Introduction
Recent North Carolina policy changes have expanded coverage for pregnant people in North Carolina. A 2022 state law extended coverage for people who qualify for the state’s Medicaid for Pregnant Women (MPW) program from 60 days after birth to a full 12 months.1
North Carolina’s MPW program offers full Medicaid benefits to pregnant people with a family income up to 196% of the federal poverty level, compared to 138% for Medicaid eligibility for all adults under Medicaid expansion.2,3 As a result of the 2022 policy change, pregnant individuals have access to the full slate of Medicaid benefits throughout both their pregnancy and the 12-month postpartum period.
Additionally, Medicaid expansion has allowed 687,663 North Carolinians to access insurance, allowing even more people to access continuous care before, during, and after pregnancy.4
Jessica Beach is a maternal health expert who is currently working toward her doctorate at the UNC Gillings School of Global Public Health. Her career includes work in maternal health and Medicaid spaces in Arizona, North Carolina, and Washington State. In this interview, Jessica discusses pregnancy Medicaid in North Carolina, why health care coverage leading up to and after birth is vital, and how state and federal policy changes are impacting pregnant North Carolinians.
This interview has been edited for length and clarity. To listen to this interview, click here.
Brady Blackburn: Jessica, thank you so much for joining me today. To get us started, could you introduce yourself and tell me a bit about your background?
Jessica Beach: It’s great to be here today. I’ve been working in the Managed Care space for Medicaid beneficiaries in Arizona, in North Carolina, and in Washington since 2018. A lot of my initial experience was actually in the space of tribal health and tribal affairs and really focused on families with young children. That’s what first got me interested in Medicaid, because so much of the work that I did in the tribal health space with the organization I was with at the time overlapped with Medicaid for young children and their families.
From there, I had the opportunity to start working in Managed Care and learned more about it. And since transitioning to working more on the Managed Care side, I have focused a lot on maternal and child health and family health and family experiences in Medicaid. And so, that’s one of my passions and the things that I love most about my job.
Brady Blackburn: So, what initially drew you to work in health care and in maternal health?
Jessica Beach: Well, first of all, I’m a mom, so there’s an easy connection there. I have 3 kids. And knowing a lot of the disparities that exist in underserved communities like tribal communities and rural communities, I have just been naturally drawn to, how do we leverage Medicaid as a program, as well as other resources, from the federal and the state level to influence and improve health outcomes for families who are navigating these systems?
Health care is really complicated, and navigating it is really complicated when you layer on chronic health conditions, risk, and historic distrust of the systems that you’re navigating. It can be really challenging to know what works well and who’s doing what. And I think that navigating those systems myself with my family, watching my friends do the same, and now in my professional role kind of seeing it from the provider side, the state plan side—seeing all of those different pieces, it’s really continually drawn me to, how do we use these systems to improve family health outcomes and support families?
Brady Blackburn: Could you tell me a little bit about your current work, both your professional work and your academic pursuits?
Jessica Beach: Yeah, absolutely. So, one of the things that I’m currently working on professionally and academically is really understanding that piece of, how does Managed Care support our members in Medicaid in having better maternal and infant health outcomes, recognize our members’ goals, and help them achieve their goals throughout pregnancy and beyond?
I’m really focused on how we make the most out of the postpartum period. So, how do we take advantage of expanded coverage to create strong health? How do we leverage postpartum coverage and expanded postpartum coverage to continue this engagement with health care—for a mom’s personal health—[at the same level of engagement] that she had during the pregnancy period?
Folks are going and accessing health care a ton while they’re pregnant. And then you have a baby and it kind of drops off because your priorities have shifted a little bit. And so how can we make sure that mom and the family overall stay really engaged in their health care? I think that’s where a lot of my work is focused on right now. So, what do we do? What does Managed Care do? What do providers do? Who are the partners that are really critical in making that happen?
