Despite improvements following the implementation of the Affordable Care Act (ACA), the state of Mississippi has among the high rates of uninsured along with some of the poorest maternal and infant health outcomes in the country. Under the ACA, pregnant women with incomes of 138% of the Federal Poverty Level are eligible for Medicaid coverage of basic prenatal and postpartum services. Regardless of coverage, access to skilled health care professionals, especially among rural counties, is severely limited resulting in poorer care.
Mississippi has some of the nation’s worst health indicators. Due to health disparities in the state, rural counties that are primarily comprised of African Americans face some of the largest barriers to accessing care. Higher rates of uninsured, poverty, lack of transportation, and a limited number of skilled providers have led to the highest infant mortality rate in the country. Skilled obstetricians and primary care physicians opt to work in urban areas, leaving women in small towns and rural areas with fewer options. Limited access to preventive care and health education are the main reasons for maternal chronic conditions associated with high infant mortality. Under the ACA Medicaid provides temporary coverage or may limit coverage during pregnancy, potentially interrupting care for women with chronic health issues. This is further exacerbated by the fact that many women who might benefit from Medicaid coverage of perinatal services are unaware of their eligibility.
- Option 1: Increase access to expertise and perinatal care via the use of telemedicine in rural counties in Mississippi. This would mean establishing a stronger network and telecommunication system between physicians in rural and community health facilities and the academic health center in Jackson. Telemedicine provision is funded by the state’s Medicaid program and would dramatically improve access and quality of care for underserved rural populations.
- Option 2: Approve Medicaid expansion under the ACA to increase coverage for eligible low-income women in the state. Although increasing insurance coverage may have a wider reach, it would meet with the most political resistance and does not fully address the issue of limited access to skilled health care professionals in rural counties.
Greater cost-effectiveness, political feasibility, and administrative ease provide stronger evidence in support of the first option. While increasing insurance coverage for low-income women with state Medicaid expansion may have the potential to reach more women, improving access to skilled perinatal care in underserved counties will have a greater immediate impact and serve to provide more equitable and quality care.
To: Senator Derrick Simmons, Mississippi District 12
From: Karen Politis Virk, George Washington University, Milken School of Public Health
Subject: Infant Mortality: Rural and Racial Health Disparities in Mississippi
Date: April 29, 2019
Medicaid eligibility under the Affordable Care Act (ACA) includes individuals with incomes at or below 138% of the Federal Poverty Level (FPL) (United States Health & Human Services, 2019). Several years since the proposal to nationalize state expansion, and the opposing 2012 Supreme Court ruling, Mississippi remains one of 14 states with no expanded Medicaid coverage (Kaiser, 2019).
Currently, under the ACA, Mississippi Medicaid is required to cover basic prenatal care and up to 60 days of postpartum care for eligible pregnant women. However, for some coverage is temporary and limited to pregnancy-related health services. Temporary coverage disrupts both continuities of care and the management of chronic maternal health conditions associated with higher rates of infant mortality. Additionally, women enrolled in qualified health plans (QHP) and new mothers may receive less coverage than if they were not pregnant. (MACPAC, 2014).
Mississippi has the highest number of infant deaths in the United States (CDC, 2018). Although the underlying issues are complex and multisectoral, many infant deaths are preventable. Large health disparities persist and primarily impact African Americans who comprise 38% of the population (US Census, 2017). Underserved, rural populations are especially vulnerable due to higher rates of uninsured and poverty, and poor access to care. Despite public funding dedicated to the issue, additional programs are required to address the root causes of high infant mortality in the state.
Mississippi’s Infant Mortality Rate (IMR) is the highest in the country, reported in 2017 at 8.72 deaths per 1,000 live births compared to the national average of 5.9 deaths per 1,000 live births (CDC, 2018). Mississippi’s obesity rate is 38% among women of reproductive age which puts their infants at a higher risk of being born either prematurely or with LBW. Maternal obesity has been strongly linked to these two predisposing factors to infant mortality (McDonald et al., 2010). the most common risk factor associated with infant mortality in Mississippi is preterm birth (State Department of Health, 2017). African American women in Mississippi have an increased incidence of chronic conditions due to higher rates of obesity and have more preterm deliveries and LBW babies (The March of Dimes, 2016). As a result, African Americans in Mississippi have significantly higher rates of infant mortality, despite progress in the rest of population (State Department of Health, 2017).
Mississippi’s poor infant health outcomes are deeply rooted in systemic inequities (Brown, 1988; Almond, 2007). African Americans have higher poverty rates as compared to whites (32.3% vs.13.2%), and there is 23.1% poverty in rural counties compared to 15.9% in urban counties (Center for American Progress, 2017; Rural Health Information Hub, 2019). Fourteen percent of nonelderly (0-64) are uninsured, higher than any other state in the region (Kaiser, 2017). Mississippi is also among the non-expansion states with the highest number of uninsured individuals living in non-metropolitan areas. (Hoadley et al., 2018).
Inadequate prenatal care is a large risk factor for preterm birth and LBW as well as infant mortality (Cox et al, 2011). For rural Mississippians, the barriers are significantly greater due to low patient-to-provider ratios and lack of transportation (Warshaw, 2017; Hoadley et al., 2017; Fine Maron, 2017). Most skilled providers opt to work in metropolitan health facilities, leaving women in rural areas with fewer options and having to travel large distances to reach better care. Half of the state’s population lives in rural counties, mostly composed of African Americans, with the largest concentration residing in the Mississippi Delta region (US Census Bureau, 2017). A comparison of infant outcomes in this region with that of other counties in the state demonstrates the vast health disparities (Partners Healthy Start Initiative, 2012).
