Meeting the Medicaid moment

This year, a decade of maternal health innovation and federal payment reform are set to collide.

Last December I went to the White House.

Vice President Kamala Harris was convening a small roundtable on maternal health—not to discuss America’s problems (which are well-documented) or even ideas to fix them (which have been long-evident). This meeting was to review working solutions, and to announce a government plan with the potential to weave them into the fabric of the American health system. 

Inside the Vice President’s ceremonial office is a handsome, century-old mahogany desk that I was told survived the 1929 fire that engulfed much of the West Wing. Everything about the room—the sage green walls, ornate chandeliers and oil portraits—imbues an unmistakable sense of living history.

Government has the power to do truly great things. And yet, to make lasting change, industry must be at the table.

Representing Maven, I spoke about the promise of digital health. Mostly though, I marveled at the fact that we were there. For most of my career, maternal health has flown under the radar of presidential attention. 

The aforementioned roundtable, with government and industry maternal health leaders together in one room.

Breaking through

Pregnant women benefited from White House efforts to start and evolve programs like Medicaid in 1965 and the Children’s Health Insurance Program in 1997. But it wasn’t until 2018, when gumshoe journalism and community outcry amplified a rising maternal mortality crisis, that the wellbeing of American moms came into focus. Headline after headline told wrenching stories of avoidable deaths rooted in an underfunded and racially biased system.

As 2018 drew to a close, the weather was particularly chilly in D.C. and the midterm politics even chillier. With the holiday break approaching, Congress struggled to agree on a new budget, an impasse that led to the longest government shutdown in American history. For 35 days stretching into the New Year, hundreds of thousands of government workers went unpaid, and nothing got done. 

In this context, any new legislation would have faced grim prospects. But just before everything inside the Beltway ground to a halt, a commonsense maternal health provision found a groundswell of bipartisan support. On December 21, President Trump signed into law the Preventing Maternal Deaths Act, a first, critical step to making sure maternal mortality was systematically tracked across all 50 states.

At the time I was on the board of March for Moms, one of the organizations that had been pushing for the bill. Jamie Belsito, our seasoned maternal health advocate, was in the Capitol Building that day and called me excitedly to break the good news. “I was floored,” she reminisced. Maternal health was finally on the national agenda. 

Medicaid as the vehicle

Six years later, maternal health has sustained momentum from one administration to the next. Vice President Kamala Harris, now the Democratic nominee for President, has been instrumental to that sustaining force.

When Harris served as the Senator from California, she co-sponsored a package of 13 bills known as the “Momnibus” that included significant investments in digital health. As Vice President, she played a key role in pushing for states to extend Medicaid coverage from two to 12 months postpartum (almost all of which have done so today). Perhaps most significantly she took the lead in laying out the White House blueprint to address the maternal health crisis, which in turn brought me to that hallowed room not so long ago.  

Nobody knows for sure who will carry this vision forward in January. But we do know what will happen next Friday: applications will close for states to apply to a first-of-its-kind maternal health Medicaid pilot. Fifteen state Medicaid agencies with the most promising proposals will receive a full decade of funding to experiment with how maternal health is paid for. The experiments are likely to be wide-ranging and might include doula training, midwifery integration, or even telehealth. 

Talk to maternal health researchers, and they’ll give it to you straight: in 2021, over 40% of all births were financed by Medicaid. In states like Mississippi, that number is closer to 60%, and among Black and Hispanic mothers, it’s 64% and 58% respectively. Medicaid Managed Care plans comprise 72% of all enrollees today, which means the vast majority of these births happen under the purview of the federal government, state governments, and private insurers. 

This means that the recipient Medicaid agencies must innovate squarely in that federal-state-private intersection. It means that efforts that can bring the whole ecosystem into a coordinated partnership are most likely to succeed.

Follow the money 

Public policy can do two things: it can fund and it can regulate. Housed within the U.S. Department of Health and Human Services, the Centers for Medicare and Medicaid Services (CMS) do both. 

The challenge is that while Medicare enjoys broad bipartisan support, Medicaid is more of a political football.  Where 80% of Americans have historically supported Medicare, that number trails closer to 70% for Medicaid, with a much sharper split along party lines. 

The former was designed to finance healthcare for the elderly, and the latter was designed to finance health care for the poor. Over time, Medicaid has also come to cover people with disabilities, people unable to work, and pregnant people. And though they were born on the very same day, by the very same President (Lyndon B. Johnson), and are both jointly funded by the federal and state governments, the two programs have always been sisters and never twins.

John McCarthy, a former state Medicaid leader in Ohio and Washington D.C., attributes this difference, in part, to how the two programs appear on the average pay stub. “Every single paycheck you get, you see that money go to Medicare. If we did the same thing for Medicaid, instead of it just being in your taxes, maybe people would start seeing it differently,” he told me. 

In 2010 the Affordable Care Act established the Center for Medicaid and Medicare Services Innovation Center (CMMI) —an entirely new institute within CMS designed to tinker with healthcare solutions in individual states before applying those pilots to the rest of the country. In the first ten years of its existence, CMMI initiated 49 payment models but almost all of these pilots have been in Medicare, not Medicaid. A Medicaid model, with a decade long funding commitment, dedicated exclusively to maternal health, is therefore groundbreaking.

