This story was co-published with ProPublica.

The only way to solve America’s maternal mortality problem is to fix its insurance problem. That’s the clear takeaway from a widening pool of research. The majority of deaths involving pregnancy and childbirth aren’t happening in the delivery room, they’re happening after a woman has a baby — sometimes months after.

As many as 13 percent of these deaths occur six or more weeks after a woman gives birth, and a rising number are linked to chronic conditions such as cardiac-related illnesses and mental health disorders.

It’s no coincidence that many American mothers lack adequate health insurance during this critical period of their lives, when access to medical care can mean the difference between life and death.

Nowhere is this more apparent than with Medicaid, the publicly funded health insurance program that pays for nearly half of all births in this country. The federal government requires every state to offer Medicaid to low-income women during pregnancy. But hundreds of thousands of mothers every year are kicked off the program just 60 days after giving birth, turning the safety net into a cliff.

Even women who are privately insured frequently run into trouble getting the postpartum care they need. “[Obamacare] took a giant step forward for women to have an affordable coverage option during their reproductive years,” said Joan Alker, a professor at Georgetown University McCourt School of Public Policy. But many states — even those that have embraced the Medicaid expansion that was at the heart of the Affordable Care Act — have large coverage gaps.

The alarming link between maternal deaths and lack of health insurance is starting to capture the attention of policymakers and legislators. At least five states — Texas, California, New Jersey, South Carolina, and Illinois — are considering measures this year that would extend pregnancy Medicaid for new mothers until a year after delivery.

Meanwhile, several Democrats on Capitol Hill — including presidential hopefuls Kamala Harris, Kirsten Gillibrand, Elizabeth Warren, and Cory Booker — have co-sponsored federal legislation. One of their goals is to reduce racial disparities in maternal health outcomes: Black mothers are three to four times more likely than white women to die from pregnancy-related causes.

The most surprising state legislation is in Texas, where a reported spike in maternal deaths — and the state’s sloppy methods of tracking of them — have become a national embarrassment. Maternal health advocates and medical groups have made extending postpartum Medicaid coverage one of their top priorities for the current legislative session. Despite the projected cost, supporters of the legislation remain hopeful that even some conservatives who have opposed Medicaid expansion under the ACA — and support an ongoing Texas lawsuit that would strike down the entire landmark 2010 health law — may be swayed.

It’s not just red states that have coverage gaps. California, with the most Medicaid births in the country, is considering legislation that would give income-qualified new mothers with a mental health condition full benefits for a year. (Missouri passed a similar but narrower bill in 2018.) Illinois has an omnibus bill that does everything from extending Medicaid coverage to mandating that certain private insurance plans in the state cover treatments for postpartum complications.

New Jersey’s approach is even more sweeping. After learning that black mothers are five times more likely to die from pregnancy complications than white moms in the state, lawmakers have been working to push through a package of 14 bills that include a Medicaid extension and a doula pilot project. “Our goal,” said the state’s first lady, Tammy Murphy, “is to be the safest place in the US to deliver babies.”

For now, though, the US remains one of the most dangerous high-income countries in the world for women to give birth. And with the uninsured rate rising across the country — particularly among people with low incomes — an already dangerous situation could deteriorate even further. That’s why ProPublica and Vox are teaming up for a reporting project about the gaps in health insurance and access that women experience during and after pregnancy.

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