In 2022, Camber began working alongside City of Hope to envision a robust model for supportive care services that provides comprehensive whole-person care for patients undergoing cancer treatment such as physical, practical, emotional and psychological, social, educational, and spiritual supports. We had the opportunity to build on that work in 2023, collaborating with the client to strategize how to potentially leverage technology to extend the supportive care services model beyond the City of Hope ecosystem

One of the key objectives of the project revolved around expanding supportive care access to underserved populations who face systemic socioeconomic, racial, or geographic barriers to care and often suffer inequitable and subpar health outcomes as a result. Such inequitable outcomes serve to compound the myriad injustices that typically characterize the under-resourced members of our society.

As a first step in exploring how to expand access to City of Hope’s supportive care model to all those in need, especially the underserved, Camber launched an extensive primary research campaign revolving around three key activities—convening an Advisory Board comprising supportive care subject matter experts; fielding a survey of cancer patients; and conducting focus groups with cancer patients, survivors, and caregivers. While the strategic insights gleaned from the Advisory Board meetings, we facilitated were invaluable, it was imperative to balance the insights garnered from those who operate from a place of authority with those affected by cancer as patients and caregivers who often do not have a guaranteed seat at the table.

Camber thus placed great emphasis on ensuring that the content, structure, and delivery of the survey and focus groups was considerate of the circumstances of cancer patients, survivors, and caregivers as well as designed to generate a deep understanding of a diverse set of needs. Given the sensitive nature of our primary research topic—living the cancer journey, from diagnosis to hopeful remission—we collaborated closely with the client to craft survey and focus group questions using appropriate and respectful language that provided the space for authentic sharing. To include the voices of non-English speakers, we worked alongside City of Hope to translate questions into Spanish; though Camber is cognizant that cancer is not limited solely to Spanish and English speakers, these two languages combined are spoken at home by ~90% of Americans. Finally, we sought to ensure that survey and focus group participants were representative of the US cancer population, especially with regards to their geographic, financial, and racial/ethnic backgrounds.

Camber leveraged everything we learned from the survey and focus group participants to better understand the different barriers preventing people from benefiting from supportive care services as well as which services should be prioritized. We utilized this nuanced understanding to develop the overarching model for a digital supportive care services tool expressly designed to mitigate access barriers and provide those services deemed most in need and/or most impactful by our primary research participants. Our recent work with City of Hope reinforced the importance of employing an intentional approach to understanding and addressing health inequities that not only elevates the voice of those most impacted, but also is cognizant of the historical and social roots of those inequities—and the Camber US Health team is excited to continue to further build out and refine this approach through our 2024 project work.

Part One: The Basics, and the Basic Problem

With the recent Congressional and Presidential declaration that the Covid emergency “has ended,” there remain a lot of questions and confusion about what Americans can expect, and about how our healthcare system operates in general. Our Director of Impact and Equity Rozella Kennedy sat down with our Director of US Health Kim Langenhahn for a far-reaching conversation about US healthcare and its many facets, angles, deficits—but also opportunities and bright spots in the quest to provide equitable, quality healthcare more broadly to people living in the United States. This is a jam-packed conversation, so we will parse it into two parts. Enjoy Part One, where we look at the “end of the pandemic,” and some general facts, figures, and frustrations about US healthcare as it currently is delivered. Part Two will dive more into issues around (in)equity and how societal shifts are pointing towards some possible encouragements.

US Healthcare 101

Rozella Kennedy: So, to start off this conversation Kim, can you provide a high-level description of what healthcare access actually is in our country?

Kim Langenhahn: Sure. Knowing that no national healthcare system is perfect, we could start with a comparison and contrast. When you think about a place such as the United Kingdom, they have a single-payer system, with care provided through government-based providers. That leads to one holistic system that ostensibly covers everyone’s healthcare needs in the country.

RK: Ostensibly.

KL: Right. While some people may fall through the cracks, the structure lends itself to greater simplification and less of that kind of risk.

Now on the other hand, when you think of the US, it’s really a mixed system. We have a combination of private insurance, with some of those insurers being nonprofit, and others for-profit. Add to that the government, which covers some forms of public insurance, it’s quite complex.

When it comes to private insurance, a majority of the people in the US—I’ve seen data that says at least half of the people—get their coverage through an employer-based insurance program.

