Typical care for a pregnancy covered by Medicaid can include a number of services, depending on the state: recurring check-ups interspersed with nutritional guidance, parenting classes, and even postpartum mental health assessments. For many pregnant undocumented immigrants, their care is more like a door cracked ajar and then abruptly shut.
Federally Qualified Health Centers, which provide services on a sliding scale to underserved areas, as well as hospital charity care, offer limited care options.
But undocumented immigrants, as well as Lawful Permanent Residents who have resided in the U.S. for less than five years, are ineligible for Medicaid. Unable to access prenatal or postpartum services through the program, they can instead use Emergency Medicaid, which provides care for emergency medical conditions. When it comes to pregnancy, only hospital birth and delivery are covered.
Many states are in the midst of reconsidering pregnancy care through Medicaid, responding to federal encouragement to extend postpartum coverage to improve maternal health outcomes. While 37 states have elected to pass such legislation, only eight have done so for pregnant people irrespective of immigration status.
Yet this minority of states is collectively moving to decouple immigration status from pregnancy care provision, rendering citizenship an effectively redundant consideration when it comes to Medicaid eligibility for pregnant people.
A provision in the 2021 American Rescue Plan Act serves as the federal backdrop to the recent reappraisal of pregnancy care through Medicaid. It created a pathway for states to lengthen coverage to a year for postpartum people, which went into effect April 1, 2022.
The Biden administration recently reissued this charge in the “Blueprint for Addressing the Maternal Health Crisis.” As a part of the policy package—whose goal is to build “a future where the United States will be the best country in the world to have a baby”—states were again encouraged to extend their Medicaid coverage.
The call has been heeded. Legislation has now been passed in nearly all corners of the U.S. to extend Medicaid coverage to a year postpartum, with states such as Nevada, Idaho, Iowa, and South Dakota remaining outliers.
This marks a significant legislative shift—one that implies a mutuality between the demonstrated causes of maternal health disparities and policy aimed at mitigating the latter.
Prior to the recent wave of Medicaid coverage expansion, pregnancy-related care extended to two months postpartum. However, the broader timeline through which maternal health risks present conflicts with this two-month cut-off.
Maternal mortality does not exclusively refer to deaths during pregnancy or delivery. Instead, it also accounts for what has been called the “fourth trimester,” or the postpartum period that extends to up to a year after giving birth. According to a 2022 study by the Centers for Disease Control that examined 1,018 pregnancy-related deaths from 2017 to 2019, the majority of maternal deaths occur during this fourth trimester. Fifty-three percent of deaths occurred between days seven and 365 of the postpartum period.
The causes of maternal mortality vary across race, as does the burden. Among Latinx and white parents, mental health is the leading cause. For Black parents, it is cardiac and coronary conditions. Black women have significantly higher maternal mortality rates than white women and Latinas. Ultimately, the vast majority of these maternal deaths—80%—are preventable.
Given that 4 in 10 births are covered by Medicaid, expanding its coverage to a year postpartum will be consequential. However, the program’s legislative expansion largely excludes undocumented immigrants in many states.
There are “3.7 million unauthorized immigrant women who are of reproductive age living in the US, with approximately 7.5% giving birth annually.” That amounts to undocumented immigrants giving birth nearly 250,000 times each year. Inequitable health care and outcomes define many of these pregnancies.
A 2005 study published in BMC Public Health pulled birth certificate data of undocumented immigrants in Colorado and found that they were more likely to experience pregnancy complications, including excessive bleeding, fetal distress, and umbilical cord prolapse. They were also more likely to postpone prenatal visits during their pregnancy. In many states, undocumented immigrants do not have access to routine prenatal care—not to mention postpartum care.
A 2020 Health Equity study found that “being undocumented was associated with greater odds of” postpartum depression due to “poor patient-provider communication, inadequate prenatal care, or nonadherence to clinical recommendations.” Rayna Hetlage, director of strategic policy at Center for Health Progress, a membership-based organization that fights for health equity in Colorado, described an illustrative case to Prism: one of their members was diagnosed with postpartum depression but was simply unable “to do anything about it,” such as obtain medication, because of their undocumented immigration status.
These disparities can be attributed to the difficulty of obtaining private insurance through an employer because of the types of jobs members of this community are likely to have, as well as distrust toward accessing programs and services due to anxiety around immigration status. For the latter, “living under the perceived threat of detention and deportation” contributes to a culture of fear around status exposure, which can even occur in hospital settings through medical deportations. However, “structural policy barriers erected by the federal government” are chief among these barriers.
Some states have begun to chip away at government barriers, often with immigrant-led grassroots organizing leading the charge.
In Maryland, there are many undocumented residents “who went to the doctor for the very first time on the day of their delivery,” Cathryn Paul, public policy director at CASA, a membership-based organization, told Prism. And because mothers are not receiving regular preventative care, their health is not addressed until an emergency.
