence that persistent racial disparities continue to exist for pregnant and postpartum individuals. 

“We are steadfast in our collaboration with the department to reduce these disparities and improve outcomes,” McGinnis said. “This aligns with priorities at Colorado Access through things such as our Healthy Mom, Healthy Baby digital programming, and we are excited about new policies to support our members including the extension of postpartum coverage to a full 12 months, and implementation of Medicaid coverage for children and pregnant people regardless of immigration status in 2025. Our goal continues to be to make childbirth a positive and empowering experience for all those who give birth.”

Denver Health, a safety net hospital in the metropolitan area, has a volunteer doula program. Pia Lea Long, a full spectrum doula with the birth justice advocacy organization Elephant Circle, serves as the training coordinator for that program and has been working closely with HCPF on Medicaid reimbursement for doula services. 

Elephant Circle has received a grant to initiate the stakeholder engagement process for building the new Medicaid doula benefit so that services are ready by the time funds become available in July. 

Long, who took part in the webinar advocating for further action on birth equity, spoke to State of Reform about the importance of a process led primarily by doulas of color with lived experience of doing the work in Colorado.

“It is important that we have the stakeholder process so that the doulas can talk about what works already so that it’s not just a lot of amazing policy leaders trying to kind of emulate what’s happening in other states,” Long told State of Reform. “Each state has different needs and different resources and who [better to talk to] than the folks who are already out here doing the work. So I’m really excited.”

Some 20 doulas from across the state are scheduled to take part in the early sessions. Long said an important piece of the conversation will be what the payment structure should look like, ensuring doulas are not in pay-scale competition with midwives and other licensed birthing professionals. Another component, she added, is ensuring that doula certification or registry is fair and equitable. 

The CDC’s National Vital Statistics Report showed home births in the US hit a 30-year high in 2021, increasing 22% between 2019 and 2020 and another 12% between 2020 and 2021. 

Home births nationwide increased 21% for Black women, 15% for Hispanic women, and 10% for White women in 2021.

Home births for low-risk pregnancies have safe outcomes and involve fewer interventions such as cesarean delivery, labor induction, regional analgesia, and episiotomy, according to the American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice.

The Colorado Department of Public Health and Environment reported of the nearly 63,000 live births in 2020-2021, 1,214 or 1.9% of births were performed at home. This places Colorado above the national average of 1.2%

Advocates say the disparate outcomes and lack of cultural competency in maternal health have fostered a lack of trust in the health system among the Black community.  Ensuring equity will mean improving access to home birth care and other viable options for members.

“[We’re] making sure that in Medicaid’s reimbursement structures, we are looking at expanding ways that birthing people of color can give birth in [the] community in the way that they choose—it doesn’t have to be in a hospital setting,” Hunter Nelson, policy analyst at CCC, told State of Reform.

“Home births are so beautiful within the Black community; everyone’s cooking food and everyone’s happy. It just makes [birthing] a better experience. But a lot of folks, if they’re on Medicaid, may be very limited based on where they may be covered to give birth. So I think that’s also something to be focused on when it comes to equity.”