And there are even more layers of complexity to contend with. Small businesses often do not, or cannot, offer insurance. Many employers provide coverage that does not meaningfully meet the actual needs of the employees at all.

RK: Entrepreneurs have to cover themselves, which makes it extremely difficult to launch a successful business or start-up.

KL: That’s right. And even among the half of insured people who receive coverage through their employer, there are so many people who do not have access to those types of jobs. The fortunate among them may find they can be covered through a government program like Medicare or Medicaid.

RK: Oh, so there is a safety net!

KL: Not so fast. Those systems are really fragmented, particularly Medicaid. The money for this entitlement comes from the federal government, but each state creates its own laws and policies and regulations, and each state runs its own Medicaid systems.

Let’s Get into Dollars and Sense

RK: States’ rights. The lottery of location.

KL: Compounded with the market-based core of the American society, we are left with a system that has lots of gaps and leaves lots of people behind.

RK: Connecting healthcare to money and maximizing profit seems to invite cost-cutting, price gouging, and other practices—all on the backs of healthcare patients.

KL: This is a sad fact. And we live in a nation whose organizing economic principle is capitalism. I am not saying capitalism is inherently evil, but the way we give it primacy and the way that we do not do a good job of regulating and putting in guardrails from government, that’s where things get problematic.

RK: I’m old enough now to remember when there was a safety net, flawed or not, in the tradition of FDR’s Great Society, fortified by LBJ—and decimated, by design, during the Reagan years. I personally heard the stump speeches where he said the nine most terrifying words in the English language were: “I’m from the government and I’m here to help.”Many of us are aware that it has been a decades-long plan to diminish federal government services. The outcome is this fragmentation, complexity and too many people falling between the gaps. Many of the people working in health equity arena say this is deliberate.

Let’s talk about the “gaps” for a minute and who falls between them. We can start with the more privileged strata of society. I have good insurance coverage, but the system is so complex, because of a new doctor’s appointment I had two days before the end of the calendar year, and how my provider coded the visit, I was on the hook for some $600 and could not apply my HSA to it. I should have waited a week. I was furious!

KL: Yeah, it’s a mind game trying to navigate it all. Even if you do have the information and the resources.

RK: Paying it was an annoyance but not a catastrophe. But I couldn’t help but think about people with less-good care, or no care at all. Or who, for a variety of reasons—not just money or coverage but also negative personal or family experiences with inferior care discrimination, bias, and harm, or don’t trust the healthcare system and don’t engage in preventative care … every time there is a cold, they are in the ER.

Because they don’t have a general care provider, they don’t get checkups. I have relatives who live this way, so this is not some theoretical.

KL: There are so many ways people can be alienated from care and healthcare awareness. Not least of which from the very poorest or unhoused people, but there are also the folks who work two and three jobs, or who don’t have control over their work schedules. They have enormous constraints on their time.

So even if they do have employer-based insurance and, presumably, access to “quality care,” they’re not going to be able to just go in and see a doctor, right?

RK: And if they get to the point where they are sick enough, they go through the ER. This exacerbates this ethos of scarcity and inconvenience and panic for people who are already struggling. Emergency rooms are traumatic places! The lights, the cacophony, the long, long waits. It’s demeaning.

I really think we’re in a societal spiral of stress and sadness and lacking. It’s a tragedy, from an equity standpoint, and actually, from a humanity standpoint.

KL: Even if I could set aside the morality of ensuring people have access to those things they need to live full, healthy lives—which is not something I can actually do—there is still the economic fact that many hospitals are nonprofits operating under charity status, meaning they have to provide a certain amount of care to people who show up whether they’re insured or not.

And if the patient cannot pay, that cost is eventually paid by us, the taxpayers.

RK: It’s nonsensical. Non-cents-ical, if I could make a terrible pun.

KL: Indeed. Just consider the economic impact in terms of the increased cost and lost productivity, again, it should not pass anyone’s capitalist-efficiency standard.

The Pandemic Temporarily Tightened the Safety Net

RK: (Deep sigh.) And so, we had the pandemic, during which many healthcare protections were put into place.

There was more access to telehealth, it became easier to get prescriptions through a video call, and other benefits. And as they say, once the public has been given a benefit or entitlement, it is extremely difficult to take it away. But away some of it has gone…. Seriously, we had something close to guaranteed income for a minute, right? And as far as I know, there were no statues of Karl Marx erected anywhere…. We did not devolve into a Communist dictatorship.Can you provide for the layperson, the landscape of some of the protections that were put in place during the pandemic that are now gone?

