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Threats of a filibuster in the Missouri Senate this year extinguished a proposal to extend health care for new moms to a full year after giving birth. Few realized at the time that it also dealt a blow to a program lawmakers passed in 2018 designed to help pregnant women recover from substance abuse.

In February, Missouri’s Medicaid program notified the federal government it was pressing pause on the implementation of a program lawmakers authorized four years ago to expand health care coverage of substance abuse treatment for low-income women from 60 days after their pregnancy ended to 12 months.

State officials cited two main reasons for not moving forward.

Voter-approved Medicaid expansion was expected to decrease the number of women who could be served under extended postpartum coverage. And lawmakers at the time were considering an expansion of postpartum coverage to allow for full benefits to be provided.

“As we all know, that did not happen,” said Sen. Jill Schupp, a Creve Coeur Democrat who worked on the legislation, “which is disappointing on a multitude of levels.”

Todd Richardson, the director of Missouri’s Medicaid program, paused the expansion of substance-abuse coverage in a Feb. 7 letter to the Centers for Medicare & Medicaid Services.  Lawmakers and advocates say they first learned of the letter when contacted by The Independent about it last week.

The setback is the latest in a years-long effort to expand the length of time low-income pregnant women receive health care, which advocates hope will help curb Missouri’s maternal mortality rate that ranks it in the bottom quarter of states nationwide.

“It literally means that we’ll lose the lives of some mothers that we didn’t have to lose,” said Sheldon Weisgrau, Missouri Foundation for Health’s vice president of health policy. “That’s the disappointing part of this.”

Asked whether the department plans to resume its implementation of the extended substance use coverage in light of the legislature failing to pass the more comprehensive coverage, Caitlin Whaley, a spokeswoman for DSS, said the department, “plans to regroup with CMS on the issue of postpartum coverage waivers now that the legislative session has concluded.”

DSS is still working to calculate how the implementation of expanded Medicaid coverage will impact the number of people estimated to be eligible, Whaley said.

Advocates said the silver lining is that due to the federal public health emergency still being in place, Medicaid recipients have been allowed to keep receiving health care coverage even if their eligibility has changed. And they’re optimistic the passage of a comprehensive postpartum extension will be imminent when lawmakers return next session.

“Hopefully, with a little bit of a new landscape that might have better luck next year,” said Casey Hanson, the director of outreach and engagement for Kids Win Missouri, a coalition of organizations that advocate for child well-being.

Pressing pause

The extended health care coverage for pregnant women with substance use disorders was originally expected to go into effect at the start of January. A spokeswoman for DSS did not clarify if any residents were covered by the new program or if it failed to get off the ground as planned.

Advocates said while they were disappointed to see the implementation of the extended substance use coverage paused, they hope to see it resume.

This year, lawmakers allocated $1.4 million in the department’s budget to go toward funding the extension of coverage for women with substance use disorders, and “there’s, as far as I’m concerned, no reason to hold that up,” Schupp said.

Funding for the program has been included in the department’s budget since 2018, when lawmakers passed a bill authorizing the extension.

That year, DSS data indicated nearly 8% of women on Medicaid who gave birth were diagnosed with a substance use disorder. Of the 28,762 births covered by Medicaid, 684 women with substance use disorders lost their benefits or transitioned to coverage that did not cover treatments for substance use after the 60-day postpartum period, the Department of Social Services wrote in its 2020 application to CMS.

Substance use disorders contributed to 54% of pregnancy-related deaths in Missouri in 2018, according to the Pregnancy Associated Mortality Review Board’s most recent report.

Rep. Sarah Unsicker, D-Shrewsbury, said she hopes to see DSS resume implementation of the coverage, noting that nearly two-thirds of pregnancy-related deaths in Missouri occur between 43 days and one year after giving birth.

“We need to make sure women are covered for a year after childbirth,” Unsicker said.

‘Please, let’s get this done’

The delays aren’t new for the department, which previously didn’t take steps to implement an extension of postpartum mental health coverage lawmakers had authorized in 2020.

Schupp previously said the department had given conflicting answers as to why, and the department said last fall it hadn’t submitted a waiver to CMS because lawmakers failed to appropriate a specific line item of funding.

Schupp said DSS has since indicated that CMS would like to see states pass the comprehensive coverage, rather than taking a piecemeal approach. Under the American Rescue Plan Act, states have been given five years to take advantage of the option.

As of mid-May, 13 states have already extended postpartum coverage to a full year and another 16 states are planning to, according to the Kaiser Family Foundation, a nonprofit that focuses on national health issues.

“I’m just throwing up my hands saying, ‘Please, let’s get this done,’” Schupp said of extending postpartum care.

With hopes pinned this year on passing the comprehensive postpartum coverage, a specific line item was not included in DSS’ budget to fund the mental health coverage extension. Funding for the full postpartum benefits was removed from the final version of the budget lawmakers passed.

“The saving grace has been the public health emergency,” Weisgrau said. “In normal times, I think the delay would have been much more damaging.”

For now, Missourians who are receiving health care coverage through the state’s Medicaid programs have been able to remain covered during the federal public health emergency — which federal officials indicated last week would be extended for at least another 90 days past its July 15 expiration date, according to CNN.

Once that ends, states will begin the process of reverifying recipients’ eligibility, where residents may be moved to new programs they may now qualify for, like expanded Medicaid, or risk losing their coverage.

“We don’t know when that emergency is going to be called and end,” Schupp said, “and we want to make sure that we know that these women and their children and their families are going to continuously have what they need.”