While celebrating last month's U.S. Supreme Court decision overturning the constitutional right to an abortion, Gov. Greg Abbott pointed to the millions of dollars in spending that state lawmakers approved during the 2021 legislative session to help pregnant women and new mothers.
Among the measures he touted was a law that extended Medicaid health care coverage for pregnant women until six months after they give birth or miscarry, exceeding the federal government's requirement that states provide at least two months of the benefit.
"Texas is a pro-life state, and we have taken significant action to protect the sanctity of life," the Republican governor said in a June 24 statement. "Texas has also prioritized supporting women's healthcare and expectant mothers in need to give them the necessary resources so that they can choose life for their child."
Abbott's statement neglected to mention that Texas lags behind at least 33 states, including 11 led by Republican governors, as well as the District of Columbia, all of which have already expanded or are working with the federal government to extend postpartum Medicaid benefits for a full year after giving birth. In 2021, the Texas House passed a measure that would have lengthened that coverage to 12 months, but during the waning days of the legislative session one of the senators who co-authored the state's restrictive abortion law halved the time period.
Texas is among a dozen states that have also declined to expand broader Medicaid coverage under the Affordable Care Act to additional people with low incomes, leaving it with some of the strictest eligibility requirements in the country. For example, single parents with one child must earn $196 or less a month to qualify.
"It is such hypocrisy," Adrienne Lloyd, a senior health policy associate for the Children's Defense Fund Texas, said about the contrast between state legislators' battle against abortion access and the services they provide to pregnant people. "If you really care about that health and safety, then the pregnant person and baby will have so much better outcomes if they're covered long before and after giving birth."
The state's Maternal Mortality and Morbidity Review Committee recommended extending postpartum Medicaid to one year in a 2020 report that showed cardiovascular and coronary conditions, along with mental disorders, were the leading causes of deaths related to pregnancy. Nearly a third of 54 deaths determined to be directly tied to pregnancy occurred between six weeks and 12 months after birth, the committee found as part of an analysis of 2013 data, the most recent available.
Medicaid is the most comprehensive federal- and state-funded health coverage offered to pregnant people and new parents. The assistance, which is generally available to people with low incomes or with disabilities, has higher income thresholds for those who are pregnant. Medicaid covers hospital visits, specialist care and X-rays that are not provided by other Texas programs.
Extending the eligibility period is critical, said Dr. Carla Ortique, a gynecologist and vice chair of the review committee, because treatments for many of the primary causes of pregnancy-related deaths, such as postpartum depression and cardiomyopathy, take time to work.
"It makes a difference in your outcomes and has been shown to make a difference for future pregnancies," Ortique said.
Had the state's lawmakers heeded recommendations to extend the eligibility period beyond six months, Texas could have led the nation in expanding postpartum Medicaid for pregnant people instead of trailing behind, said Diana Forester, director of health care policy at Texans Care for Children, an advocacy group.
"Why wouldn't we want to manage those chronic conditions for that first year postpartum so that they can focus on getting healthy and getting back to work and ensuring their kid has what they need to succeed? It just seems like a no-brainer," Forester said.
A spokesperson for Abbott did not respond to questions about the Legislature's decision or whether the governor supports the longer coverage period.
As it stands now, people who are eligible for Medicaid during their pregnancies are allowed to stay on the program indefinitely under federal pandemic rules. But that extended coverage could end as soon as this fall if President Joe Biden's administration allows the emergency declaration to lapse, making states' Medicaid eligibility decisions critical for new parents in need of health care coverage.
To qualify for pregnancy-related Medicaid, single people having their first child need to make $3,022 or less a month, compared to a $196 monthly income cap otherwise.
Connie Bunch, a single mother from Abilene, understands the consequences of losing health care coverage too soon after giving birth.
Bunch received Medicaid in 2013 while pregnant with her first child at age 28, marking the first time she had health care coverage as an adult. At the time, Texas had not yet passed any legislation that exceeded the federal government's requirement, so she lost the benefits two months after giving birth.
The new mother couldn't manage the cost of private insurance through the Affordable Care Act. And the $600 average monthly income Bunch received from her part-time job, child support and disability assistance for her daughter's cerebral palsy kept her from qualifying for Medicaid under Texas' income requirements once her postpartum benefits expired.
As a result, Bunch could no longer pay for doctors' visits and treatment related to the high blood pressure, hypertension and gestational diabetes that doctors had diagnosed her with during her pregnancy. Diabetes affects about one in 10 pregnant people across the country, and two of the top six causes of maternal mortality in Texas are related to high blood pressure.