KL: Certainly. Throughout the course of the pandemic, there were a lot of moving parts, with a lot of different legislation put in place relating to the overall well-being of the population and specifically in the health sphere. To elaborate fully would require at least a few more interviews, but one of the most notable pieces of legislation was implemented in the very beginning of the pandemic: “The Families First Coronavirus Response Act.”

This legislation provided increased federal Medicaid funding for all states, provided they followed some rules. One of these rules was a requirement to maintain continuous coverage for people within the Medicaid system.

RK: Guaranteed Medicaid?

KL: Yes. Pre-pandemic, it was up to each state to annually re-evaluate whether a beneficiary would be eligible to receive continued Medicaid benefits, a process called redetermination.

People could, and did, (and will) fall off the rolls for a variety of reasons: their contact information is no longer up to date, or they no longer meet the income thresholds, and other factors.

During the pandemic, the federal government declared: “We’re going to scrap the redetermination process. For the duration of this public health emergency, people will remain enrolled in Medicaid, no matter what.”

RK: That sounds good, making sure people don’t get kicked off healthcare because maybe they are going through other tough situations, like eviction, illness, divorce, or any other reason that might lead to contact information going awry. On top of a global pandemic that caused more than 1.1 million fatalities in the United States between 2020 and today.

KL: It was a humane response to an unfathomably frightening and chaotic public health crisis. And so, we had this moment in time over the last couple of years where people were not getting bumped off Medicaid.

And at the same time—no surprise—we had record numbers of people signing up for Medicaid. Between the beginning of the pandemic and toward the end of 2022, we had almost 21 million additional people enrolled in Medicaid. This is a very significant number.

RK: You told me at the peak, there were over 90 million Americans covered by Medicaid.

KL: Correct. Now, to be clear, some of those numbers included children who are covered by CHIP, the Children’s Health Insurance Program. But nonetheless, you saw enormous numbers of previously uninsured people getting access to healthcare coverage. This was, I think, America’s biggest step toward universal coverage.

RK: And it was good, right?

KL: So it was. It was an interesting social experiment.

RK: And we didn’t send anyone to a Gulag.

KL: No, as you said, we did not devolve into a socialist state by providing some folks additional coverage. It was, on the whole, a good thing—especially for people who are typically left out of that patchwork American system that we talked about earlier.

There Really is No “Us” and “Them”

RK: There is a subset of our population that is historically always on the losing equation of anything approaching prosperity or dignity, or even minimal service to live and thrive. We address this discrepancy in a lot of our Economic Mobility work. And when we are discussing healthcare, I think it’s important to say that this is not entirely racial. It’s not just Black people. It’s not just Brown people. I read something there are more poor white people in the United States than any other racial group.

KL: Yes, the number of white people living in poverty greatly outstrips the number of impoverished Black people. However, the percentage of Black people living below the poverty line is twice that of whites. So yes, this goes beyond the color of your skin.

RK: And it’s older people. It’s rural people, it’s disabled people. Can you give us a lens into some of the groups and untold stories that people need to be thinking about when they think about health equity in the big picture.

KL: This is an enormous topic, Rozie, but let me share at least that there is such a convergence of -isms and deficits at play.

A whole host of people are being imperiled when they don’t have access to care. The causes for this lack of access range from structural racism to lack of economic mobility to the affordable housing crisis to the expensive education system which creates a lack of access to quality education, especially when you consider the importance of early education.

We don’t have enough kids in quality early education programs and at the end of the day this creates the system where you have a group of people who are more likely to experience employment volatility or unable to get a job, among many other adverse outcomes.

RK: This relates to what we were discussing regarding people falling off the Medicare rolls for reasons that are not necessarily their ‘fault.”

KL: Correct. We have a large group of people who have trouble securing safe, affordable housing and maintaining that housing. And they are prone to have a harder time keeping their contact information up to date with government agencies, and they’re the ones that have a harder time verifying their employment and income stats.

Additionally, because of time commitments, resource constraints, even lack of access to reliable transportation, they often don’t have the time or wherewithal to fill out the paperwork or answer the necessary questions.

KL: Further, as we said, the system is full of complexity. There is certainly a good portion of this population that don’t even understand how the process works and what they should be doing to make sure that they maintain the Medicaid benefits.