Brady Blackburn: Great, thank you. So, I want to turn our attention to North Carolina’s Medicaid for Pregnant Women program. Could you tell me a little bit about what North Carolina’s Medicaid for Pregnant Women program is, who it covers, and why expanded access to Medicaid during and after pregnancy is important?
Jessica Beach: Yeah, sure. So, Medicaid for Pregnant Women in North Carolina is really similar to pregnancy Medicaid in a lot of states. It allows for expanded eligibility criteria to the Medicaid program for folks who are pregnant. That’s important because pregnancy care is critical, and that’s a big piece of overall health and wellness. Positive health outcomes for mom and baby. That just is not there when you don’t have access to care. And so, the increased eligibility allows for folks who may not generally meet Medicaid eligibility to enroll in Medicaid so that they’re able to access care while they’re pregnant, for themselves.
And then the expanded postpartum coverage is important because it allows for families who would drop off of Medicaid eligibility after the standard postpartum period to still access care for themselves, up to 12 months after pregnancy, which is really crucial for continued support after the end of a pregnancy, re-engagement in primary care and preventative care, and really setting an entire family up for positive health outcomes.
Brady Blackburn: Gotcha. So, your experience includes working in maternal health in North Carolina, in Arizona, and in Washington State. What has your multi-state experience taught you about North Carolina? What makes our state unique and what can we learn from other states?
Jessica Beach: I think my work in multiple states has definitely shown me that North Carolina is really unique in some ways, but that there are also really similar barriers nationally, kind of wherever you are when it comes to Medicaid and pregnancy Medicaid. I think one of the things that makes North Carolina really unique is the case management structure for people who are pregnant on Medicaid. Typically, in states that have Medicaid Managed Care, you’ll see at least a portion of that handled at the MCO [Managed Care Organization] level. That’s generally not what happens in North Carolina.
Also, North Carolina has a decentralized local health department structure. So, that is a little bit different from some of the things that you may see in other states, and that can impact how a local health department is run, who does what, and the structure. I think that’s something that I’ve seen that’s a little bit different. But I think the reason for that is because the program in North Carolina is really responsive to the experience of North Carolina and what families in North Carolina need and are looking for when they’re pregnant. I think that the delegation of care management or case management helps to keep families connected with resources that are local to them, maybe their provider who they’re more familiar with, or someone they’re engaged with regularly.
Comparatively, some of the things that we see that are similar [to other states] are a lot of the barriers and just awareness of things like expanded postpartum coverage. Not everyone knows and there’s not an easy way to promote it, especially if it’s something that is automatic in terms of you just become eligible for it. It’s hard to build that awareness. And I think we tend to see less utilization of those benefits.
Something else that seems to be a barrier across the states that I’ve worked in is access to behavioral health services when you’re pregnant. That seems to be something that nationally a lot of states are struggling with in terms of access and providers who are specifically prepared and willing to serve people who are pregnant.
Brady Blackburn: You mentioned Managed Care as something that makes North Carolina unique. Could you tell me a little bit about how Managed Care Organizations should support pregnant people with Medicaid insurance?
Jessica Beach: Yeah, I mean, I think that there are a lot of great examples in North Carolina of how Managed Care Organizations currently or should support Medicaid beneficiaries. There are connections to local community resources that are kind of specific to the unique needs of pregnant people and their families. I think that, you know, [a part of it is] being intentional about identifying those resources and having a systemic way to connect people, leveraging all of the systems that exist within North Carolina to do that so that we’re constantly kind of reconnecting folks back to their local community, and then also having really strong, responsive relationships with those delegated case management entities for folks who are high risk so that communication is there, the transitions are there, and they’re getting the attention that they need. And those relationships are there, so there can be the smooth sharing of information across the board.
Brady Blackburn: So, we’ve talked a little bit about some barriers, from navigating the system, understanding eligibility, and even understanding what services are included with your Medicaid insurance. What are some of the most common barriers you see for individuals trying to enroll in or navigate the Medicaid for Pregnant Women program?