For those who meet the eligibility criteria for pregnant women, Mississippi Medicaid covers basic maternity care, including prenatal visits, vitamins, ultrasound, amniocentesis, childbirth delivery, and 60 days of postpartum care (Medicaid, 2019). Under the ACA, however, issues with temporary Medicaid coverage during pregnancy as well as coverage limited to pregnancy-related services pose greater challenges. Disrupted coverage may result in less care of chronic health conditions (Johnson 2012), and new mothers or women with a QHP may receive less benefits when they are pregnant (Kaiser, 2019). In Mississippi, Medicaid also offers a perinatal high-risk management program (Medicaid, 2019). But women are eligible only if a health care professional refers them to the program. As a result, women in underserved areas are less likely to be enrolled. Poor information access is another barrier for many who may not know they are eligible for Medicaid coverage during their pregnancy and cannot otherwise afford care.
- Option 1: To increase access to quality perinatal care for rural populations using telecommunications technology. Arkansas established a collaboration between the state’s Medicaid program, the main academic health center, and physicians to deliver perinatal services to underserved populations. By increasing access to expertise, education, and support via telecommunication, primary obstetric care showed marked improvement (Lowery et al. 2007; 2014). The program, which utilizes telemedicine and clinic networks to facilitate access to consultation services, also provides continuing education for rural practitioners. This allows physicians in academic centers to offer expertise to providers in rural facilities and helps to provide more equitable care for women throughout their pregnancy.
Telemedicine in the context of maternal health is gaining recent political support due to its cost-effectiveness. A similar system to Arkansas’s can be replicated in Mississippi via a collaboration between the University of Mississippi Medical Center in Jackson, the state Medicaid program, and physicians throughout the state. A past study at the University of Mississippi provides further evidence that high-risk pregnancies can yield improved outcomes using telemedicine (Morrison, 2001). Current investment in perinatal care can be enhanced with the use of telemedicine, expanding access for rural underserved counties such as the Mississippi Delta region. Moreover, Mississippi Medicaid currently covers telemedicine for services that are the same as services provided by a physician in person (Ulmers, 2018). This would facilitate implementation of such a system into the existing framework.
- Option 2: To expand Mississippi’s Medicaid coverage under the ACA to increase coverage among eligible uninsured women. Kentucky adopted federal Medicaid expansion in the early stages, effectively reducing the uninsured rate among low-income adults from 43% in 2008 to 13% in 2015 (Hoadley, et al. 2018). In 2016, Louisiana was the first southern state to accept expanded Medicaid coverage. Medicaid expansion, in conjunction with non-expansion Medicaid, expected to cover 37% of the state’s population with current enrolment rates, reported a 50% reduction in uninsured rates between 2013 and 2017 (Norris, 2018). Rural areas and small towns have particularly benefited from expansion, as they typically have a larger percentage of uninsured (Cole, et al., 2018).
Medicaid expansion in Mississippi would improve coverage among low-income women. About half of Mississippi’s uninsured are working in service industries and cannot afford to pay for their own insurance (Families USA, 2015). Approximately 167,000 uninsured adults with incomes between 100 and 138% of the FPL would be eligible for ACA Marketplace coverage (Kaiser, 2019). Additionally, an estimated 35% of low-income adults in rural areas would potentially benefit from expanded public coverage (Hoadley et al., 2018).
Poor maternal and infant health currently places a larger financial burden on the health system than that of increased investment in public funding or access to better care. Although the second option may have wider reach, under the current administration it will be met with greater political resistance. The state’s political landscape regarding Medicaid expansion remains unfavorable, similar to the situation in 2013 when you proposed state expansion legislature without success. Delays in obtaining approval for this legislature may also have negative consequences. More importantly, expanded Medicaid coverage does not address the issue of access to skilled providers or improve quality of care in rural communities. Two years after expansion in Louisiana infant mortality was reported at 7.8 deaths per 1,000 live births, indicating that coverage is not the only factor affecting outcomes (CDC, 2017). Expanded public funding can help reduce long-term costs associated with chronic disease by increasing the number of insured in the state. However, pregnancy-related Medicaid coverage of services alone cannot improve access to medical expertise and quality of care for underserved populations.
The first option is therefore the best and the path of least resistance. The Arkansas model is cost-effective, politically feasible, and can be accomplished with administrative ease by enhancing existing mechanisms. Telemedicine is highly utilized in many rural communities with limited access to health services. Strengthening the existing network of providers between the academic healthcare center and community and rural health facilities can significantly improve health equity and provide better quality of care. The Maximizing Outcomes for Moms through Medicaid Improvement and Enhancement of Services (MOMMIES) Act provides political support of Medicaid coverage using telemedicine to provide services for pregnant women (Wicklund, 2018). This may facilitate passing this initiative in Mississippi. Additionally, since most telemedicine services are covered under Medicaid, this can be incorporated into the existing framework of Mississippi Medicaid services for pregnant women. Dissemination of information promoting greater awareness of public funds available for low-income women during pregnancy is required for the success of this program in an effort to reach all eligible women in the state’s rural areas and small towns.
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