Advancing Women’s Reproductive Health Access: Medicaid Should Be A Part Of Your Growth Strategy – Healthcare
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The Medicaid Market: A Huge and Growing Investment
Opportunity
Medicaid is a critical source of health care coverage for women
in their childbearing years, covering 1 in 5, or 13 million, women
of reproductive age1, 2 and accounting for 75 percent of
public dollars spent on family planning.3, 4 Ensuring
that individuals who are enrolled in Medicaid are able to access
high-quality family planning and reproductive health care services
is not only the right thing to do, it is also good business and
should be a key part of any women’s health company’s growth
strategy.5
Manatt Health, together with RH Capital and Town Hall Ventures,
convened investors, women’s health care providers, innovators
and thought leaders at a recent forum to discuss the importance of
serving Medicaid enrollees. Below we highlight the key takeaways
from the Medicaid panel discussion.
The Basics: Medicaid Coverage of Family Planning and
Reproductive Health Care Services
Federal law requires all states to provide mandatory family
planning, pregnancy and postpartum services for all individuals
meeting state Medicaid eligibility criteria,6 though
states have flexibility in deciding exactly which family planning
services to cover. States also have the option to establish a
separate Medicaid family planning program for individuals with
incomes too high to qualify for the state’s full-scope Medicaid
benefits package.7 These separate Medicaid family
planning programs, currently established in 30 states, cover people
with incomes often double or more the limits for full-scope
Medicaid, and are particularly critical in states that have not yet
expanded Medicaid to their adult population.8
Medicaid is also an important source of coverage for pregnant
individuals,9 covering more than 4 in 10 of all births
in the country and a disproportionate share of births for women in
rural areas; for women under age 19; and for Hispanic, African
American, and American Indian and Alaska Native women.10
Maternity-related services covered by Medicaid include prenatal
care, labor and delivery, and postpartum care.
Finally, Medicaid covers critical health care services during
the postpartum period. In recognition of the fact that more than
half of pregnancy-related maternal deaths occur in the 12-month
postpartum period, federal law recently provided states the option
of extending the Medicaid coverage postpartum period from 60 days
to 12 months. To date, 35 states plus D.C. have taken this
option.11
Business Case: Why You Should Care About Medicaid
For emerging companies focused on women’s reproductive
health, Medicaid provides a significant and often underappreciated
market opportunity.12 Medicaid spending totaled $734
billion in 2021, or 17 percent of total national health
expenditures, and about 6 in 10 people enrolled in Medicaid are
women.13 Not surprisingly, improving family planning and
reproductive health outcomes is a key area of focus for most state
Medicaid programs and, as applicable, their contracted managed care
plans (which now deliver the majority of Medicaid benefits across
the country). This focus has only heightened in the aftermath of
the U.S. Supreme Court’s recent decision overturning the
constitutional right to abortion services in Dobbs v. Jackson
Women’s Health Organization.14 States are
increasingly exploring innovative strategies such as doulas,
community health care workers, enhanced care management, and
maternal depression-related services, and are well-positioned to
pay for technology-supported or -enabled solutions that can improve
beneficiaries’ access to and receipt of services and compliance
with their care plan. Medicaid managed care plans, responsible for
managing the total cost of care, are increasingly partnering with
innovators providing solutions that improve health outcomes while
reducing cost.
Finally, state Medicaid programs and their health plans are
increasingly looking for ways to address health inequities. In the
past 20 years, inequities in maternal health care have grown,
disproportionately affecting low-income women and women of color.
Black women are three times more likely than white women to
experience a pregnancy-related death and are twice as likely to
experience a pregnancy-related complication.15 As
Medicaid covers nearly half of all women of reproductive age who
have incomes below the federal poverty
level16—nearly one-third of all Black women of
reproductive age17 and more than one-quarter of all
Hispanic women of reproductive age18—providing
innovative solutions to individuals enrolled in Medicaid (and
investing in women’s health companies) has the potential to
significantly improve health equity and outcomes for women.
In short, Medicaid and their contracted health plans have
dollars to spend and an imperative to improve women’s
reproductive health care access and outcomes and will pay for
innovative delivery solutions that can achieve these aims.
