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When Victoria Ferrell Ortiz had her daughter in 2017, she was covered by a limited form of Medicaid in Texas — which ended just two months after she gave birth. Losing insurance so soon was stressful. She supports a push for Texas to extend Medicaid coverage for a full year after childbirth.
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When Victoria Ferrell Ortiz had her daughter in 2017, she was covered by a limited form of Medicaid in Texas — which ended just two months after she gave birth. Losing insurance so soon was stressful. She supports a push for Texas to extend Medicaid coverage for a full year after childbirth.
Yfat Yossifor / KERA
Victoria Ferrell Ortiz found out she was pregnant during the summer of 2017. The Dallas resident was finishing up an AmeriCorps job with a local nonprofit, which offered her a small living stipend but no health coverage. She applied for Medicaid so she could be insured during the pregnancy.
“It was a time of a lot of learning, turnaround and pivoting for me, because we weren’t necessarily expecting that kind of life change,” she says.
But applying for Medicaid didn’t come with an instruction manual. She was inundated with forms. She spent days on end on the phone trying to figure out what was covered, and where she could actually go to get care.
“That was a really huge privilege because it took so much time, and then sometimes the representative that I would speak to wouldn’t know the answer,” she says. “I would have to wait for a follow up and hope that they actually did follow up with me.”
More than 471,000 pregnant Texans are currently navigating that fragmented, bureaucratic system to find care. Medicaid provides coverage for about half of all births in the state — but the coverage is so paltry that many people lose eligibility not long after giving birth.
Medicaid covers about half of all births in Texas. During pregnancy, many rely on that Medicaid coverage to get access to everything they need — from doctor’s appointments to prenatal vitamins.
But pregnancy-related Medicaid coverage ends just two months after childbirth — and advocates and researchers say that strict cutoff contributes to high rates of maternal mortality and morbidity in the state. They support a bill moving through the current legislative session that would extend pregnancy Medicaid coverage for a full 12 months, postpartum.
Texas is one of 11 states that has chosen not to expand Medicaid to its population of uninsured adults — that’s a benefit offered under the Affordable Care Act, with 90{b574a629d83ad7698d9c0ca2d3a10ad895e8e51aa97c347fc42e9508f0e4325d} of the cost paid for by the federal government. That leaves more than 770,000 Texans in a coverage gap — they don’t have any job-based insurance, nor do they qualify for subsidized coverage on HealthCare.gov, the federal insurance marketplace. In 2022, 23{b574a629d83ad7698d9c0ca2d3a10ad895e8e51aa97c347fc42e9508f0e4325d} of women between the ages of 19-64 were uninsured in Texas.
Pregnancy Medicaid helps fill the gap, temporarily. Close to half a million Texans are currently enrolled in the program. The majority are Hispanic and Latinx women between the ages of 19 and 29.
Undocumented Texans and lawfully present immigrants are not eligible, though they can get different coverage which ends immediately when the baby is born.
In states where the Medicaid expansion has been adopted, coverage is available to all adults with incomes below 138{b574a629d83ad7698d9c0ca2d3a10ad895e8e51aa97c347fc42e9508f0e4325d} of the federal poverty level. For a family of three, that means an income of $34,307 a year.
But in Texas, childless adults don’t qualify for Medicaid at all. Parents can be eligible for Medicaid if they’re taking care of a child who receives Medicaid, but the income limits are low. For a three-person household with two parents, they can’t make more than $251 a month.
The pregnancy-related Medicaid in Texas is available to individuals who make under $2,243 a month. It lasts through pregnancy and two months after giving birth, covering everything from prenatal visits to postpartum check-ups.
For Ferrell Ortiz, the hospitals and clinics that accepted Medicaid near her in her Dallas neighborhood felt “uncomfortable, uninviting…and a space that wasn’t meant for me,” she says. But she did find out that Medicaid would pay for her to give birth at an enrolled birthing center.
“I went to Lovers Lane Birth Center in Richardson,” she says. And I’m so grateful that I found them because they were able to connect me to other resources that the Medicaid office wasn’t.”
