5. What Are Best Practices for Promoting Healthy Births?
Prematurity and other birth-related problems, such as low birth weight and birth defects, have profound and lasting effects on individuals, families and society. Preterm birth, defined as those that occur at least three weeks before their due date, is a leading cause of infant mortality and disability. Moreover, an increasing number of babies born with neonatal abstinence syndrome—a drug withdrawal syndrome resulting from maternal drug use—is associated with poor outcomes for infants and moms alike.
In addition to the human toll, poor birth outcomes are costly to states. Today, one baby in 10 babies is born prematurely, resulting in long-term medical, early intervention and special education costs of more than $26 billion annually. Because Medicaid finances about 45 percent of all births in the United States, and because the rate of preterm birth is 25 percent higher for the Medicaid population than for the privately insured, state efforts to improve birth outcomes within the Medicaid population offer a powerful opportunity to improve health care quality, achieve better outcomes on a large scale, and save costs.
After several years of declining rates of preterm births, the U.S. preterm birth rate increased for two consecutive years in 2015 and 2016. As shown in Figure 7, preterm birth rates range from a low of 7.8 percent in New Hampshire to a high of 13.7 percent in Mississippi. Babies born with a low birth weight, or under 5.5 pounds, are more likely to experience health problems and longer-term developmental problems or disabilities.
The Centers for Disease Control and Prevention (CDC) recommends several strategies for reducing preterm birth. They include providing access to care before and between pregnancies, identifying women at risk for preterm delivery and offering treatments to prevent early births, discouraging deliveries before 39 weeks without a medical need, and preventing unintended pregnancies. In addition to state actions outlined below, CMS has implemented several initiatives to help states improve health outcomes and reduce the cost of care for women and infants in Medicaid and CHIP, including the Maternal and Infant Health Initiative (MIHI) and the Medicaid Innovation Accelerator Program’s MIHI Value-Based Payment Technical Support Initiative.
Improve access to early, high-quality prenatal and postpartum care
Infants born to women who receive late or no prenatal care are twice as likely to have low birth weights as infants born to women who receive prenatal care in the first trimester. Timely prenatal care reduces unhealthy behaviors that can harm infants and connects pregnant women with appropriate services. States have taken various steps to facilitate access to prenatal care for Medicaid enrollees, including through changes to eligibility and enrollment procedures, as described below.
- Medicaid Eligibility. States are required to provide Medicaid coverage to pregnant women with incomes up to 133 percent of federal poverty guidelines and they have the option of extending it to pregnant women with higher incomes. According to a 2017 Kaiser Family Foundation report, as of January 2017, 34 states covered pregnant women with incomes up to 200 percent of the poverty limit (or an annual income of $50,200 for a household of four in 2018). Five states covered pregnant women through CHIP, and 16 states used the unborn child option to cover income-eligible pregnant women under CHIP.
- Enrollment Procedures. As of January 2017, 30 states had adopted “presumptive eligibility” under Medicaid that allows immediate access to prenatal care services for pregnant women while their eligibility is determined.
States are required to cover pregnancy-related services for women enrolled in Medicaid, and they have the option (with waiver approval) to cover specialized or enhanced prenatal services for high-risk expectant mothers. For example, Colorado’s Prenatal Plus Program targets high-risk pregnant women enrolled in Medicaid with early and comprehensive services, such as nutrition counseling, mental health services and care coordination. New York’s Community Health Worker program provides outreach, education and home visiting to uninsured and underinsured pregnant women at risk for poor health outcomes.
Reduce Early Elective Deliveries
Between 10 percent and 15 percent of all U.S. births occur early, without a medical reason, according to a 2012 report by the Centers for Medicare & Medicaid Services. Early elective deliveries are associated with increased risks of neonatal morbidity, breathing and feeding problems, blood infections and other complications that may require costlier hospital stays and cause long-term health problems. The U.S. Department of Health and Human Services estimates that just a 10 percent reduction in deliveries before 39 weeks of gestation would lead to more than $75 million in annual Medicaid savings for associated complications.