RK: On a bad-attitude day, I’d almost say it is deliberate punishment of the poor.

KL: This falling off the registry is called “administrative churn,” and there’s some pretty distressing statistics related to this. When you consider that the public health emergency has been sunsetted, and that the redetermination process is once again happening, it is estimated that upwards of 18 million people could lose Medicaid coverage due to this administrative churn or no longer meeting the Medicaid requirements. 

There will likely be a differential racial impact here.  Almost half of the 18 million people projected to lose Medicaid will be Black or Hispanic, despite the fact that when combined, they comprise approximately 33% of the overall population.  And when we are talking about those most likely to lose Medicaid due solely to administrative reasons, Hispanic beneficiaries will be disproportionately impacted.

RK: It’s shocking to think we are going backwards.

KL: A number of those people will be able to secure alternate insurance through an exchange or potentially through a new employment situation. But four million or so could become fully uninsured.

Within that group of 18 million that are projected to lose Medicaid coverage, there are seven million that they are thinking will lose it purely due to this administrative churn that we just talked about. 

RK: That is not great in any way, America! Let’s take a breath here and continue this conversation next week.

Kim Langenhahn draws on more than 15 years of consulting, operational, and startup experience in the domestic and international health and nonprofit sectors to help organizations navigate complex issues, operate more effectively, and deliver greater impact. During the course of her career, Kim has helped numerous healthcare organizations tackle a variety of strategic challenges such as scaling Terrapin Pharmacy’s remote medication adherence system, launching a MENA-focused healthcare incubator, devising system-wide strategy for the Saudi Arabian Ministry of Health as part of PwC’s consulting practice, and developing a market forecast for a pharmaceutical company alongside her L.E.K. Consulting colleagues.  She is also the Cofounder of a small social enterprise that she runs with her family

Kim earned a Master of Business Administration and a Master of Public Policy from the University of Chicago as well as a Master of Science in Quantitative Management and a Bachelor of Arts from Duke University.  An avid traveler, reader, bread baker, ice cream churner, and (aspiring) cheese maker, she also enjoys helping her husband tend to their rooftop garden and vermiculture operation.  She currently resides in Washington, D.C.

As Camber Collective’s Director of Impact and Equity Rozella Kennedy helps direct the firm’s internal Impact, Equity, and Belonging work as well as the external practice. Her theory of impact seeks to leverage equitable values to influence and impact the humanitarian, development, philanthropic, and social impact sectors. The long focus is to expand awareness and practice in local and global post-colonial contexts. Rozella is also the creator of Brave Sis Project, a lifestyle brand using narrative and social engagement to uplift BIPOC women in U.S. history as a tool for learning, growth, celebration, and equity allyship; her book “Our Brave Foremothers: Celebrating 100 Black, Brown, Asian, and Indigenous Women Who Changed the Course of History” was published by Workman Press in Spring, 2023.

… Between the Redetermination Process, Expanded Maternal Coverage, and the Ongoing Struggle for Health Equity 

Introduction

The Consolidated Appropriations Act, passed in December 2022, illustrates how any change to the American social safety net requires sub-optimal compromises and trade-offs. This give and take is particularly present in today’s partisan political environment. Case in point: the $1.7 trillion federal omnibus spending bill introduces Medicaid provisions that will simultaneously reduce insurance coverage for certain enrollee subgroups while expanding it for others—effectively creating a coverage tug of war among our most vulnerable populations. While this legislation can be seen as a victory for maternal health coverage (albeit a somewhat limited one), in aggregate it will likely reduce access to care for those who need it most. The maternal health provisions will undoubtedly help improve both gender and racial health equity in maternal and newborn care; however, the Medicaid redetermination process will have a disproportionately negative impact on current Black and/or Hispanic* enrollees (see Figure 1).

