The medical crisis that finally convinced Republicans in North Carolina to expand Medicaid

The early days of Courtney Smith’s pregnancy were dark. She bled for six weeks, a common but frightening experience during the first trimester of pregnancy. Doctors in Louisiana, where Smith was living at the time, made matters worse by suggesting she might miscarry. After diagnosing her with hypertension, diabetes and depression, the doctors “threw pills at me,” Smith says. Medicaid paid for her care, but the care was poor: Her Prozac dose was too high, her blood pressure medication was too low, and they gave her medication to control her diabetes without giving her a way to monitor her blood sugar. Meanwhile, her boyfriend made it clear he wasn’t interested in being a father. By the time she was eight weeks pregnant, she was ready to drive into the bayou and end her life. Her family urged Smith to come home to Hendersonville, N.C., where in January her older sister helped enroll her in that state’s Medicaid program. Because Smith’s pregnancy was high-risk and many providers don’t accept Medicaid, it took her two months to get a prenatal appointment. She was 19 weeks along when she finally got into the Mountain Area Health Education OB/GYN clinic in Asheville. This time, her experience with Medicaid was entirely different.

A family nurse practitioner corrected her medications, put her on insulin to control her diabetes, and connected her to a mental health counselor. Her bleeding had stopped and an ultrasound revealed she was due to deliver a healthy girl in August. “They have been wonderful to me,” Smith, 31, says of the staff at MAHEC. “I’m so glad I’m getting the prenatal care I need now.” But there was a catch. When Smith first arrived at the clinic this winter, she was told her Medicaid benefits would end two months after her due date. Federal law requires Medicaid to cover low-income mothers for just 60 days after they give birth, a period that is often not long enough to treat chronic issues such as diabetes and postpartum depression. Obstetricians and maternal health advocates have worried for years that prematurely cutting off coverage has exacerbated a nationwide maternal mortality crisis; the U.S. has the highest rate of maternal deaths in the developed world. Then Smith got some surprising and welcome news. In April, North Carolina became one of 15 states to extend Medicaid coverage to 12 months postpartum. And the lawmakers who voted for the change were the same Republicans who had fought Medicaid expansion for years. The impact of this extension, say health experts, will be dramatic. In 2020, 41 percent of births in North Carolina were covered by Medicaid, according to the Kaiser Family Foundation. The state Department of Health and Human Services estimates this postpartum extension could help more than 50,000 women, at a cost to the state of about $12.5 million a year. “It’s a really, really big piece,” says Sarah Verbiest, executive director of the Collaborative for Maternal and Infant Health at the University of North Carolina School of Medicine. “For people who don’t have access to insurance, they can’t get any of this care.”