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State by State Women Health - Navigating Shifting policies and outcomes

The Commonwealth Fund⁠

webinar delving into the implications of new state-level data from the 2024 State Scorecard on Women’s Health and Reproductive Care. The scorecard evaluates how well health systems are working for women across 50 states and the District of Columbia – assessing state health care access, affordability, quality of care, and outcomes.

Moderator: Eleanor Klibanoff from The Texas Tribune

Guests: Caitlin Cross-Barnet, Ph.D. from the Center for Medicare and Medicaid Innovation, Noya Woodrich, M.S.W. from the Minnesota Department of Health and Zsakeba Henderson, M.D., FACOG from ESW Consultants & NICHQ

Stats presented in the webinar:

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Here are the key points from Caitlin Cross-Barnet's explanation about Medicaid:

1. Medicaid is completely state-run, which many people don't understand.

2. The federal government funds at least 50% of state Medicaid programs, but decisions are made at the state level.

3. There's a block of required services, including standard emergency care, physician services, and some maternity-related services.

4. Specific services include access to certified nurse midwives, birth centers, and smoking cessation for pregnant women.

5. Many services vary by state, partly due to state licensure issues.

6. The Affordable Care Act allowed states to expand Medicaid coverage to adults at or below 138% of the poverty line.

7. States can choose to expand adult Medicaid at any time, as North Carolina did recently.

8. There's an option for states to expand postpartum care for a full year. All but 4 states have done this.

9. Access to services can be limited by state licensure levels or restrictions, such as regulations on midwives.

10. States could potentially make larger use of their existing workforce by expanding the scope of practice.

11. Doula coverage can also be included in Medicaid programs.

Here are the key points from Dr. Zsakeba Henderson's response:

1. There are specific reasons why some states are underperforming in maternal health, and it's not coincidental.

2. The same regional areas tend to have the worst outcomes and lower scores on the report.

3. These are the same states where there's increased maternal vulnerability, with higher rates of HIV, STDs, and cancer deaths.

4. Maternal health issues are multi-factorial, with interconnected contributing factors.

5. When considering solutions, it's important to think about all levels where a patient is impacted - individual and community.

6. There's a close interconnection between access to benefits and having an appropriate, adequate workforce.

7. Having coverage is important, but there also need to be enough providers to deliver care.

8. The quality of care is another crucial factor - providers need to offer the highest quality care possible.

9. Policy surrounding the quality of care needs improvement.

10. The settings where care is delivered and empowering all providers who can offer maternity care services are important considerations.

11. The ultimate goal is to provide care in the best way possible.

Dr. Henderson emphasizes the complex, interconnected nature of maternal health issues and the need for comprehensive solutions that address multiple factors at various levels.

Here's a summary of Noya Woodrich's comments on Minnesota's maternal health initiatives:

1. Minnesota's Medicaid is in the Department of Human Services, while they are the Department of Health. They work closely together on maternal and child health matters.

2. They have a robust maternal mortality review that informs decision-making about who is dying and how.

3. They have CDC funding for their Maternal Mortality Review Committee (MMRC), supplemented by state funding.

4. Minnesota ranks high nationwide in maternal health, but this masks significant disparities, particularly in American Indian and African American communities.

5. They're implementing promising practices led by communities impacted by maternal mortality.

6. They're working with community-based organizations, including: - Minnesota Quality Collaborative - Division of Indian Work (serving the native community) - A nonprofit focused on the African American community and substance users - An organization serving tribal communities in Northern Minnesota

7. They plan to use learnings from these pilot programs to secure funding for more organizations.

8. They're working on identifying and mitigating implicit bias and discriminatory policies in healthcare and insurance.

9. Minnesota has the Dignity in Pregnancy and Childbirth Act, implemented about 3 years ago, which requires hospitals and birth centers to provide continuing education on anti-racism, implicit bias, and structural racism's impact on Black and indigenous people's health.

10. They worked with the University of Minnesota to create a curriculum for hospitals and clinics, focusing on unique features of communities of color.

11. The Minnesota Legislature has funded the creation of an Office of American Indian Health and an Office of African American Health to ensure effective community connections.