But on July 1, 2022, the Healthy Babies Equity Act went into effect in Maryland, providing Medicaid coverage to pregnant and undocumented people in the state. Unlike coverage being passed in states for the general population, it will likely not be available for a full year in Maryland. “As of February 2023, Maryland Medicaid anticipates that they will only have enough funding to cover mothers for four to five months after giving birth,” state Del. Joseline Peña-Melnyk, who sponsored the bill, told Prism. She hopes that this could change in the future as data collection shows the impact of the program.
Local immigrant women, many of whom are mothers, spearheaded the campaign for the bill’s passage in Maryland. They were “the heart of the bill” and “the only reason why this bill moved, period,” Paul told Prism. Community members organized press conferences, rallies, town halls, district lobby meetings, and social media campaigns, and groups of immigrant families visited the Statehouse a few times a week. Especially in Maryland, which has a part-time legislature and therefore experiences an overcrowding of bills when in session, this community-led advocacy work was crucial to the bill’s success.
“Health care is a human right. Everyone deserves access to health care, regardless of their immigration status,” Peña-Melnyk explained to Prism. “The health of a community depends on all its people being safe and healthy.”
In 2022, Connecticut began providing prenatal care to pregnant undocumented immigrants. Recently, the state went further. On April 1 of this year, “state medical postpartum coverage” went into effect in Connecticut, providing 12 months of care for people who meet income eligibility requirements but are unable to access Medicaid because of their immigration status.
Husky 4 Immigrants, a coalition that has broadly been advocating for health care expansion in Connecticut, pushed to secure coverage for pregnant undocumented immigrants through its broad-based organizational make-up. Carolina Bortolleto, a leader of Husky 4 Immigrants, told Prism that the coalition is made up of immigrant rights organizers from health care, community, faith-based, and union sectors. Bortolleto said that she hopes Connecticut could serve as a model for other states.
Colorado has enacted legislation, which will go into effect in 2025, that provides full health insurance coverage for people who would otherwise be eligible for Medicaid and Children’s Health Insurance Program (CHIP) “if not for their immigration status.” Such coverage will continue for one year postpartum and includes prenatal care. The policy was shaped by an 11-member steering committee of people who had been impacted by the issue from across the state.
These legislative efforts correspond to a body of research demonstrating the promise of positive outcomes among pregnant and undocumented immigrants who are given access to care.
A 2021 JAMA Network Open study found that the inclusion of postpartum care through Emergency Medicaid was “associated with increased attendance at postpartum visits and increased use of all forms of effective contraception.” The latter is one of the “most effective strategies we have for maternal health and infant health,” said Dr. Maria Isabel Rodriguez, professor of obstetrics and gynecology at Oregon Health and Science University and a co-author of the study. Contraceptive care reduces rapid repeat pregnancies, which contribute to adverse maternal and neonatal health outcomes.
A 2022 National Bureau of Economic Research working paper compared data from births among immigrants in California before and after the introduction of the 1988 legislation that made pregnancy care through Medi-Cal accessible to undocumented immigrants. The legislation was considered a “landmark” policy that inspired states such as Connecticut to follow suit, and the 2022 research found it led to an increase in average gestation length and birth weight for newborns born to undocumented women.
“Allowing people who are low income to enroll in Medicaid regardless of citizenship status would be the right thing to do—both from a health and human rights perspective, but also from a program perspective,” Rodriguez told Prism. “Restricting access to preventative care is foolish: it ends up in worse health outcomes and usually costs losses for the program.”
Yet, the extension of postpartum coverage “is only as good as the foundation of coverage in each state,” Maggie Clark wrote for Georgetown University’s Health Policy Institute Center for Children and Families. As Lily Levine wrote for Prism, as many as 15 million people may lose their Medicaid coverage as a part of a “nationwide unwinding process” of the continuous enrollment legislation introduced during COVID-19. Given the bureaucratic and psychosocial barriers undocumented immigrants experience concerning the state, formal and sustained enrollment could be a challenge.
And to have maximal impact, legislation should echo what is being passed across the country for the general Medicaid-eligible population and ensure 12 months of postpartum care for undocumented immigrants.
The dire state of maternal mortality in the U.S. has been a stable refrain for at least the past decade. Regardless of the high-income country selected to serve as the point of comparison—be it Sweden, Australia, the Netherlands, or Japan—the U.S. pales vis-a-vis its peers. Beneath this oft-cited corporate statistic is a layered set of maternal health inequities stratified by race, class, and citizenship status.
Some states, such as Maryland, Connecticut, and Colorado, have initiated a process of disentangling the right to pregnancy care from immigration status, creating the opportunity for a more equitable landscape of maternal health and inching toward the possibility of universal health care.
Peña-Melnyk remembered a time about a couple of years ago when she got a call to her office from one of her constituents regarding a young undocumented pregnant woman, for whom she was seeking help. “Her life and her baby’s life were in danger,” Peña-Melnyk told Prism. It became clear that “our state’s health care system was clearly failing her.”
Next time, when a call comes through, there can be a different response.