The first experiments 

Around the time Maven Clinic was being founded, organizations like Black Mamas Matter, the Center for Reproductive Rights and SisterSong Women of Color Reproductive Justice Collective were documenting the devastating realities of childbirth for Black women in the United States. In 2014, they compiled these findings in a joint report submitted to the United Nations. 

That year, something else happened that received far more media coverage: after back and forth with the courts, the Affordable Care Act granted states the right to extend Medicaid coverage to non-elderly adults who earned up to 133% of the federal poverty line. Around the same time, CMMI granted six of its first grants for the State Innovation Model Simulation, allowing states to truly experiment with payment reform. While these grants weren’t maternal health specific, some did choose to focus there. Afterall, pregnancy and childbirth is uniquely well-suited for characterization as an “episode” of connected services—these services are highly utilized, with the need to improve care highly apparent. 

Arkansas was one of the very first states to win a grant, and one of the first Southern states to expand Medicaid. They also implemented a unique plan that used Medicaid funds to purchase private health insurance for low-income Arkansans. Maven Clinic’s own VP of Clinical Outcomes today, Dr. Christa Moss, then at McKinsey, worked on episode-based modeling for maternity care through this program. 

The Arkansas Medicaid leader at the time was Andy Alison–a quintessential civil servant, at once inspiring and self-effacing. On the day he took the job, Alison told me he wrote on the whiteboard in his office, “We are payment improvement.” He wanted to make clear to both the public and his staff that the road to change led through Medicaid payments. “Don't think of us as an insurance claims agent. What we do is, we drive quality care by paying for it correctly,” he said. 

But in the end these early experiments were hard to codify as lasting policy. “Ultimately, you can’t 50-state innovate your way towards national payment reform,” Alison told me. “Change is a choice. At some point, the experiments have to be permanent. That’s the part the federal government hasn’t gotten to yet.”

Leading with care delivery

A decade ago, while serving as the head of health programs in the Obama White House, my friend Adaeze Enekwechi oversaw a staggering $1 trillion in health care spending across the Federal agencies. Today, she is working with considerably smaller budgets as CEO of Cayaba Care, a startup devoted to improving Black maternal health by connecting Medicaid recipients with better care. 

When I asked her about what motivated her latest career pivot, she was matter-of-fact. “I am a Black woman who had a baby in this country,” she told me. She relayed her personal story of giving birth, echoing an all too common experience of dismissal and disrespect. At one point, her anesthesiologist wanted her to bend over for the epidural and actually struck her in the back out of frustration. 

She was stunned—the person who was supposed to be relieving her pain had beaten her. “It never occurred to me that I could be treated so horribly,” she said. 

Experiences like hers are not only a problem of bad actors. They are also a problem of calcified delivery models that exclude midwives and doulas; that fail to ensure the right care is available to those who need it most. They are a problem of gross underfunding that leaves labor and delivery units threadbare and overwhelmed, resulting in toxicity and burnout among the providers–and traumatic and dangerous care for patients. They are, in other words, a care delivery problem. 

The promise of the latest set of Medicaid innovation experiments is the opportunity to tackle both payment and care delivery. Compared to the early experiments, there is greater political momentum and a wider array of working solutions. The challenge, of course, will be to scale them up by bringing federal, state, and private programs into alignment.

At Maven, we will assume risk for maternity members in six Medicaid markets this year. In fact, perhaps as a legacy of 2013, Arkansas was our very first market. The early results are promising. Seventy-five percent of our Medicaid members enroll in their first or second trimester. Defying conventional wisdom, digital engagement with care support among those members is high. Our published data indicate that they are more likely to disclose social needs to us than to an in-person doctor with a white coat. And leading indicators show that C-section rates and NICU admissions with this support are declining, particularly among Black and other historically disenfranchised populations.

Digital health, with its borderless providers and offices, may be uniquely suited to scale these results nationally. And as Adaeze told me, “The system is not designed to do what we want to see happen in maternal health. We are going to have to invest in it.”

At Maven, alongside our partners, that is exactly what we intend to do.

What my team is reading, considering, and building against: 

• For just about any subject worth writing about, there’s an Atul Gawande piece worth reading. This one, about how Americans view Medicare vs. Medicaid, told from the perspective of his hometown friends in Athens, Ohio, is well worth a read. 

• We often talk about the financial toll of fertility treatment. But that’s to say nothing of the tremendous emotional toll, which cannot be overstated. This compelling piece in Allure compiles the fertility journeys of 30 different people—including Maven Clinic’s very own medical director, Dr. Danielle Dang. We are so proud of her bravery, and lucky to have her lived experience on our team!

• New research from my team at Maven found that every hour of Maven usage was associated with reduced risk of preterm birth in pregnant members. We have long observed this general association. But this paper takes it one step further, by analyzing individuals who had low-risk pregnancies that quickly became high-risk. Among those members, access to our digital platform yielded twice the impact in reducing preterm births. Pregnancy is dynamic and ever-changing—increasingly, digital tools are best positioned to meet that dynamism. 

• We have long known that Black women are more likely to receive C-sections than their white counterparts. New research from economists at NBER (with an excellent accompanying write-up by Sarah Cliff at the NYT) offers a new suggestion for why this is though—they found that hospitals are recommending Black women for C-sections to fill empty operating rooms. Further showing that the most terrible health care problems are challenges of both payments and care delivery.