Ferrell Ortiz was glad she had found a welcoming and supportive birth team. But the Medicaid coverage ended not long after her daughter arrived — just two months after giving birth. She says losing insurance when her baby was so young was stressful.
“The two months’ window just puts more pressure on women to wrap up things in a messy and not necessarily beneficial way.”
In the 2021 legislative session, Gov. Greg Abbott signed a bill extending pregnancy Medicaid coverage from two months to six months postpartum.
That extension was denied by the federal government in the fall of 2022; The Texas Tribune reported some legislators believed the application was rejected “because of language that could be construed to exclude pregnant women who have abortions, including medically necessary abortions.”
The state’s Maternal Mortality and Morbidity Review Committee is tasked with producing statewide data reports on causes of maternal death and intervention strategies. Members of that committee, along with advocates and legislators, are hoping this year’s legislative session extends pregnancy Medicaid to 12 months postpartum.
Lack of health care coverage led to worse outcomes for pregnant people in Texas
Kari White, an associate professor at the University of Texas at Austin, says the bureaucratic challenges Ferrell Ortiz experienced are common for pregnant Texans on Medicaid.
In Texas, maternal health care and Pregnancy Medicaid coverage “is a big patchwork with some big missing holes in the quilt,” says White, who is also the lead investigator with the Texas Policy Evaluation Project (TxPEP).
TxPEP studies the various impacts that state policy has on people’s reproductive health. A March 2022 TxPEP study surveyed close to 1,500 pregnant Texans on public insurance. It found that “insurance churn” — when people lose health insurance in the months after giving birth — led to worse health outcomes and problems accessing postpartum care.
“People are either having to wait until their condition gets worse, they forgo care, or they may have to pay out of pocket,” White says. “There are people who are dying following their pregnancy for reasons that are related to having been pregnant, and almost all of them are preventable.”
For example, chronic disease accounted for almost 20{b574a629d83ad7698d9c0ca2d3a10ad895e8e51aa97c347fc42e9508f0e4325d} of pregnancy-related deaths in Texas in 2019, according to the latest report from the Texas Maternal Mortality and Morbidity Review Committee (MMMRC). Chronic disease includes conditions such as high blood pressure and diabetes.
The report determined at least 52 deaths were related to pregnancy in Texas during 2019. Serious bleeding (obstetric hemorrhage) and mental health issues were among the top causes of death.
“This is one of the more extreme consequences of the lack of health care,” White says.
Black Texans, who make up close to 20{b574a629d83ad7698d9c0ca2d3a10ad895e8e51aa97c347fc42e9508f0e4325d} of pregnancy Medicaid recipients, are also more than twice as likely to die from a pregnancy-related cause than their white counterparts, which is a statistic in Texas that has held true for close to ten years with little change, according to the MMMRC report.
Stark disparities such as that can be traced to systemic issues, including the lack of diversity in medical providers; socioeconomic barriers for Black women such as cost, transportation, lack of childcare and poor communication with providers; and even shortcomings in medical education and providers’ own implicit biases — which can “impact clinicians’ ability to listen to Black people’s experiences and treat them as equal partners in decision-making about their own care and treatment options,” according to a recent survey.
Diana Forester, the director of health policy for the statewide organization Texans Care for Children, says Medicaid coverage for pregnant people is a “golden window” to get care.
“It’s the chance to have access to healthcare to address issues that maybe have been building for a while, those kinds of things that left unaddressed build into something that would need surgery or more intensive intervention later on,” she says. “It just feels like that should be something that’s accessible to everyone when they need it.”
Extending health coverage for pregnant people, she says, is “the difference between having a chance at a healthy pregnancy versus not.”
As of February, 29 states have adopted a 12-month postpartum coverage extension so far, according to a Kaiser Family Foundation report, with 7 states planning on implementing this extension in the future.
“We’re behind,” Forester says of Texas. “We’re so behind at this point.”
