AcademyHealth hosted an exclusive briefing for organizational members with the Medicaid Medical Directors Network (MMDN) on the clinical landscape for patients and providers following the Supreme Court’s ruling on Dobbs v. Jackson Women’s Health Organization that overturned Roe v. Wade.
The MMDN is a dynamic learning network comprised of senior clinical leaders that centers on advancing and using evidence-based medicine, improving and measuring healthcare quality, and redesigning healthcare delivery within Medicaid and is hosted by AcademyHealth. Mohammad Dar, M.D., Senior Medical Director for MassHealth, and Charissa Fotinos, M.D., M.Sc., Medicaid Director for the Washington State Health Care Authority, shared insights into the immediate and long-term impacts of the U.S. Supreme Court’s Dobbs decision for Medicaid patients and providers. Medicaid is the leading payer for pregnancies as it finances nearly 45 percent of them in this country, providing care to a chronically underserved population that is highly vulnerable to inequities and adverse health outcomes. The panelists also discussed the differential effects across states, including how Washington and Massachusetts state Medicaid programs have responded to the ruling. Sarah H. Gordon, Ph.D., M.S., moderated the briefing.
The current landscape, potential challenges, and increased state-level variations in health care outcomes and options
Under the Hyde Amendment, the federal government limits Medicaid funds for abortion to cover services in specific instances, such as if the person is a victim of incest, rape, or if pregnancy continuation risks the mother’s life. While the amendment confines Medicaid coverage of abortions in most states, 16 states use state-only dollars to fund abortions under Medicaid in other circumstances beyond Hyde restraints. The short-term and long-term effects will vary considerably across all states, including non-restrictive states. States that have not outlawed abortion could face increased demands for access to available services. Additional issues that state Medicaid programs should be alert to are privacy protections for patients and providers, legal protections for providers, licensing protections, and how the Hyde restrictions impact primary funding of community-based organizations that provide primary and preventative care to Medicaid patients, such as Federally Qualified Health Centers (FQHCs). These safety net providers receive funding from the Health Resources and Services Administration (HRSA), which binds them to federal abortion laws. Dr. Fotinos noted that some states, like Washington, are better positioned to address changes in the abortion care landscape due to:
- Existing payment structures that cover a range of abortion services beyond those allowed in the Hyde amendment with state-only dollars,
- The removal of prior authorization requirements to reduce barriers to abortion services and simplify the process of accessing care, and
- Pay parity for in-person, audio-only, or video-only services.
Medicaid programs in states that have restricted or banned abortion services can, even under current law, support perinatal health and improve maternal morbidity and mortality through a multipronged approach, such as by extending Medicaid postpartum coverage up to twelve months after delivery, expanding telemedicine parity payment for pregnancy-based care, and coverage of doula services. Additional opportunities mentioned by the panelists include coverage of home visitation, contraception methods without prior authorization, teen pregnancy community supports, improving care delivery through medical homes, mental health service integration, and providing same-day LARC services. Dr. Dar emphasized, "if there is one thing we have seen across the perinatal landscape, morbidity and mortality do not come from one single source alone, so all sorts of interventions are needed.”
Tracking data and information to assess the immediate and long-term effects of Dobbs
Data from Medicaid billing codes and hospital admission records could reveal trends in abortion services delivery, and utilization within and across states as pregnant people travel for care. However, the fidelity of claims data due to data lags and silos in the U.S. healthcare system are barriers that could impede these efforts. A critical task for stakeholders like providers, payers, policymakers, and other decision-makers in determining how to document, record, and report the consequences of Dobbs for pregnant people who face increased risk, such as those who will have to carry unwanted pregnancies to term. From the Medicaid perspective, tracking the volume of individuals seeking care from other states could help determine if states that have not banned or further restricted access to abortion services can maintain their internal capacity through the current networks of services. This information could reveal pressure points of access for in-state residents. A potential challenge is how to capture these data and information while ensuring provider privacy protections and patient confidentiality. The capability to share Medicaid data across states could pose risks if this information gets into the wrong hands or if pregnant people who travel for care face legal ramifications after accessing abortion services.
Health equity and the implications of the Dobbs decision
The Dobbs decision will likely worsen health disparities. Medicaid is the leading payer for maternity care and birth deliveries in the United States. The program has a pivotal role in covering health care services for populations often underserved, are limited in choice, and face various structural vulnerabilities, disparities, inequities, and adverse health outcomes. These groups include black and brown communities, persons experiencing homelessness, and poor people. The inequities that mirror a person being on Medicaid are often the same inequities that reflect trends in maternal morbidity and mortality data. According to Dr. Fotinos, the current landscape “requires us to be better partners in community engagement. If not to the direct communities themselves, then reaching out to advocacy organizations that support them or community-based organizations that can help us understand how we can best support people seeking care within these groups.”
Amidst the uncertainties of the actual impact of the ruling is space for Medicaid agencies and states to engage in innovation and pilot studies to gauge what policy levers can support women’s health, reproductive health, and family and community supports. A unified pregnancy notification system could help bridge this gap and support population health efforts to improve pregnancy outcomes. Intentional stakeholder engagement can boost efforts to advance patient-centered care. Examples include collaborating with providers, including the doula and midwifery communities, and working directly with groups most at risk for adverse maternal health outcomes to assess individuals’ pregnancy intention, social support networks, birthing process preferences, and access to contraceptives and reproductive health.
This briefing is part of AcademyHealth’s efforts to advance its advocacy work to support better health outcomes and health equity by disseminating evidence and the experts in our field that generate it. The MMDN falls under AcademyHealth’s Evidence-Informed State Health Policy Institute (ESHPI). You can learn more about our organizational membership and the benefits they receive here.
JAMA Network recently published a commentary from members of MMDN. Read it here.