Advancing Women’s Reproductive Health Access: Medicaid Should Be a Part of Your Growth Strategy | Manatt, Phelps & Phillips, LLP

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 age^{1, 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.

_{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.}

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_{¹⁹ https://www.linkedin.com/pulse/medicaid-mae-what-we-have-learned-so-far-meetmae%3FtrackingId=9LnE8TDcSSiXLG4QGGCVzg%253D%253D/?trackingId=9LnE8TDcSSiXLG4QGGCVzg%3D%3D.}