Arkansas ranks worst in the nation for maternal mortality. What's the plan?

On March 6, Gov. Sarah Sanders gathered state officials, health care advocates and a gaggle of babies at the Capitol to announce a plan to address Arkansas’s dismal maternal health statistics. The state ranks last in the nation in maternal mortality, with almost 44 deaths per 100,000 births; the national figure is 23.5.

The gaps go beyond that, the governor said: “Of the 35,000 pregnancies in Arkansas each year, 10,000 women wait until they’re after their first trimester to see a doctor. Eleven hundred women never see a doctor until they are in labor.”

She then signed an executive order creating a new “Strategic Committee for Maternal Health,” made up of the heads of the Arkansas Department of Human Services, the Department of Health and other agencies. Their tasks include creating a strategic plan over the next six months, exploring “changes to the Medicaid program” and taking “immediate steps to enroll pregnant and postpartum women in Arkansas with available health coverage options, streamline coverage transition processes, and eliminate gaps in care.”

The order is as ambitious as it is vague. Sanders didn’t give many details about what’s being considered, but one thing looks to be off the table: Extending pregnancy Medicaid coverage. Arkansas is one of only four states that hasn’t taken the federal government up on a new option to allow eligible new mothers to stay on Medicaid for a full year, rather than just 60 days, despite recommendations from a state committee on maternal mortality to do just that.

Sanders faced blowback in recent weeks for refusing the 12-month Medicaid extension option while talking a big game about supporting mothers and families. She says the critics have it all wrong: The problem in Arkansas isn’t a lack of coverage, but poor education about existing options. 

Extending postpartum Medicaid would “create a redundant program” that would “make for a good headline” without solving the underlying issues, the governor said at her press conference. “Arkansas already has resources for pregnant women through all nine months of pregnancy and beyond.”

State Rep. Aaron Pilkington (center) supports the 12-month Medicaid extension.

Does she have a point? Actually, yes. Unlike states such as Texas or Tennessee, Arkansas expanded Medicaid under the Affordable Care Act a decade ago, allowing hundreds of thousands of low-income people to get insured. The majority of women who qualify for pregnancy Medicaid likely will qualify for ARHOME, the state’s Medicaid expansion program, after they give birth. 

But that’s not the whole story. Arkansas has also made it harder for people — new mothers included — to get and keep Medicaid coverage than it needs to be, as shown by the state’s mad rush last year to purge the Medicaid rolls of ineligible people as quickly as possible. Many were kicked off simply for not returning a form to DHS quickly enough.

And while the state could automatically enroll eligible new moms in ARHOME or another program, it doesn’t appear to be doing so in many cases. That means a woman who’s just given birth needs to be shopping for new insurance and filling out paperwork while juggling a 6-week infant. 

Keesa Smith, the executive director of Arkansas Advocates for Children and Families, said the group recognizes there are other coverage options but still thinks the 12-month Medicaid extension makes sense for Arkansas.

“Many women are dropping off the rolls as they transition from pregnancy Medicaid to other forms of Medicaid,” said Smith, who served as a deputy director at DHS until last year. “So why not make that process easier?”

A patchwork of coverage

A joint venture between states and the federal government, Medicaid provides safety net health insurance for various groups or “categories,” including disabled people, the elderly, children and pregnant women. It might be better thought of as a collection of programs rather than one single thing. Each Medicaid category has different eligibility requirements based on income and other factors, and states have leeway to set those eligibility rules. 

The federal government requires states to offer Medicaid coverage to pregnant women below a certain income threshold throughout the course of pregnancy and for roughly 60 days afterwards. In Arkansas, the cutoff is 214% of the federal poverty line, which is about $32,228 for a one-person household or $43,742 for a family of two. (Medicaid pays for more than half of all births in the state, Sanders noted on March 6 — more than 19,000 each year.)

The biggest change to Medicaid in recent decades came with the passage of the Affordable Care Act in 2010. The ACA gave states new federal funding to offer coverage for a new catchall category of low-income, working-age, able-bodied adults, though many red-leaning states were skeptical of creating a broad new benefit program and refused to do so. Fourteen years later, 10 states — mostly in the South — still haven’t expanded Medicaid, meaning millions of their poorest residents have no decent insurance options. 

These “non-expansion” states are the ones who stand to benefit most from the new 12-month pregnancy Medicaid extension, which was created temporarily by a Covid relief bill signed by President Biden in 2021 and later made permanent. According to a tracker from the health policy nonprofit KFF, 45 states have implemented the 12-month extension as of February. 

Usha Ranji, associate director of women’s health policy at KFF, said the field of maternal health has come to recognize postpartum health goes well beyond two months post-birth. “One year [of coverage] brings the policy standpoint more in line with what’s going on with clinical care,” she said.