Without medication, Bunch said, she suffered debilitating headaches, exhaustion and a loss of appetite.
Once Bunch became pregnant with her second child last year, she again qualified for Medicaid. Her extended coverage has allowed her to once more have access to hypertension and diabetes medications. She said her headaches have disappeared, she's no longer tired all day and her blood pressure has stabilized.
Now living closer to family in Austin, Bunch said she hasn't been able to work because she cannot afford child care. Her monthly income shrunk to $350 from the child support and disability payments she receives. But it is still too much to qualify for Medicaid coverage, except for that specifically provided to people after they give birth.
This means that as soon as the federal freeze ends, Bunch will lose coverage.
"That's really scary," Bunch said. "That's something that I really worry about."
"Philosophical" resistance to Medicaid
In April 2021, Toni Rose, a Democratic state representative from Dallas, went before the 150-member Texas House to lay out her bill to expand Medicaid to a full year after pregnancy. Within three minutes, the bill passed the chamber with bipartisan support. Some lawmakers applauded its passage.
The ease with which the measure sailed through the House inspired advocates to hope that the 12 months of coverage stood a chance to become law in Texas. Of the 14 members of the public who testified on the bill during a House committee hearing, not one spoke against the measure. And not a single representative publicly raised concerns about the bill before it eventually passed by a 121-24 vote.
More than a month later, on the same day that Abbott signed into law the Texas Heartbeat Act, which banned most abortions after about six weeks of pregnancy, the state Senate took a different approach.
During a hearing that month, Lois Kolkhorst, the Senate sponsor for the postpartum Medicaid bill, ticked off a list of states that had applied to the federal government to extend coverage for new parents to 12 months or that were considering passing legislation to do so.
But she said that, at the time, only Illinois had fully enacted such coverage. Missouri, she said, had limited its extensions to substance abuse and mental health services. On the other hand, Georgia had extended full Medicaid benefits but limited them to six months, said the Republican, who represents the small Central Texas city of Brenham and chairs the Senate's Health and Human Services Committee.
"Certainly, Texas would be on the cutting edge of this if we were to pass this bill in any form, extending past the 60 days," Kolkhorst said.
Although her bill put forward the 12-month extension approved by the House, Kolkhorst did not indicate a preference for the full year of postpartum coverage. Instead she referenced what she characterized as a common criticism of the federal program, saying, "I think it's a great discussion of what is the right number and some people say, well, once you get pregnant, you stay on Medicaid for forever."
Kolkhorst suggested that Texas was already a leader, pointing to a program that she helped create in 2019 called Healthy Texas Women Plus that offers 12 months of postpartum coverage. The program aims to provide some of the benefits available through Medicaid, primarily those that would help prevent the leading causes of deaths associated with childbirth. Most eligible Texans haven't had to use it because they still qualify for Medicaid under the federal pandemic freeze. And Kolkhorst acknowledged that Medicaid was a "more comprehensive plan."
Women's health advocates and physicians have criticized the Texas program as what one called a limited "package of outpatient services," because it does not include what they said is the full range of necessary care, such as emergency room visits, specialist appointments and hospitalizations. The state initiative also has a far smaller network of providers, which experts said makes it harder to get treatment.
After the May hearing, Kolkhorst accepted an amendment by Sen. Dawn Buckingham, a Republican from Austin and an eye surgeon, that slashed the House's proposed postpartum coverage in half.
Buckingham never publicly raised concerns about the 12 months of care during committee hearings or before the full Senate. Rose, the representative who authored the measure in the House, said when she raised questions about the cut, Kolkhorst replied that she thought six months was "progress."
The Senate passed the amended bill just after 3 a.m. on May 27, four days before the end of the session.
Neither Kolkhorst nor Buckingham, who were among the authors of the state's restrictive abortion bill during the same legislative session, responded to requests for comment.
Kel Seliger, a Republican senator from Amarillo who serves on the Health and Human Services Committee, said the aversion to further extending postpartum coverage stems from a fundamental opposition by some Republicans to Medicaid expansion.
"There was philosophical resistance," he said. "Medicaid is quite removed from Obamacare. We've been doing Medicaid for a long time. But it got to the point where Medicaid expansion was simply a buzzword for Obamacare."
Seliger said he thought six months of postpartum Medicaid coverage was a sufficient compromise.
"I think it's practical to increase Medicaid by three times" the minimum required by the federal government, he said. "And let's see what the effect is. And let's see where the Medicaid population goes and let's see what the cost is."