Many versions of bills that would extend pregnancy Medicaid coverage to 12 months have been filed in the legislature this year, including House Bill 56 and Senate Bill 73. Forester says she feels “cautiously optimistic.”
“I think there’s still going to be a few little legislative issues or landmines that we have to navigate,” she says. “But I feel like the momentum is there.”
Ferrell Ortiz’s daughter is turning 5 this year. Amelie is artistic, bright, and vocal in her beliefs. When Ortiz thinks back on being pregnant, she remembers how hard a year it was, but also how much she learned about herself.
“Giving birth was the hardest experience that my body has physically ever been through,” she says. “It was a really profound moment in my health history — just knowing that I was able to make it through that time, and that it could even be enjoyable — and so special, obviously, because look what the world has for it.”
She just wishes people, especially people of color giving birth, could get the health support they need during a vulnerable time.
“If I was able to talk to people in the legislature about extending Medicaid coverage, I would say to do that,” she says. “It’s an investment in the people who are raising our future and completely worth it.”
Congress gave the Food and Drug Administration more power to hold drugmakers accountable as part of the mammoth spending bill that became law in December 2022. Sarah Silbiger/Getty Images hide caption toggle caption Sarah Silbiger/Getty Images Congress gave the Food and Drug Administration more power …
Jennifer Mitchell thumbs through her husband’s medical records from his time at the Montana State Hospital. Records show doctors took Mitchell’s husband off some of his congestive heart failure medications. Mitchell says she was never consulted. Aaron Bolton/Montana Public Radio hide caption toggle caption Aaron …
When he was in prison, Lee Reed was in agonizing back pain. His doctors there told him he needed back surgery, but because he was so close to his release date, they said he’d have to get it done on the outside. Reed saw that surgery as his ticket to being able to get a job and effectively reenter society.
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When he was in prison, Lee Reed was in agonizing back pain. His doctors there told him he needed back surgery, but because he was so close to his release date, they said he’d have to get it done on the outside. Reed saw that surgery as his ticket to being able to get a job and effectively reenter society.
Amy Osborne for Tradeoffs
Lee Reed spent his first night after getting out of a state prison sleeping in the stairwell of a parking garage in downtown San Francisco.
Just a few days shy of his 62nd birthday, Reed had nowhere else to go. During his two decades in prison, his mom and wife had died, and he’d lost touch with most of his family.
“I had nothing. I had nobody,” Reed said.
But he wasn’t alone on that first night. He had the same companion he’d had for years: agonizing back pain.
“Imagine somebody standing on your foot, and you can’t stop that pain,” Reed said. “It’s going to be there when you wake up. It’s going to be there when you go to sleep. Half the time I never even got out of bed while I was in prison because I couldn’t stand up, it was so painful.”
Reed’s doctors in prison told him he needed back surgery, but because he was so close to his release date, they said he’d have to get it done on the outside. Reed saw that surgery as his ticket to being able to get a job and effectively reenter society.
But without health insurance or a support network, being able to do any kind of work seemed impossible as he laid down in the concrete stairwell, his prison-issued walker his only blanket.
“I was tired, and I was literally ready to give up,” Reed said.
Around 600,000 people leave prison in the U.S. every year, and another 10 million are released from county jails. Like Reed, many of them suffer from chronic physical, mental and substance use conditions. Research shows they are also at an extremely high risk of hospitalization and death; one study from Washington state found that recently incarcerated people were 12 times more likely to die in their first two weeks after release from prison than the general population.
That’s why in January, federal health officials for the first time signed off on having Medicaid pay for services for some people in state or local jails, prisons or juvenile facilities. The goal is to use the time before someone leaves a corrections facility to connect them with medical providers in the community and limit any disruption in their care as they transition out of incarceration.
Most people who are incarcerated are eligible for Medicaid based on their low income, but a provision known as the “inmate exclusion policy” prohibits federal Medicaid dollars from being spent on a person’s care while incarcerated. (The only exception is for an overnight hospital stay.) Many counties and states try to connect people to Medicaid as soon as they’re released, but it can be a bureaucratic nightmare, and even if it works, people often have other priorities like finding a job, food and a place to live.