Jessica Beach: Yeah, I think that some of the barriers that I’ve seen most often are probably connected to access to certain types of services. I think something that is not unique to pregnancy Medicaid is access to care in rural areas. We have a number of maternity care deserts in North Carolina. You know, just because a service is covered, if you can’t find a provider locally who will actually serve you, that is a challenge. And so how do we navigate those barriers with an eye to what beneficiaries need, what Medicaid members need?
So, I think those are some of the barriers: access to services—I mentioned earlier behavioral health services.
[Pregnancy and postpartum periods are] really critical times to engage in behavioral health treatment if there is a need. I think particularly for folks who maybe have a substance use experience or a background of that, sometimes it’s harder to get access to those services when you’re pregnant because providers are hesitant to serve pregnant people. And then I think in more global perinatal behavioral health, there’s not as many of those providers across the state. I don’t think that’s necessarily unique to North Carolina, but it is a challenge when you’re thinking about, how do I ensure I’m getting the best possible access to high-quality care when I’m pregnant?
Brady Blackburn: Absolutely, and as the 2nd largest rural population in the country, I think what you’re mentioning about rural disparities in particular, are uniquely felt in North Carolina.5 So, from your perspective, where do you see the biggest opportunities to strengthen Medicaid coverage or care delivery for people during pregnancy and postpartum?
Jessica Beach: I think the biggest opportunity, for one, is workforce development, because for a lot of the barriers I mentioned, it’s not just an issue for Medicaid or an issue for rural North Carolina. It’s an issue that those providers don’t exist or that there’s really limited access to the providers. So, I think workforce development is really critical. I think responsive rate setting is really important in terms of getting as many providers as possible to accept Medicaid. And I know that the financial component is always a barrier, especially, you know, with where we’re at right now. But I think those are some of the big opportunities.
I think also, you know, coordination of services locally, building awareness of the resources that exist, strengthening relationships between those resources. There are a lot of great examples across North Carolina where this is happening at the local level. And kind of working to break down some of those silos that we see between systems, right? There’s a lot of great examples out there in North Carolina of that happening to address some of these care navigation issues.
I think that also the local health departments are really great with helping to support some of that navigation for all Medicaid beneficiaries, but especially for pregnant families. So, I think just kind of building on those opportunities—continuing to fund expanded postpartum coverage is a really critical piece of a lot of this as well.
Brady Blackburn: Next, I want to talk a little bit about some policy changes, both at the state and the federal level. In 2022, North Carolina extended postpartum coverage under Medicaid for Pregnant Women from 60 days up to 12 months.1 The legislation that authorized this extension also allowed NC Medicaid to add new coverage, including for oral health care, which had previously ended at birth. Why is postpartum coverage important, and how does something like an extension from 60 days to 12 months—how does that help people access the care they need?
Jessica Beach: I mean, where to start? There are so many critical pieces within that 12-month window. Before the expanded coverage, like you said, at the 60-day mark, that’s when Medicaid coverage would end. I think that what we’ve learned about maternal mortality and morbidity is that’s not enough time for someone to have access to a provider, right? We look at maternal mortality and morbidity in the full, you know, 12 months after the end of a pregnancy, and to lose coverage at 60 days and not have access to care is really detrimental to so many that are on Medicaid. If you don’t have access to a provider, you’re probably not going to go because you’re scared you can’t afford it. And that contributes to people dying. So having that extended coverage is really, really critical.
I think some of the other issues that it touches on with the expanded access to postpartum care is it gives people time to reintegrate into, you know, normal health access behaviors, right? When you’re pregnant, you’re going to the doctor really, really frequently, even if you’re not a high-risk pregnancy. You’re following a set schedule of appointments. You have a baby. And now you have a baby, and the baby has all of these appointments. You may have—you ideally have—at least one postpartum visit. But after that you’re kind of disconnected.