Before You Enter: What to Know Before Approaching State
Medicaid Agencies or Their Medicaid Managed Care Plans
While there is tremendous opportunity to meet your business
goals while also doing good, entering the Medicaid market cannot be
done with a one-size-fits-all strategy—each state’s
Medicaid program, benefits and priorities differ. Each market
should be carefully considered and offered a value proposition that
addresses the unique needs of the individuals covered, the services
currently available and the local stakeholders (anchor provider
systems, Medicaid managed care plans, etc.). Mae, a pregnancy and
postpartum support solution tailored to the needs of Black women,
said it well in its recent article about entering the Medicaid
market: “Know your market. Regulatory variability and
reimbursement is nuanced and navigating various state programs can
be difficult. Strategically select markets and expand your reach
there, so you are well versed in the dynamics at that
level.”19
Entering a state can be slow and requires patience and
nimbleness. State Medicaid agencies and, if applicable, their
contracted Medicaid managed care plans are presented with potential
innovative new care delivery models or technology regularly.
Because state Medicaid agencies and health plans have limited time
to vet each proposal and no desire to use dollars on solutions that
will not work, it is important for any company to show how it will
improve outcomes while reducing costs, and to support those claims
with evidence. What works in one state market may not be the right
fit in another, and so the company may have to adjust its financial
proposals to align with the state’s or contractor’s
preferred method of contracting, e.g., fee for service, sub
capitation or value-based.
Footnotes
1. We use the term “women’s health” to
encompass needs of people who identify as women, people who are
assigned female at birth and people who have female reproductive
organs. We acknowledge that not all people assigned female at birth
identify as women and vice versa.
2. Guttmacher Institute, Why Protecting Medicaid Means
Protecting Sexual and Reproductive Health (March 9, 2017),
available at https://www.guttmacher.org/gpr/2017/03/why-protecting-medicaid-means-protecting-sexual-and-reproductive-health.
3. Guttmacher Institute, Publicly Supported Family
Planning Services in the United States (October 2019), available at
https://www.guttmacher.org/sites/default/files/factsheet/publicly-supported-fp-services-us.pdf.
4. Medicaid and CHIP Payment and Access Commission,
“Medicaid’s Role in Financing Maternity Care”
(January 2020), available at https://www.macpac.gov/wp-content/uploads/2020/01/Medicaid’s-Role-in-Financing-Maternity-Care.pdf.
5. Guttmacher Institute, Why Protecting Medicaid Means
Protecting Sexual and Reproductive Health (March 9, 2017),
available at https://www.guttmacher.org/gpr/2017/03/why-protecting-medicaid-means-protecting-sexual-and-reproductive-health.
6. Social Security Act § 1905(a)(4)(C).
7. K. Serafi, C. Mann, M. Carrera, M. Kress, N. Pauly and
A. Striar, “Implementing State-Level Policy and Operational
Processes That Enhance Access to Medicaid Family Planning Program
Services,” Manatt Health (June 2023), available at https://www.manatt.com/Manatt/media/Documents/Articles/Medicaid-Family-Planning-Program_Issue-Brief_2023-06_b.pdf.
8. Id.; see also “Enhancing Access to Medicaid
Family Planning Program Services: State-Level Best Practices”
(June 8, 2023), available at https://www.manatt.com/insights/newsletters/health-highlights/enhancing-access-to-medicaid-family-planning-progr.
9. Medicaid and CHIP Payment and Access Commission,
“Medicaid’s Role in Financing Maternity Care”
(January 2020), available at https://www.macpac.gov/wp-content/uploads/2020/01/Medicaid’s-Role-in-Financing-Maternity-Care.pdf.
10. Id.
11. Kaiser Family Foundation, Medicaid Postpartum
Coverage Extension Tracker (July 6, 2023), available at https://www.kff.org/medicaid/issue-brief/medicaid-postpartum-coverage-extension-tracker/.
12. Forbes, VCs Still See Opportunity in Medicaid Even as
Healthcare Investments Contract (March 28, 2023), available at https://www.forbes.com/sites/katiejennings/2023/03/28/vcs-still-see-opportunity-in-medicaid-even-as-healthcare-investments-contract/?sh=1887ac0a646f.
13. CMS National Health Expenditure Data Fact Sheet,
available at https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/nhe-fact-sheet.
14. 597 U.S. ___ (2022).
15. https://meetmae.com/aboutus.
16. Guttmacher Institute, Why Protecting Medicaid Means
Protecting Sexual and Reproductive Health (March 9, 2017),
available at https://www.guttmacher.org/gpr/2017/03/why-protecting-medicaid-means-protecting-sexual-and-reproductive-health.
17. Id.
18. Id.
The content of this article is intended to provide a general
guide to the subject matter. Specialist advice should be sought
about your specific circumstances.
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