Federal approval of Missouri postpartum extension could be at risk over abortion amendment

Conservative state senators argue the bill can’t pass without the provision. But proponents worry it could run into trouble with federal authorities

By: - February 23, 2023 9:04 am
Rep. Tracy McCreery

Rep. Tracy McCreery, D-Olivette, sponsored one of the postpartum Medicaid extension bills filed this session. She raised concern during a Senate debate Tuesday night that new compromise language could hurt the state's changes of its plan being approved by the federal government (Tim Bommel/Missouri House Communications).

A push to expand postpartum Medicaid coverage in Missouri could face hurdles to federal approval after an abortion-related provision was added by Senate conservatives.

The bill, which would extend postpartum Medicaid coverage from 60 days to one year, seeks to lower Missouri’s maternal mortality rate. The state had the 12th highest maternal mortality in the nation from 2018 to 2020, and the Missouri Pregnancy Associated Mortality Review Board found last year that three-quarters of pregnancy-related deaths in the state were preventable.

But new language added by a pair of conservative Republican state senators on Tuesday seeks to make clear that women who have abortions cannot receive postpartum benefits, as well as add other language that seeks to “reform” Medicaid.

Democratic Sen. Tracy McCreery of Olivette said she has concerns the new language could run afoul of federal guidelines and cause the federal Centers for Medicaid and Medicare Services, which must sign off on the proposal, to delay approval or reject the plan.

A similar scenario played out in Texas after a bill extending postpartum coverage was passed with language about abortion in 2021. The state has still not received federal approval to implement the extension. 

“Other states have tried to be clever with this and have not been able to get these customized state plan amendments through,” McCreery said, “So I just don’t want to do anything that jeopardizes the bill.”

Michelle Trupiano, executive director at Missouri Family Health Council,  a nonprofit that advocates for health care access, said she is concerned the new language threatens the goal of postpartum extension because the federal government has “made it very clear that they need clean legislation” to authorize a state plan. 

“We are very disappointed that once again, political ideology by a few members of the Senate is standing in the way of making that bipartisan, full support for postpartum folks happen,” Trupiano said. 

A proposal to extend postpartum Medicaid coverage was close to gaining approval from the legislature last year, but narrowly failed as a group of Republican senators blocked a version of the legislation.

Joan Alker, executive director of Georgetown’s Center for Children and Families, called the focus on abortion a “solution in search of a problem.”

If Missouri legislators are sincere and want to address the needs of postpartum women they should do what the majority of states are doing and stick to the standard language,” Alker said.

The federal Medicaid agency provides a template for states to apply for the program. They wrote in guidance to the states in late 2021 that individuals under state extension plans are “entitled” to postpartum coverage “regardless of the reason the pregnancy ends.”

At the public hearing on the bill in January, Sam Lee, a longtime lobbyist for Campaign Life Missouri, framed the extension of postpartum Medicaid as pro-life. Lee said that women seeking abortions would typically not be enrolled in Missouri Medicaid for pregnant women in the first place, and so would not qualify for the extension of coverage. 


Sen. Mike Moon, R-Ash Grove — who along with Sen. Bill Eigel, R-Weldon Spring, took credit for and advocated for the new compromise language in the bill — said his concern was that providing extended benefits upon the “end of pregnancy” could mean providing benefits for women who had abortions. 

Missouri law bans abortion except in the case of medical emergency or when necessary to save the mother. 

New language in the bill specifies that an individual would be enrolled in the postpartum coverage “when a physician or the managed care plan notifies the MO HealthNet program of the pregnancy ending involuntarily or necessarily to save the life of the mother.” 

McCreery questioned what “involuntary” ending of pregnancy means and wondered “if the reason that this wording is so vague is because we think CMS is not going to notice that we’re talking about abortion.”

Eigel, when asked if the provision was about abortion, said: “Sure, but I would hesitate to say that’s the only thing we can be talking about.”

Another senator, Sen. Jill Carter, R-Granby, said during the debate that keeping “that strong language — pro-life language” would allow the bill to get through with Republican support.

The bill also includes a line that no woman who “knowingly receives services in violation of state law shall be eligible for benefits,” which McCreery argued was overly vague and could include any violation of law, such as receiving a speeding ticket.

Texas’s bill to extend postpartum coverage passed in 2021, but only covered six months postpartum rather than the full twelve. It specified that coverage was directed to women who deliver or have an “involuntary miscarriage.”

The federal government notified Texas officials it was not going to approve the language, Texas’s health and human services agency told the Texas Tribune last August, raising speculation the delay could be related to the language about abortion. The plan is still under federal consideration, but has not been approved, Texas’s health and human services confirmed to The Independent on Wednesday. 

A spokesperson for CMS declined to comment on Missouri’s bill, citing agency policy regarding active legislation.

The new version of Missouri’s legislation includes several other changes to Medicaid that Eigel said are designed to “say ‘hey, this program needs to go through a reform process.’”

One provision requires Missouri’s Medicaid program to remove from its rolls the same number of people as are expected to receive extended postpartum coverage before the postpartum extension can go into effect. 

McCreery estimated the postpartum extension would serve a “few thousand” Missourians per year — around 4,000 — who would otherwise lose coverage after 60 days postpartum and go uninsured.

Because the state is set to begin re-checking the eligibility of all Medicaid participants in April after a three year pause, far more than 4,000 participants will be removed from the rolls, McCreery pointed out. But she said she has concerns the provision could still cause a delay in implementation or cause issues with the federal government.

Eigel said the bill would be unlikely to pass without the compromise pieces, and ultimately, they remained in the legislation approved Tuesday. 

“The value in the bill that’s before us right now is the reform aspects,” he said. 

“If it was just a conversation about expansion of benefits,” Eigel added, “then…that is a conversation that would get extensive discussion here on the Senate floor, and may not ultimately lead to a place where we would get any bill at all.”

The bill needs final approval from the Senate before it can move onto the House.


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Clara Bates
Clara Bates

Clara Bates covers social services and poverty. She previously wrote for the Nevada Current, where she reported on labor violations in casinos, hurdles facing applicants for unemployment benefits and lax oversight of the funeral industry. She also wrote about vocational education for Democracy Journal. Bates is a graduate of Harvard College and a member of the Report for America Corps.