Some states like Arizona require private Medicaid plans to connect with incarcerated people before they are released, which state officials say helps individuals get care more quickly when they get out. And small pilot programs in California and New Mexico showed offering care coordination before release led to more primary care visits, less recidivism and fewer ER trips. But the inmate exclusion policy remains a significant barrier.
In 2018, Congress directed federal health officials to help states figure out a better transition plan for people leaving incarceration. Since then, 15 states from across the political spectrum have asked the Centers for Medicare and Medicaid Services to let them test what would happen if they turned Medicaid on before people leave jail, prison and juvenile facilities. In January, California became the first state to get the green light.
“We hope that what we are approving today is an exciting model for what we are able to partner [on] with states across the country,” said Dan Tsai, deputy administrator and director of the Center for Medicaid and CHIP Services at CMS.
All of the proposals pending before CMS share a common goal: bridging care between incarceration and the community for the more than 10 million people who leave incarceration each year. Many policymakers also see this as a way to improve health equity — people of color are disproportionately incarcerated in the U.S.
In theory, getting people connected to care sooner and keeping them on their medications should improve health outcomes and, over time, help state Medicaid programs save money, because fewer people will end up needing expensive hospital and ER visits. But with limited previous experience to guide them, states are having to guess at the best way to use finite Medicaid dollars when it comes to who should receive these new benefits, what benefits they should receive and when those benefits should start.
“If you are providing and paying for the Medicaid services, you want to ensure that you are focused on those that truly need it,” said California Medicaid Director Jacey Cooper.
Most states, including California, would limit eligibility to incarcerated people with documented health needs, such as chronic physical and mental health conditions or substance use disorder. Cooper estimates around 70{b574a629d83ad7698d9c0ca2d3a10ad895e8e51aa97c347fc42e9508f0e4325d} of people incarcerated in California meet this criteria.
In West Virginia and Kentucky, only people with a substance use disorder would be eligible, as part of those states’ broader efforts to address addiction. Research shows drug overdose is one of the most common ways people die after leaving prison, with studies suggesting returning prisoners are 40 to 129 times more likely to fatally overdose in their first two weeks after release.
Rhode Island, Vermont, Washington and Oregon would offer pre-release services to everyone in jail and prison who is eligible for Medicaid.
“The odds are so high that people in that situation are going to need the support that it didn’t seem to make sense to us to be trying to distinguish who did and who did not meet some threshold or have a particular condition,” said Amy Katzen, the director of policy and strategy for Rhode Island’s Medicaid program.
Rhode Island is one of four states — along with Massachusetts, Utah and Vermont — that would offer people soon to leave jails and state prisons the same Medicaid benefits as anyone else in the community.
“This is going to be so complicated to implement,” said Mike Levine, director of MassHealth, Massachusetts’ Medicaid program. “When we finally do, there’s something to be said for just if you are a MassHealth member, you’re getting the MassHealth benefit.”
The other 11 states would offer a more limited set of services for people in the weeks or months before they leave incarceration, focused on transitioning someone back into the community. Services would include connecting them to new doctors, making sure they can get their prescriptions filled and helping them find housing.
In most of these states’ proposals, services like addiction treatment and daily medications would continue to be provided and paid for by the jail or prison. However, Rahul Gupta, the director of the White House Office of National Drug Control Policy, said on Tuesday that states would be required at a minimum to provide mental health and drug treatment services in this pre-release period. CMS would not confirm Gupta’s statement and said the agency plans to release further guidance for states soon.
Some advocates believe Medicaid should take a larger role in health care during incarceration, pointing to numerous reports of inadequate and negligent health care behind bars.
“I’ve seen people wither away — literally, people who were 280 pounds solid, healthy-looking individuals, wither all the way down to skin and bones. And that was because something that they had was diagnosed late or was misdiagnosed in the beginning,” said Khalil Cumberbatch, who served 6½ years in a New York prison before becoming the director of strategic partnerships at the Council on Criminal Justice.