Evolution of Medicaid Coverage in the Wake of the COVID-19 Public Health Emergency

To anticipate and address the nation’s healthcare needs during the COVID-19 public health emergency (PHE), the Families First Coronavirus Response Act (FFCRA) was signed into law in March 2020. Notably, the FFCRA provided increased federal Medicaid funds to states with the stipulation that they abide by specific requirements, including prohibitions on involuntary disenrollments and decreased income eligibility levels. Over the past three years, the Act’s continuous coverage provision has played an effective and impactful role in mitigating both Medicaid “churn” (the temporary loss of coverage in which enrollees disenroll and then re-enroll within a short period of time) as well as the outright loss of coverage that often occurs due to changes in employment status and/or income.[i]

As a result, the Centers for Medicare & Medicaid Services (CMS) estimates that Medicaid ranks swelled by 20.5 million enrollees between February 2020 and October 2022, a massive 32% increase. The net impact of the FFCRA is 91 million Americans, including 41 million children, being covered by Medicaid and CHIP programs—a record.[ii] The primary driver of Medicaid enrollment growth was not the addition of new program participants but rather the retention of existing enrollees.[iii] Notably, the pregnant individuals eligibility group experienced the greatest increase in enrollment during the pandemic, adding more than 650,000 expectant-mother beneficiaries to the Medicaid program, a 62% increase over pre-pandemic numbers. Not only does the enrollment increase for this subgroup point to a significant gap in maternal coverage under pre-pandemic policies, it also highlights the marked health disparities between racial groups in the U.S.[iv]

Despite making up about one third of the general U.S. population, pregnant Black and Hispanic women** comprised approximately 55% of the increase in expectant-mother Medicaid beneficiaries due to the continuous coverage provision (see Figure 2). Without the protections offered by this type of provision, pregnant Black and Hispanic individuals struggle more than other racial and ethnic groups to secure and maintain access to coverage, putting both mother and baby at risk.

After three years of steady and stable Medicaid expansion, the 2023 Consolidated Appropriations Act is poised to eliminate a significant portion of these coverage gains. The legislation eliminates the continuous coverage requirement as of March 31, 2023, allowing states to once again begin the process of Medicaid eligibility redeterminations and disenrollments. The federal government implemented guardrails to ease the Medicaid redetermination process such as a gradual ramp down of the enhanced Federal Medical Assistance Percentage (FMAP) match implemented during the public health emergency and data reporting requirements for the states. Unfortunately, such provisos will not prevent significant loss of coverage for many people because most states simply do not have the budget surplus necessary to sustain higher coverage without the injection of enhanced federal assistance.

The Impact of Coverage Redetermination on Racial Health Equity

The Urban Institute estimates that 18 million people will lose Medicaid coverage between April 2023 and May 2024, with approximately 4 million becoming uninsured as a result.[v] The Department of Health and Human Services (HHS) projected that approximately 45% of those people likely to lose Medicaid, either due to the outright loss of eligibility or administrative churn, are Black or Hispanic. The disparity is striking when one considers that these groups combined comprise only 33% of the American population.[vi]

According to HHS estimates, approximately 7 million eligible people will lose Medicaid coverage solely due to administrative challenges resulting from the redetermination process. These administrative roadblocks requiring beneficiaries to “prove” their eligibility include lengthy wait times, unreasonable deadlines, burdensome and missing paperwork, lack of knowledge about the redetermination process, and incorrect contact information. The structural racism embedded in American social systems further exacerbates the difficulties faced by People of Color, who are more likely to experience housing and employment volatility. The compounded issues make it difficult for state agencies to contact eligible individuals and verify administrative details such as income level and current address. For this reason, Hispanic enrollees are more likely to lose coverage due to administrative issues than white Medicaid enrollees (see Figure 3).[vii]

The Impact of the Recent Federal Legislation on Maternal Health

Prior to the American Rescue Plan Act of 2021 (ARP), federal statute mandated that states provide pregnancy-related Medicaid care for only 60 days postpartum with a minimum income threshold of 138% of the federal poverty line (FPL). While some individuals would qualify for Medicaid coverage via other means after this 60-day window closed, an estimated 45% of new mothers would lose coverage under this stipulation.[viii] Effective April 2022, the ARP gave states the option to extend postpartum care and receive matching federal funds for 12 months of post-birth coverage through the use of state plan amendments. The stipulation that this option would expire in 2027 led some states to demur from expanding coverage that would need to be rolled back in the near future. Given the unacceptable U.S. maternal mortality rate—The Commonwealth Fund estimated that the U.S. recorded 23.8 maternal deaths for every 100,000 births in 2022, a maternal mortality rate that is more than three times that of France, the country with the second-highest rate among developed nations [ix]—a concerted effort was undertaken to advance maternal health. A stipulation in the December, 2022 Consolidated Appropriations Act provided a fortuitous outcome as it eliminated the 2027 expiration date, thereby establishing permanency for the 12-month postpartum coverage option.