This summary highlights Minnesota's multifaceted approach to addressing maternal health disparities, with a focus on community engagement and addressing systemic racism in healthcare.

Question Session from HOST

Eleanor Klibanoff, the host, asked Dr. Cross-Barnet to provide an overview of why some states are doing a better job screening for postpartum depression and what policy changes states should consider to improve screening rates and outcome

Answer : Here's a summary of Dr. Caitlin Cross-Barnet's response regarding postpartum depression screening and related policies:

1. Their "Strong Start for Mothers and Newborns" initiative required all participants to screen patients for depression at their first prenatal visit.

2. The biggest predictor of postpartum depression is prenatal depression. Many people enter pregnancy with existing depression or anxiety that may be exacerbated during pregnancy.

3. Anxiety can cause as many or more postpartum problems as depression, but depression gets most of the focus.

4. There are existing recommendations for depression screening at primary care visits, but communities lacking mental health providers are reluctant to screen because they have no referral options.

5. Screening someone who is a suicide risk requires immediate handling, which can be challenging for providers with limited time and resources.

6. Building a maternity care workforce should include considering mental health as a critical component, including developing referral systems for mental health resources.

7. There is flexibility in Medicaid for the types of providers who can offer mental health services.

8. Medicaid offers flexibility in the types of providers who can be reimbursed for mental health services, not limited to licensed psychologists. States can expand to include various providers with unique licensures.

9. Peer counseling services can be helpful, especially for people with milder mental health issues.

10. Postpartum care expansion and access to care are important considerations.

11. Having insurance doesn't guarantee provider availability or appropriateness for pregnant populations. There's a need for providers trained to handle pregnancy-specific issues.

12. Depression is a significant risk factor for preterm birth and other complications, making mental health services a crucial preventative measure.

13. Integrating mental health into maternity care is a big task that can't be solved instantly, but it's an important consideration.

14. The amount of time providers spend with patients is crucial for listening to concerns and offering individualized care.

15. Pregnancy and transition to parenthood are profound social episodes as well as medical ones.

16. In the birth center model of care and Strong Start initiative, typical prenatal appointments were 30 to 60 minutes long, allowing for more in-depth patient-provider relationships.

17. Longer appointments led to higher comfort levels, more willingness to reveal problems, and time to discuss issues thoroughly.

18. While ideal care might involve longer appointments, the shortage of maternity care providers makes this challenging to implement universally.

19. There's a need to prioritize certain aspects of care, balancing ideal practices with practical constraints.

Dr. Cross-Barnet emphasizes the importance of comprehensive, time-intensive, and mental health-inclusive maternity care while acknowledging the challenges in implementing such care given current resource constraints.

2. Eleanor Klibanoff asked Dr. Henderson a question about breast and cervical cancer deaths. She acknowledges the importance of the previous topic (mental health in maternal care) but wants to move on to discuss breast and cervical cancer deaths. She notes that Southern states are performing poorly on this metric. She mentions that these deaths are often preventable if the cancers are diagnosed early enough and handled appropriately. The specific question posed to Dr. Henderson is: "What from your perspective as a provider is contributing to this regional, but also racial and ethnic disparity on cancer deaths?"

Answer : Dr. Zsakeba Henderson provides a comprehensive response to the question about regional and racial/ethnic disparities in breast and cervical cancer deaths:

1. These cancers are largely preventable, especially when detected early.

2. There are glaring racial and ethnic disparities in both cervical and breast cancer deaths.

3. The issue is multifactorial, similar to maternal deaths.

4. Racial and ethnic minority groups and those who are socioeconomically disadvantaged are less likely to have access to: - Vaccination and screening for cervical cancer - Screening for breast cancer - Adequate insurance coverage for screenings

5. Rural areas face particular challenges in accessing these services.

6. Healthcare quality issues contribute to poor outcomes, including: - Ability to follow up on bad findings and refer for treatment - Disparities in the aggressiveness of treatment based on racial/ethnic groups - Differences in quality of care received - Access to clinical trials and studies

7. Socioeconomic burdens can prevent people from accessing care even when they have coverage.

8. There's a need for expansion of screening programs and vaccination.

9. Education campaigns are needed to address vaccination hesitancy, particularly for cervical cancer prevention.

10. For breast cancer, black women are often diagnosed with more aggressive forms of cancer, even when screened early, contributing to increased disparities in breast cancer deaths.