For now, states are unwilling to go that far. Most are asking for Medicaid to start paying for services 30 days before someone is released, but a few have asked for more, including California, which has been approved to start coverage 90 days pre-release. Medicaid Director Cooper said that’s a more realistic window to build a trusting clinical relationship with someone, get all their appointments set up and make sure they have everything they need before they’re released.
Medicaid experts suggested the quickest way for the other 14 states to win CMS approval may be to follow California’s lead on these questions, but they believe federal health officials might want to let states make different choices so they can gather more evidence about what works best.
In California, the first incarcerated people won’t receive Medicaid services until April 2024, Cooper said, with full implementation expected to take until 2026. That’s in part due to the daunting task of integrating the health care and criminal justice systems. The state asked for and received $561 million from the federal government to help providers and correctional facilities build up the infrastructure to do things like share data and bill appropriately.
Massachusetts’ Mike Levine said his team has been working closely with law enforcement and corrections officials for years. “You can’t wait to engage correctional partners when it’s time to implement,” Levine said. “They have to be involved in the policy design because this is going to require so much change within their workflows and their daily business that they have to be at the table.”
Advocates insist that people who are incarcerated or formerly incarcerated need to be included in these conversations too. “If we want people to use that Medicaid card to engage in services in the community, we need to ask them, what is it you need? How can we support you best in coming home?” said Shira Shavit, a professor of family and community medicine at the University of California San Francisco and executive director of the Transitions Clinic Network, which specializes in caring for people post-incarceration.
Including those perspectives, Shavit said, could prevent unintended consequences, like people becoming less likely to engage with Medicaid because they see it as a part of a criminal justice system they don’t trust.
This entire conversation is coming too late for Lee Reed. No one reached out to him before he got out of prison. He spent two days sleeping in that parking garage stairwell before a security guard pointed him toward a nearby homeless shelter.
A few weeks later, a doctor at the shelter restarted Reed’s medications for diabetes and high blood pressure, and referred him to a specialist who scheduled his back surgery for early 2023 — more than six months after Reed had been released from prison.
Six months after he was released, Reed finally got his back surgery. He’s in less pain now, but he’s still homeless, jobless and struggling to find purpose in his life.
Amy Osborne for Tradeoffs
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Amy Osborne for Tradeoffs
Six months after he was released, Reed finally got his back surgery. He’s in less pain now, but he’s still homeless, jobless and struggling to find purpose in his life.
Amy Osborne for Tradeoffs
But his pain continued to get worse. The constant agony and Reed’s inability to support himself took a toll on his mental health, occasionally making him wonder if his life was worth living.
“Who would want to live this? This is horrible, man,” he said. “I can’t do anything to protect myself. I can’t do anything to feed myself. How the hell am I a man?”
The doctor at the shelter referred Reed to Shira Shavit’s Transitions program at the Southeast Family Health Center, a community clinic run by the San Francisco Department of Public Health. Shavit prescribed a medication patch for Reed’s back and scheduled follow-up appointments for his diabetes. The program also gave him a bag of groceries, a bus card and ordered him a winter coat.
“When people come out of prison, they have so many needs,” Shavit said. “[We’re] just trying to bring people to the starting line to kind of get them to where they need to be to then even start to be able to become successful in the community.”
Reed finally got his surgery at the end of January, the day after CMS approved California’s request to bring Medicaid behind bars. He’s in less pain now and dreams of moving back to Arkansas to spend time with his grandchildren.
But his challenges are far from over. He’s still living at the homeless shelter without a job and struggling to find purpose. He said if someone had reached out to him before he left prison and helped him get his surgery sooner, there’s a better chance he’d be supporting himself by now.
“I’m trying to keep a positive attitude on everything because my whole world feels like it’s falling apart,” he said a week after his surgery. “I have no control over my own life right now. I’m just like a child. I’m just helpless.”
This story comes from the health policy podcast Tradeoffs. Dan Gorenstein is Tradeoffs’ executive editor, and Ryan Levi is a reporter/producer for the show, where a version of this story first appeared.