The World Health Organization (WHO) defines the postpartum period as beginning at childbirth and lasting around six weeks, encompassing the time during which the mother‘s body begins transitioning to a non-pregnant state. While an estimated 35% of pregnancy-related deaths in the U.S. occur between one and 42 days postpartum, approximately 30% occur between 43 and 365 days postpartum. [x] This statistic clearly indicates that after-birth care must extend beyond the generally accepted six-week postpartum period. Loss of insurance coverage and lack of access to care are driving factors of many of these deaths, including those that occur months after giving birth. According to the CDC, between 60% and 80% of all pregnancy-related deaths are preventable. Thus, the pre-pandemic federal policy that mandated only 60 days of postpartum coverage created a potentially life-threatening gap in care, one that inordinately impacted nonwhite individuals. As an example, Medicaid covers approximately 40% of births nationwide—2 million mother-baby pairs—but that number increases to nearly 70% for Black individuals.[xi] Furthermore, maternal mortality rates are three times higher for Black women than white women.[xii]

While the coverage extension option is undoubtedly a step in the right direction for maternal health, the fact that it remains an option for states, rather than a mandatory requirement, certainly blunts the policy’s impact. Despite this deficiency, a majority of states currently support expanded coverage. As of March 2023, 28 states plus the District of Columbia have elected to adopt 12 months of postpartum coverage; it is expected that additional states will follow suit this year (see Figure 4).[xiii] It is estimated that this policy change has provided approximately 500,000 individuals with extended postpartum coverage and, if all states adopt the measure, an estimated 720,000 people would be eligible for a full year of postpartum care.[xiv]

According to Congressional Budget Office estimates, it would cost the federal government $1.2 billion over 10 years if all 50 states plus the District of Columbia implemented the extended postpartum coverage provision.[xv] Assuming that the U.S. live birth rate increases 1% per annum over the next decade, while the maternal mortality rate remains constant, many lives would be saved. Indeed, our calculations project that, if all states extended postpartum coverage from 60 days to a full year, approximately 960 maternal deaths would be prevented.

Even beyond the moral imperative of valuing the lives of each expectant mother in America, the economics of savings lives is obvious. Expanding upon the above scenario, the estimated cost per life saved would be $1.3 million, well below the mean value of a statistical life (the estimate of the willingness to pay for small reductions in mortality) of $9.4 million in today’s dollars (see Figure 5).[xvi] [xvii] The implementation of full-year postpartum coverage across all states is clearly a cost-effective policy in addition to an ethical one.

It is worth noting that this analysis likely underestimates the cost per life saved by extending postpartum coverage, because the calculation assumes a constant maternal mortality rate. The fact is however, that extending coverage to a full year will undoubtedly decrease this rate even further. Additionally, the cost per life estimate of extended postpartum coverage likely fails to fully reflect the overall positive impact and effectiveness of this policy since it does not account for the holistic impact on mother and child health.

Extended postpartum coverage is an issue that cuts across partisan boundaries—at least to some extent. Of the 24 states that have banned or are expected to ban abortion since the US Supreme Court overturned Roe v. Wade in June 2022, half have elected to provide a full year of Medicaid coverage post-birth.[xviii] Notably, seven of the 11 states that have not expanded Medicaid in the wake of the Affordable Care Act (ACA), such as Georgia, Florida, and Tennessee, have implemented full year postpartum coverage. While the expanded postpartum coverage is undeniably helpful in improving maternal health outcomes, for many people, it simply postpones the inevitable loss of coverage, especially in the non-Medicaid expansion states where income limits for non-pregnant adults are typically well below 138% FPL.[xix] [xx] On the other hand, a number of Medicaid-expansion states such as Arkansas have been slow to extend postpartum coverage to a full year. This state consistently ranks among the worst in the nation when it comes to maternal mortality with 30.2 maternal deaths per 100,000 live births. This rate greatly exceeds the national average of 23.8.[xxi] When racial disparities are layered on top of such dismal statistics, the outcomes are even more stark. In Arkansas, Black mothers are more than twice as likely to experience a pregnancy-related death than white mothers.[xxii]

It is likely that not all states will elect to provide 12 months of continuous postpartum care, putting numerous mothers at risk, with nonwhite mothers bearing more of that risk, especially in those states that have implemented abortion bans in the post-Roe era. In December 2021, the University of Colorado quantified the uptick in pregnancy-related deaths that would occur due to the heightened mortality risk of continuing a pregnancy as opposed to having a legal abortion—a 21% increase across all women, but a 33% rise for Black women.[xxiii] While this study, published in advance of the Dobbs v. Jackson Women’s Health Organization decision, assumes a national ban on abortions and is not specifically focused on the postpartum period, the findings are illustrative of the U.S.’ inequitable maternal health policies.