The 12-month extension has been a huge boon for low-income moms in non-expansion states like Texas or Florida, who previously had no Medicaid option at all after the 60-day postpartum period ended. Now, they’ll have another 10 months of coverage.

Arkansas, though, is a Medicaid expansion state. It expanded coverage in 2013 under then-Gov. Mike Beebe, a Democrat, giving insurance to hundreds of thousands of poor Arkansans. The expansion program has gone by many names in the decade since — the private option, Arkansas Works and now ARHOME — but it remains in place today, despite some conservative legislators’ best efforts to undo it over the years.

This is part of what Sanders means when she says Arkansas women already have coverage options. To qualify for ARHOME, a person must make under 138% of the federal poverty line, which is $20,783 for a family of one or $28,207 for a family of two. A single woman who makes $20,000 annually could get ARHOME after her 60-day pregnancy Medicaid window expires — but so could a single woman who makes $25,000, since the addition of the new baby would enlarge her household size.

Not everyone is in that group, however. An expectant mother who makes $30,000 a year might qualify for pregnancy Medicaid but not ARHOME. What are her options after 60 days?

Some women may pick up coverage through an employer or a spouse, though that option clearly isn’t available to everyone. The Sanders administration points to the federal health insurance marketplace as an alternative for the rest. That may seem odd, considering Republicans tried for years to repeal the Affordable Care Act, aka Obamacare (which created the marketplace), but the fact is that it really is a decent option for many families on the lower end of the income scale.

Individual health insurance is expensive, but the federal government subsidizes people’s coverage on a sliding scale based on income. For those who make just a bit too much to qualify for ARHOME, the out-of-pocket costs can be quite modest. A new mother in a two-person household in Arkansas who makes $30,000 annually could buy private insurance for just $2 a month, according to a KFF calculator. If she made $35,000 annually, it would be around $32 monthly.

Paper vs. real life

All of that, though, is on paper. In the real world, a $32 premium can be unaffordable to a struggling family. And the hassle and time and frustration involved in shopping for coverage, understanding available options, and navigating DHS’ maze of paperwork can discourage anyone, especially a person dealing with the stress of a new baby.

State Rep. Aaron Pilkington (R-Knoxville) unsuccessfully sponsored a bill last year that would have signed Arkansas up for the 12-month postpartum extension option. After the March 6 press conference, he said he still thinks that’s the right thing to do. 

“Take a woman who’s just had a C-section, and she’s trying to navigate recovery,” Pilkington said. “And then we have a 40-something page document from the Department of Human Services trying to get her enrolled [in ARHOME] only to find out she’s not eligible?”

Smith, the Arkansas Advocates director, said she’s happy the state is giving fresh attention to maternal health but still favors the 12-month extension. 

“That’s going to continue to be what we advocate for until the state shows us there’s a better plan to keep women covered,” she said.

The committee created by the governor March 6 is supposed to develop that plan over the next six months. Its list of directives include creating a new health education and advertising campaign, expanding telehealth and home visits for new moms, and launching a pilot program in five counties with particularly low rates of prenatal care, among others.

Among the biggest unknowns: If a woman who’s covered under pregnancy Medicaid reaches the end of her 60-day postpartum coverage and she’s eligible for coverage under ARHOME (or another Medicaid category), will DHS automatically enroll her? Or will she have to fill out a new application, gather documents and jump through hoops to maintain coverage?

DHS spokesman Gavin Lesnick said the agency “attempts to move the beneficiary to ARHOME automatically” in such cases but will send a renewal packet if auto-enrollment isn’t possible. 

“If DHS receives information through data-matching such as a change in income, household composition, or state of residence, or information that the mother is failing to cooperate with child support,” that could require filling out new paperwork, Lesnick said. (It’s worth noting that almost every birth creates “a change in household composition” by definition.) The committee created by Sanders on March 6 will be examining whether “there are ways to optimize this process so it is even more seamless,” he said.

That may sound reasonable enough, but DHS has a history of kicking people off Medicaid over paperwork issues. Just last year, it ended coverage for hundreds of thousands of people, including some 78,500 children on the ARKids programs, as part of a post-pandemic effort to clear the rolls of ineligible people. Critics say the state swept plenty of eligible people out the door as well.

Thanks to Medicaid expansion, more Arkansans have access to insurance than residents of many Southern states. But that also shows there’s merit to the argument that focusing too much on coverage can miss the point: Even states where fewer people have health insurance are doing better than Arkansas on maternal mortality.

Smith said she’s encouraged by the five-county pilot program and its recognition that there are parts of the state with critical shortages of doctors and other medical providers. “Half of our state doesn’t have labor and delivery units,” she said. 

“I do agree with the governor that insurance coverage doesn’t equal access, so I believe coverage is just the beginning of the conversation,” Smith said. “But what are the actual next steps?”