Alabama had the highest rate of residents dying from pregnancy complications in the nation between 2018 and 2021. That’s according to an August report from the Milken Institute, a nonprofit and nonpartisan think tank. Alabama’s maternal mortality rate was 64.63 deaths for every 100,000 live births. This rate was even higher among Black women, with 100.07 deaths for every 100,000 live births. The national rate was 34.09. One hundred and fifty Alabama mothers died during those four years.
Local advocacy groups are using this information as a renewed push for Medicaid expansion in the state, including Alabama Arise, a statewide organization that advances public policies in favor of rural and marginalized Alabamians. As of July 2023, 41 states, including Washington D.C., have extended Medicaid. Alabama is one of 10 states that have yet to do so.
“There are nearly 300,000 people in the state of Alabama who lack access to health coverage,” said Debbie Smith, the campaign director for Alabama Arise. “They can’t access coverage through Medicaid because they make too much [money], and they can’t access coverage through the Health Insurance Marketplace because they make too little. Expanding Medicaid has been an option for our state for over 10 years now. I think it's common sense. Healthy women have healthy babies and healthy pregnancies. Making sure that people have access to health coverage before they even get pregnant would be a good way to reduce maternal mortality rates in Alabama.”
The information from the Milken Institute was just one of several reports published concerning Alabama and its lack of health care coverage. Georgetown University’s Center for Children and Families (CCF) released its own findings in June. The report was titled, ‘Alabama’s Women Need Medicaid Expansion.’
According to CCF, nearly one in six women aged 18 to 44 years (15.9%) lack health insurance, which is more than the national average at 11.7%. This rate is even higher among Native American (46.7%), Hispanic (41.5%) and multi-racial women (29.7%). Smith said the biggest barrier for women seeking health care coverage is the state itself.
“A lot of women are in that [health insurance] coverage gap. If we were to expand Medicaid, that would drastically reduce the amount of uninsured women of reproductive age in our state, as it has in other states,” she said. “A lot of these folks are being left out with low incomes, but there’s also chilling effects, particularly among people who might have immigrated here or who have a different citizenship status.”
Similar to high maternal mortality rates, CCF found that Alabama also has a high infant mortality rate, with 7.2 infant deaths for every 1,000 live births. This is more than the national average, which sits at 5.4 deaths. For Black babies, infant mortality is even higher, at 11.4 deaths. Smith said expanding Medicaid could both reduce infant mortality rates and lessen racial disparities in pregnancy care.
“Black folks in Alabama are just being left out in general, particularly in the Black Belt,” she said. “They have less access to rural health care providers. We’ve seen that there's a reduction in the amount of rural hospital closures in states that have expanded Medicaid. We would at least preserve the access that they have to rural health care providers there and possibly improve [them] if we were to expand Medicaid. We also know that a lot of Black folks are disproportionately in the [health care] coverage gap. Giving them access to Medicaid would obviously help that as well.”
In addition, CCF reports that between 1980 and 2019, obstetric units closed in 29 of Alabama’s 54 counties. Obstetric units assist in labor, postpartum, nursery and other pregnancy care services. CCF Program Director Maggie Clark said these closures also lead to adverse circumstances among pregnant Alabamians.
“When rural hospitals close their obstetric units, pregnant women in those areas face increased challenges in accessing critical prenatal and delivery care, forcing them to travel long distances for maternity services,” she said in her report. “This lack of local obstetric care exacerbates existing disparities in maternal health outcomes, particularly low-income women who may have limited resources for transportation.”
March of Dimes, an organization specializing in maternal health, echoed these findings in its state profile of Alabama released earlier this month. The nonprofit reports that the number of birthing hospitals in Alabama decreased 24% between 2019 and 2020, with 34.3% of all Alabama counties defined as maternity care deserts. Maternity care deserts are areas without any access to birthing facilities or maternity care providers. In addition, nearly 28% of Alabama women had no birthing hospital within 30 minutes, with some women traveling as far as 71.9 miles or 78 minutes to reach the nearest birthing hospital.
Debbie Smith with Alabama Arise said expanding Medicaid would allow hospitals and health care providers to keep their doors open, thus allowing pregnant Alabamians to receive the services that they need sooner rather than later.
“One of the biggest issues our rural health care providers have is paying for uncompensated care,” she said. “If somebody shows up at the hospital and they are uninsured, that hospital is required to take care of them regardless. That ends up costing the hospital. If we were to expand Medicaid, those people who are uninsured right now would have coverage, and the hospital would be able to get paid for those services. That would improve their finances and help them stay afloat. Thirty-three percent of Alabama's rural hospitals are at immediate risk of closure and 50% overall are at risk of closure, according to the Alabama Hospital Association.”
Alabama did extend its Medicaid postpartum coverage period from 60 days to 12 months after pregnancy in 2022. Smith said this was a step in the right direction but not enough to protect Alabama mothers and their children.
“Sixty days was just not long enough,” she said. “We know that a lot of issues happen after that 60-day period. Postpartum depression sometimes shows up as late as six months after somebody has given birth. If you don't have access to health coverage during that time, it's going to be a lot more difficult for you to access the mental health resources and everything that you need.”
While the emphasis of Medicaid expansion is on mothers and their infants, Smith said Medicaid should expand to cover more than pregnant Alabamians. It should extend to cover everybody.
“Unless you're an adult with a disability or pregnancy, you have to have an extremely low income to qualify,” she said. “A mom with two kids would need to make less than $373 a month to qualify for Medicaid. Childless adults without disabilities or pregnancy don't qualify at all. There’s just a huge misconception that a lot of low income folks are already covered under Medicaid, when that's simply just not the case. These are hardworking Alabamians who you would assume have health coverage but just don't because of our extremely low income limits.”
Like pregnant Alabamians, Smith said parents face extremely low Medicaid eligibility as well as veterans. According to Alabama Arise, more than 5,000 Alabama veterans lack health care coverage and are unable to access the Veterans Health Care System.