And so, the extended postpartum coverage for Medicaid also creates a great opportunity to continue that care journey and get reengaged with a primary care provider. Especially if you maybe have a chronic condition, a behavioral health need, just kind of making sure that you’re still getting the things that you need. And focusing, not just on the baby, but on the health of the mom.
And so, I think that’s kind of the big issue for me when I think about why extended postpartum coverage is so important: it allows you to set that strong value around family health and wellness.
I think that with the postpartum period, generally expanding that coverage, it also touches on treatment for other chronic physical conditions. So just kind of anything that’s creating that touch point back. One of the barriers I think we see is general awareness of this. Do folks know that they have access to expanded postpartum coverage? How do we promote that better? I mentioned that a little bit earlier, but I think that’s where a lot of our opportunity lies as well—how do we get the word out about this extended coverage? How can pregnancy providers be working towards the end of a pregnancy to help a mom plan that navigation in the same way that you plan to identify a pediatrician for your child? Can we also set up mom with her postpartum follow-up that’s with primary care, not just postpartum? You know, you have your postpartum follow-up visit with your pregnancy care provider, but also kind of like a warm handoff to your preventative, your primary care provider.
A lot of times people are coming to Medicaid pregnant because they’re now eligible for Medicaid. So, they may not have had a primary care provider before then because they didn’t have coverage. This is a critical time to say, “Hey, you’ve been engaged in the health care system. You may have identified some broader physical health or behavioral health needs throughout this process. This is a time for you to get connected with your primary care provider.”
Brady Blackburn: So, as we have worked on our upcoming December issue of the NCMJ, which is all about Medicaid in North Carolina, we’ve heard concerns about North Carolina Medicaid for Pregnant Women following the passage of federal House Resolution 1 earlier this year. With large funding cuts on the horizon, these concerns have been about any Medicaid-funded program that isn’t deemed absolutely essential. Especially considering the relatively recent expansion of North Carolina Medicaid for Pregnant Women, do you share concerns about its future?
Jessica Beach: Yes, absolutely. I think that anything that is not required to receive the federal match for Medicaid concerns me greatly, including Medicaid, the expanded coverage for postpartum. I just think that we’re in such an almost crisis in the Medicaid space right now. There’s so many things that are up in the air. And I think that’s what scares a lot of people. I’m worried that anything—like I said, anything that’s not required to be a part of a Medicaid program has the potential to be cut. But the reality is we don’t really know what the answer is. We know that there are likely cuts coming to Medicaid in North Carolina and in many other states. It’s just we don’t know where.
As I mentioned, there’s so many benefits to this expanded postpartum coverage. There are so many benefits to Medicaid expansion in North Carolina. North Carolina has been able to cover so many more lives with Medicaid because of the expansion. That’s had just amazing impacts on health outcomes and has the potential to, you know, continue to have those critical impacts and support rural health systems. Really kind of continuing this good work. But we’re at a time now where it looks like anything is potentially on the chopping block for Medicaid, which is really scary.
So, I think ultimately my answer is yes. I am worried, and I think that it’s a risk and it’s something to consider. I think we have to be as proactive as possible in terms of advocating for why these things are important, to you personally, to your community, to the state. I think that just building that awareness of why this coverage is so critical and is really important right now.
Brady Blackburn: Absolutely. I think that’s a really good point to wrap this interview up, just the juxtaposition between just how far North Carolina has come in recent years—expanding access to postpartum coverage, really opening new doors for pregnant people who previously didn’t have care either while pregnant or after they were pregnant—but also juxtaposing that with the current reality that these funding cuts are coming, and we don’t necessarily know what that means quite yet.
So, I think there’s a lot of reason to be hopeful for North Carolina and a lot of reason to be concerned and very wary of the future for programs like Medicaid for Pregnant Women.
Jessica, I want to thank you for your time today. I really appreciated talking with you and learning more about Medicaid for Pregnant Women and your perspective on maternal care. This has been an interview for the NCMJ, and we really appreciate your time.
Acknowledgments
The interviewee has no conflicts of interest to declare.