Texas House researchers estimated in March 2021 that the cost to the state of extending postpartum Medicaid coverage to a full 12 months would be about $84 million over the first two years. The six months of care that was instead approved by the Legislature is projected to cost an average of about $40 million annually during its first four years of implementation.
The federal government pays for nearly 60% of overall Medicaid expenses in the state. It does not contribute to Healthy Texas Women Plus, although the state requested federal funding for the program in December. Approval from the federal Centers for Medicare & Medicaid Services is pending.
Dade Phelan, the Republican Texas House speaker, blamed the Senate in a statement to ProPublica and The Texas Tribune, noting his chamber voted overwhelmingly for the expanded coverage.
"The Senate refused that proposed extension for vulnerable mothers who chose life, so ultimately we landed on extending coverage to six months," said Phelan, who is from Beaumont in southeast Texas. "The Texas House has and will continue to make certain that we support Texas women and children."
Extending postpartum Medicaid coverage does not force states to accept the federal government's broader Medicaid expansion.
Nearly three dozen states have opted to lengthen postpartum care to 12 months since April 2021, including seven that, like Texas, did not expand Medicaid more broadly, according to KFF, a national health care nonprofit tracking the proposals. Even Georgia, the state Kolkhorst referenced in her Senate testimony as having extended benefits for only six months, approved a full year of postpartum care in May.
If all states approved that coverage, as many as 720,000 pregnant and postpartum people in all could qualify, according to the federal government.
Many states took advantage of a streamlined process for taking such action under the 2021 American Rescue Plan Act. States must seek permission from the Centers for Medicare and Medicaid Services if they want to provide health care coverage beyond the 60 days required under the law, but the act made it easier to extend coverage to a full year.
Texas and Wisconsin, the two states so far to request approval for shorter time periods, must still go through a lengthy waiver process. If the Medicaid freeze ends before the federal government approves Texas' proposal, people who would have been included in the state's six-month postpartum coverage could temporarily lose that care, experts said.
The Biden administration, in a maternal mortality report released last month, called on Congress to require extending postpartum Medicaid to a full year. The report said this could eliminate "potentially deadly gaps in health insurance at a critical time for individuals."
People are dying from pregnancy-related causes in the U.S. at a higher rate than in any other developed nation, the report said.
About 700 people die annually in the U.S. because of pregnancy-related complications, about one-third occuring one week to a year after they have given birth, according to the CDC. Texas ranks among the 10 worst states in the country for maternal mortality.
Rose said the Supreme Court's elimination of the constitutional right to an abortion is an important test to see if her Republican colleagues in the Senate are willing to provide other basic supports to pregnant people.
She plans to re-file the bill to extend Medicaid coverage to a full year on the first day of the upcoming legislative session in January.
"If you want women to have babies, then you need to make sure that they have the health care that they need in order to carry those babies and to have the comprehensive health care that they need after delivery," Rose said.
She has support from health care advocates who have been asking for the bill to be reconsidered and from Phelan, the Republican House speaker, who told the news organizations that next session "the House will double down on prioritizing maternal health care and other resources for women, children and families in our state."
Phelan specifically cited the one-year postpartum Medicaid extension as a priority.
A spokesperson for Lt. Gov. Dan Patrick, who sets the legislative agenda for the Senate, did not respond to questions about whether he would support the passage of such a measure. Last May, Patrick told Spectrum News that he supported the bill but "we just needed to make it less than a year."
For Bunch, remaining on Medicaid during the federal government's public health emergency beyond what the Texas Legislature would have allowed has meant that she could treat many of her health conditions.
She will undergo a hysterectomy in August after she said physicians told her that her health conditions mean "another baby will kill you." She could not afford a sterilization procedure, which typically would require hospitalization not paid for by Texas programs, without her Medicaid coverage.
Last month, doctors found a small aneurysm on Bunch's brain, which can result from high blood pressure. Bunch said they told her that her family history made treatment particularly important. Doctors said she should also see a cardiologist for abnormalities with her heart rhythm.
Several of the additional services Bunch would need are not covered by the state's postpartum pregnancy program, leaving her fretting about how she will manage if she loses Medicaid.
The mother said she does not personally believe in abortion. But she criticized Republican lawmakers for pushing to outlaw the procedure without doing more to care for women like her after they give birth.
"On the one hand, they say, 'No, you need to be a parent,'" Bunch said. "But then it's like, 'We don't care if you're a healthy parent.'"
She added, "It's like, 'Have that baby, but then we're throwing you to the wolves.'"
Disclosure: Texans Care for Children has been a financial supporter of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune's journalism. Find a complete list of them here.