11. Access to other types of testing, such as genetic counseling and screening, is important for early detection and adequate treatment.

Dr. Henderson emphasizes that addressing these disparities requires a multifaceted approach, including improving access to care, addressing socioeconomic factors, enhancing education and awareness, and ensuring equal quality of care across all populations.

3. Eleanor Klibanoff is asking Dr. Henderson to address the connection between various health issues and policy decisions in certain states. She asked Dr. Henderson to discuss the connection between: a) States with high maternal mortality rates b) States with higher rates of breast and cervical cancer deaths c) States that are banning or restricting abortion access

Answer: Dr. Zsakeba Henderson responded to Eleanor Klibanoff's question about the connection between states with high maternal mortality, higher cancer death rates, and abortion restrictions by confirming that there is indeed a strong link. She emphasized that the issue goes beyond just the number of healthcare providers, focusing on the types and expertise of providers needed to handle complicated cases across all risk levels.

Dr. Henderson noted that even before the Dobbs decision, there was already a crisis with the healthcare workforce. She pointed out that early data shows a shift in providers moving away from states with restrictions on reproductive healthcare. More concerning, there's evidence of lower numbers of applicants to medical training programs in these states.

She explained that this trend is particularly worrying because clinicians, especially doctors, tend to practice in the states where they train. Two studies were mentioned: one by the Association of American Medical Colleges showing a continued decrease in senior medical school applicants to residency programs in states with abortion bans, and another specifically looking at obstetrics and gynecology residents, which also showed a slight decrease in applicants to programs in these states.

While the percentage decrease is relatively small, and positions are still being filled due to the general surplus of applicants, Dr. Henderson expressed concern about the quality of providers. She emphasized that it's not just about having a provider available, but having the best providers in states with the best access to care. The trend of providers leaving and potential providers avoiding these states is very concerning for the future of healthcare in these areas.

4. Eleanor Klibanoff directed her next question to Noya Woodrich, asking about Minnesota's approach to addressing workforce issues in healthcare, particularly in light of the state's efforts to protect and expand abortion access.

Answer : Woodrich acknowledged that Minnesota is still grappling with workforce challenges, especially in rural areas where some residents live 2-4 hours away from hospitals with birthing centers or obstetrics care.

Woodrich highlighted several key issues affecting the healthcare workforce in Minnesota:

1. Rural healthcare access: Many residents in rural areas face long travel times to reach hospitals with obstetric services.

2. Housing shortages: In some regions, available housing is being bought up by investors, making it difficult for healthcare workers to find places to live near their workplaces.

3. Public health nurse shortages: The state is experiencing a shortage of public health nurses across its 57 local public health partners.

4. Staffing issues in tribal areas: Consistent staffing shortages are reported in tribal regions.

5. Widespread shortages: The staffing problem extends to nonprofits and various healthcare partners across the state.

To address these challenges, Minnesota is taking several approaches:

1. Investing in home visiting programs. 2. Collaborating across state departments, including Human Services, Education, and the newly formed Department of Children, Youth, and Families. 3. Working on joint workforce development initiatives, recognizing that the issue extends beyond healthcare to early childhood, retail, and specialized care sectors. 4. Engaging with the Department of Health to monitor the number of hospitals providing obstetric care and understand why some are discontinuing these services. 5. Working with policymakers to ensure they understand the nuances of these issues and how they impact decision-making in Minnesota.

Woodrich emphasized that addressing these workforce challenges requires a comprehensive, multi-departmental approach and close collaboration with policymakers to develop effective solutions.

Links from the chat:

1. From Christina Ramsay, M.P.H.: - 2024 State Scorecard on Women's Health and Reproductive Care by The Commonwealth Fund

2. From Gabby O'Brien: - Transforming Maternal Health model by CMS (Centers for Medicare & Medicaid Services) - Maternal Opioid Model by CMS - Strong Start initiative by CMS

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