According to a 2016 Kaiser Family Foundation survey of states, 19 states had adopted a limited fee-for-service reimbursement policy to reduce early elective deliveries, and 12 states require such a policy for Medicaid managed care plans. A 2017 study published in Health Affairs found that early elective deliveries dropped by 14 percent in Texas following the Medicaid change required in a 2011 law that denied reimbursement for non-medically necessary early elective deliveries.
Promote screening and early intervention for Medicaid-enrolled pregnant women and children
Identifying developmental disorders early can prevent more costly problems later and help infants and toddlers learn skills and meet developmental milestones during their early years. Legislators can play an important role in assuring that Medicaid providers incorporate evidence-based screening guidelines. Medicaid’s Early Periodic Screening, Diagnosis, and Treatment Program benefit package for children covers the costs of periodic, comprehensive screenings, including vision, dental and hearing. In Maine, providers who incorporate the American Academy of Pediatrics’ Bright Futures standards receive enhanced reimbursement under MaineCare, the state’s public health insurance program.
Screening for pregnant and postpartum women offers another way to promote healthy birth outcomes and child development. According to the American Academy of Pediatrics, untreated maternal depression can have a long-term impact on child health and well-being. Maternal depression screening and treatment helps protect the child from the potentially negative physical and developmental effects. A 2016 federal informational bulletin clarified that, if a state chooses to do so, it can incentivize health care providers to bill Medicaid for maternal depression screening provided during pediatric well-child visits, as well as related treatment services where the child is present. As of 2017, 13 state Medicaid programs provided coverage for maternal depression screenings.
Invest in evidence-based home visitation
Home visits by a trained provider, such as a nurse or early childhood educator, support expectant and new parents to promote infant and child health, foster healthy child development and improve school readiness. Well-designed programs achieve a wide array of benefits for children and families, while creating long-term savings for states on avoidable emergency room visits, child protective services and special education, and increased parental earnings.
States support home-visiting programs through a combination of federal, state, local and private funds. The federal Maternal, Infant and Early Childhood Home Visiting Program, reauthorized in February 2018, funds states to develop and implement evidence-based and voluntary programs for at-risk pregnant women and parents with infants or young children. In 2016, the state grantee programs served over 160,000 parents and children in all 50 states, the District of Columbia, and five U.S. territories. Many states rely on Medicaid financing mechanisms to support several home visiting services, including targeted case management and enhanced prenatal benefits under both managed care and traditional medical assistance services. As described in a 2016 federal bulletin, states can cover services for pregnant women or children with home visiting through Medicaid mechanisms, including the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit, Medicaid’s benefit program for children, as well as through Section 1115 and other Medicaid waivers.
A 2017 survey of states by the Kaiser Family Foundation found that at least 30 states use Medicaid to cover prenatal and postpartum home visits. State legislatures play a key role by financing programs and advancing legislation that helps coordinate the variety of state home visiting programs as well as strengthening the quality and accountability of those programs.
- Arkansas lawmakers passed SB 491 (2013) that required the state to implement statewide, voluntary home visiting services to promote prenatal care and healthy births; to use at least 90 percent of funding toward evidence-based and promising practice models; and to develop protocols for sharing and reporting program data and a uniform contract for providers.
- In 2017, New Jersey lawmakers passed SB 1475, establishing a three-year Medicaid home visitation demonstration project to provide ongoing health and parenting information, parent and family support, and links to essential health and social services during pregnancy, infancy, and early childhood.
- During the 2016 legislative session Rhode Island lawmakers passed the Rhode Island Home Visiting Act (HB 7034). It requires the Department of Health to coordinate the system of early childhood home visiting services; implement a statewide home visiting system that uses evidence-based models proven to improve child and family outcomes; and implement a system to identify and refer families before the child is born or as early after the birth of a child as possible.
A return on investment analysis of nurse home visiting has shown an estimated $6.40 return on investment for every dollar invested in the Nurse-Family Partnership, resulting from potential gains in wages, employment and quality of life.
State Options and Actions
Promote Healthy Births
- Educate women about healthy pregnancies by supporting education and outreach.
- Reduce early elective induction and Caesarian deliveries by restricting Medicaid reimbursement for them, educating patients and providers, monitoring performance and reporting, and coordinating efforts to disseminate best practices to perinatal providers.
- Inform families about Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services through home visiting, Women’s Infants and Children Food and Nutrition Service (WIC) and other programs.