The Sixty-First Day: An Advocacy Brief for Twelve Months of Postpartum Medicaid Coverage in Kestrel
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Health Care Administration Program, Aspen University
HCA 320: Healthcare Policy and Economics
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The Sixty-First Day: An Advocacy Brief for Twelve Months of Postpartum Medicaid Coverage in Kestrel
This brief is addressed to members of the Kestrel Legislature's health committees. Kestrel, the composite state examined earlier in this course, has not expanded Medicaid, and a parent qualifies for its program only with income under about a quarter of the poverty line. Women covered by pregnancy Medicaid therefore lose coverage 60 days after giving birth unless their income is extremely low. This brief asks the Legislature to adopt the federal option to extend postpartum Medicaid coverage to 12 months, explains why the first year after birth matters, estimates the cost, and responds to the main objections.
The Request
Adopt the state plan option, made permanent by Congress in 2022 legislation, to provide full Medicaid coverage for 12 months after pregnancy ends, and fund the state share in the next budget. The change requires a state plan amendment and an appropriation; it does not require expanding Medicaid to other adults.
Why the Year After Birth Matters
Maternal deaths do not end at delivery. Reviewing 1,018 pregnancy-related deaths in 36 states from 2017 to 2019, maternal mortality review committees found that 53 percent happened after the first postpartum week but within the first year, and they judged 84 percent of all pregnancy-related deaths to be preventable (Centers for Disease Control and Prevention [CDC], 2022). The leading causes differed by group, with cardiac and coronary conditions leading among Black women and mental health conditions, a category that covers deaths from overdose and suicide, leading among Hispanic and White women. Many of these conditions, such as postpartum cardiomyopathy, high blood pressure, and depression, need treatment for months after birth, exactly the period when Kestrel mothers lose coverage.
A woman who develops heart failure in the fourth postpartum month is, under current Kestrel rules, uninsured when she needs care most.
Who Loses Coverage
Coverage loss after birth is common nationally. Using national survey data from 2005 to 2013, Daw et al. (2017) found that 55 percent of women with Medicaid or CHIP coverage at delivery experienced a coverage gap within six months, and that risk was higher for women who did not speak English at home, were unmarried, lived in the South, or had incomes between 100 and 185 percent of poverty. In Kestrel, the problem is sharper. Women with incomes between 26 and 100 percent of poverty earn too much for parent Medicaid and too little for marketplace subsidies, the same coverage gap described in the Module 4 analysis, so for them the 61st day after birth means no affordable coverage at all.
Evidence That Coverage Helps
Direct evidence on 12-month extensions is still emerging, but related evidence points in the same direction. Comparing states that did and did not expand Medicaid under the Affordable Care Act, Eliason (2020) found that expansion was associated with 7.01 fewer maternal deaths per 100,000 live births, with effects concentrated among non-Hispanic Black mothers, and a larger effect when late maternal deaths, those up to a year after birth, were included. The study was observational and cannot prove that coverage alone caused the difference, but it is consistent with the view that continuous coverage after birth saves lives and narrows racial disparities.
What It Would Cost
Kestrel Medicaid covers about 24,000 births a year. The state's Medicaid office estimates that about 45 percent of these mothers, or 10,800, lose coverage at 60 days. If 80 percent remain enrolled for the additional ten months at an average cost of $350 per member per month, the total annual cost is about $30.2 million. Because the federal government matches postpartum coverage at Kestrel's regular matching rate of about 66 percent, the state share would be about $10.3 million a year, roughly $1,190 per woman kept covered. Some of that cost would be offset by reduced uncompensated care at Kestrel hospitals and by fewer emergency admissions for untreated postpartum conditions, though the brief does not count those offsets.
Answering the Objections
Some legislators will say the budget has no room for another entitlement. The state share is small relative to the Medicaid budget, and it purchases coverage during a period in which most pregnancy-related deaths occur. Others may worry that the extension is a step toward full Medicaid expansion. It is not: the option applies only to women after pregnancy and does not change eligibility for other adults. A third objection is that women can buy marketplace coverage. In Kestrel, those below 100 percent of poverty cannot receive subsidies, so for the poorest mothers there is no affordable alternative.
Who Supports It
Obstetric and pediatric clinicians, hospitals that bear uncompensated care costs, and maternal health advocates have supported postpartum extensions across the country, and the option has been adopted by most states with both Democratic and Republican leadership. In Kestrel, a coalition of the state hospital association, the state chapters of obstetrician and nurse-midwife organizations, and community groups working on Black maternal health could present a united case to the committees. Healthcare administrators can contribute data on postpartum readmissions and uncompensated care at their facilities.
How Success Would Be Measured
If the Legislature adopts the extension, it should also ask how it will know whether the policy works. The Kestrel Medicaid office could report each year the number of women who keep coverage through the full 12 months, the share who attend a postpartum visit, and the share with a claim for blood pressure or depression treatment between months three and twelve. The state's maternal mortality review committee already reviews every pregnancy-related death; its reports should note whether each woman who died after the 60th day was insured at the time. Hospitals could track postpartum readmissions and uncompensated care for women in the first year after birth. These measures would let legislators see within two or three years whether the extension is reaching the women it was meant for, and they would give advocates evidence for or against continuing it.
Conclusion
More than half of pregnancy-related deaths happen between a week and a year after birth, and most are preventable, yet Kestrel ends coverage for many mothers on the 61st day. Extending postpartum Medicaid to 12 months would cost the state about $10.3 million a year, would not expand Medicaid to other adults, and would give the poorest mothers, and the Black mothers most at risk, continuous care through the most dangerous months. The Legislature should adopt the option in the coming session.
References
Centers for Disease Control and Prevention. (2022). Pregnancy-related deaths: Data from maternal mortality review committees in 36 US states, 2017-2019. https://www.cdc.gov/maternal-mortality/php/data-research/mmrc-2017-2019.html
Daw, J. R., Hatfield, L. A., Swartz, K., & Sommers, B. D. (2017). Women in the United States experience high rates of coverage 'churn' in months before and after childbirth. Health Affairs, 36(4), 598-606. https://doi.org/10.1377/hlthaff.2016.1241
Eliason, E. L. (2020). Adoption of Medicaid expansion is associated with lower maternal mortality. Women's Health Issues, 30(3), 147-152. https://doi.org/10.1016/j.whi.2020.01.005
How this HCA 320 Module 5 example is structured
Aspen's catalog describes HCA 320 as encouraging advocacy for vulnerable populations and participation in the political process. Aspen does not publish module deliverables, so check your classroom for the exact prompt. This example addresses a named audience, states the request, builds the case from data, estimates cost, answers objections and identifies a coalition.
HCA 320 Module 5 questions, answered
What does HCA 320 Module 5 usually ask for?
Work in this part of HCA 320 often asks you to advocate for a policy change affecting a vulnerable population, with evidence, stakeholders and a clear request. Aspen does not publish module deliverables, so your classroom's instructions govern.
When do most pregnancy-related deaths occur?
In CDC review committee data from 36 states for 2017 to 2019, 53 percent occurred between 7 days and one year after the end of pregnancy, and 84 percent of pregnancy-related deaths were judged preventable.
What should a policy advocacy brief include?
The audience, a specific request, the evidence for the problem, the cost, answers to the main objections and the coalition that supports the change.
Write yours, or have the desk draft it
This paper is an original model document written by our desk, not a submitted student paper and not an official Aspen University document. Read it for the moves, then write your own to the instructions in your classroom. If you want one built to your exact prompt and rubric, the first custom sample is free and arrives in 24 to 48 hours.