Looking Forward

Since 2020, the federal government has passed a patchwork of legislation, much of which contained embedded critical health policy shifts, even though healthcare was rarely the principal focus of such legislation. Not surprisingly, this approach creates outcomes that lack coherence and consistency in terms of their effect on the Medicaid safety net. This access and equity tug of war is emblematic of the often-paradoxical impacts of Medicaid, the “single most important publicly funded health program for low-income and underserved people,” yet one that suffers from “racism baked into the system” because it was established as an optional program for states borne out of the country’s pre-existing welfare infrastructure.[xxiv]

To amplify the positive effects of the Medicaid policy changes taking effect this year, key stakeholders such as state agencies, advocacy groups, philanthropic organizations, Medicaid managed care organizations (MCOs), communications specialists, and health technology companies should pursue targeted tactical activities, including the following:

1. Leverage Data and Community-Based Outreach

Those states that have elected to extend postpartum coverage to a full year should launch targeted outreach campaigns to ensure that everyone eligible takes full advantage of this expanded access to care, especially pregnant Black and Hispanic women. These campaigns should be multi-faceted and data-driven, bringing together key stakeholders in support of shared goals. Furthermore, this outreach should leverage community-based approaches that revolve around specific needs and circumstances as well as tap into trusted relationships. Campaign messaging should be designed strategically, taking into account the particular preferences and attitudes of different communities.  

2. Take Steps to Limit Administrative Churn

To mitigate the negative effects of what is sure to be a burdensome redetermination process, states should endeavor to minimize administrative churn as much as possible, especially among Hispanic beneficiaries, leveraging enrollment navigators as well as working with peer social services or support organizations to confirm and share contact information. Additionally, states should seek to both improve the ex parte renewal process, the first step in Medicaid redetermination whereby states can automatically attempt to renew coverage by consulting available data sources to confirm eligibility for certain enrollees, as well as increase the number of successful ex parte renewals. One method is to review the internal documents that define which cases can be renewed ex parte and determine what reasonable changes could be made to the definition and the business rules undergirding the renewal system itself. Additionally, it may be helpful to leverage supplemental data sources such as the Supplemental Nutrition Assistance Program (SNAP) to increase the percent of cases successfully handled via the ex parte process.[xxv]

3, Engage Partners for Support

State agencies and Medicaid MCOs should consider seeking temporary external assistance to help share the workload and mitigate churn. Philanthropic funders can help bridge the gap here, providing financial support to implement or expand navigator programs and facilitate data sharing. Additionally, healthtech innovators have the opportunity to step in and provide solutions related to data management and systems optimization.

*While “Hispanic” and “Latino” are often used interchangeably, and many readers show a preference for one or the other designation, or perhaps “Latino/a/e/x,” this paper uses “Hispanic” to align with Census and other federal data tracking conventions

** In line with statutes and regulations, Camber uses the term “women” when referencing individuals whose sex assigned at birth was female; however, we recognize that not all people who give birth identify as women.

Kim Langenhahn draws on more than 15 years of consulting, operational, and startup experience in the domestic and international health and nonprofit sectors to help organizations navigate complex issues, operate more effectively, and deliver greater impact. During the course of her career, Kim has helped numerous healthcare organizations tackle a variety of strategic challenges such as scaling Terrapin Pharmacy’s remote medication adherence system, launching a MENA-focused healthcare incubator, devising system-wide strategy for the Saudi Arabian Ministry of Health as part of PwC’s consulting practice, and developing a market forecast for a pharmaceutical company alongside her L.E.K. Consulting colleagues.  She is also the Cofounder of a small social enterprise that she runs with her family

Kim earned a Master of Business Administration and a Master of Public Policy from the University of Chicago as well as a Master of Science in Quantitative Management and a Bachelor of Arts from Duke University.  An avid traveler, reader, bread baker, ice cream churner, and (aspiring) cheese maker, she also enjoys helping her husband tend to their rooftop garden and vermiculture operation.  She currently resides in Washington, D.C.