A previous version of this article misidentified a woman as Yolanda Jackson in the photo caption for the second photo. She is Yolanda Washington. This version has been corrected.
Robinson worried what would happen after that.
“I wouldn’t be able to go to the doctor,” she said. “ … I’m having financial problems. The Medicaid really helped.”
The limits on Robinson’s Medicaid coverage after the emergency insurance lapses hinge on Texas’s long-standing rejection of the Affordable Care Act, which included provisions for expanded Medicaid. And it has set up an uncomfortable dynamic: While Texas and nearly a dozen other red states have resisted expanding Medicaid for those who are pregnant, many of them have also restricted access to abortion, leading to more new mothers needing coverage.
Now Republican lawmakers in Texas, Mississippi, Wyoming and other red states face a choice: focus exclusively on further restricting abortion, or join antiabortion groups and Democrats lobbying to expand postpartum Medicaid coverage.
“There’s a discussion among Republicans and those who are anti-choice about what should we be doing to support mothers?” said Usha Ranji, associate director for women’s health policy at the Kaiser Family Foundation.
Some national antiabortion groups that support postpartum Medicaid expansion have proposed other legislation to expand funding for those who are pregnant, in the wake of new state curbs on abortion after the Supreme Court’s Dobbs decision erased the protections of Roe v. Wade.
“On our side, there is an awareness and a very strong move after Roe’s overturn toward caring for women,” said Steve Aden, general counsel and chief legal officer for Washington-based Americans United for Life. “I think the whole movement is looking for ways to implement policy on the state level to support the increasing number of women who will have children.”
Republicans have long controlled both chambers of the Texas legislature, which allowed them to pass one of the strictest abortion laws in the country last year ahead of the Supreme Court’s decision. Last year, the Texas House also passed a measure that would have expanded postpartum Medicaid for a year. But the Texas Senate — including Sen. Bryan Hughes (R), author of the state’s restrictive abortion law — halved postpartum Medicaid to six months. Gov. Greg Abbott (R) signed the bill, but because it didn’t cover those who had had abortions, the Biden administration refused the extension.
Now Texas Right to Life and other antiabortion groups are lobbying for passage of a year-long postpartum Medicaid extension at the next legislative session that starts in January.
“This policy fits into a bigger collage of pro-life policies we can pass to promote a pro-life Texas,” said John Seago, president of Texas Right to Life. “We want Texas to be abortion-free, but we also want Texas to be pro-life. We want these mothers to be healthy and to have access to the care they need.”
The conservative Austin-based Texas Public Policy Foundation is also backing expanded postpartum Medicaid, arguing that it can save the state money through preventive care.
“With many complications that come up, there’s a cost that comes back around for the state with many uninsured. It’s much better to make sure these moms are healthy so they can take care of the children,” said David Balat, director of the foundation’s Right on Healthcare initiative and a former hospital executive.
Robinson was homeless when she arrived at the nonprofit Viola’s House maternity home soon after moving to Dallas from Memphis, unaware that Tennessee lawmakers had just agreed to extend Medicaid postpartum up to a year starting this spring. She said she fled a “toxic environment” of neighborhood violence, leaving her partner behind in search of a better quality of life in Texas for her son, whom she plans to name Uriah.
Robinson had graduated high school but not college. She initially worked as a hotel housekeeper but soon had to quit, unable to stand all day. She applied for front-desk and restaurant positions, she said, but, “Most jobs don’t want to hire me, seeing the belly sticking out.”
Viola’s House serves five homeless pregnant women ages 18 to 24 at a time, providing housing, coordinating medical care and offering other support. Most arrive already enrolled in Medicaid, according to Yolanda Washington, the residential services manager who helps them arrange health care.
She said extended Medicaid coverage during the pandemic has helped residents get back on their feet.
“It makes a difference. It takes that long for a woman to do her six weeks rest, breastfeeding with the baby, start to get up and get insurance from a job,” Washington said.
She said many of the women at the maternity home don’t know their Medicaid benefits will expire. Her granddaughter found out the hard way when she went to a doctor three years ago and was told she no longer had coverage.
Without Medicaid coverage, Washington said, “It stops them from going and getting preventive care, because they say, ‘How am I going to pay for a Pap smear? Or birth control?’ The only way they go is the emergency room.”
Viola’s House founder and executive director, Thana Hickman-Simmons, said it gets funding from the state as well as from those on both sides of the abortion issue, so she tries to stay out of politics. But she was troubled to see many pandemic benefits ending, potentially postpartum Medicaid.
“Can the government do more for mothers who are facing an unplanned pregnancy? Absolutely. They’re making rules and not doing enough for the rules that they’re making,” Hickman-Simmons said. “You’ve got to fund all the services it takes to support life.”
Seago’s lobbying for postpartum coverage — “Don’t call it Medicaid expansion, just ensuring insurance for moms up to a year after birth” — has won support in the Texas House, including Republican House Speaker Dade Phelan, who helped pass the measure last year and is still committed, staff said.
But for the law to pass in the upcoming session, Phelan has to convince fiscal conservatives in the Texas Senate, including hard-right Lt. Gov. Dan Patrick, that the measure saves money in the long run and should be a priority over other antiabortion proposals by Hughes and others, such as barring out-of-state travel for abortions or requiring men to pay child support from conception.
Hughes and Patrick did not respond to requests for comment on the proposal.
“It’s really a question of when are you paying for this care: preventive or after she gives birth and ends up in the emergency department? From our point of view, this is a wise investment, both financially and morally,” Seago said.
Texas Alliance for Life, the state’s other large antiabortion group, had not taken a position on postpartum Medicaid expansion, but its board was still considering the measure, said spokeswoman Amy O’Donnell.
Seago is pushing a revamped version of last year’s bill sponsored by state Rep. Toni Rose (D).
“She’s a pro-abortion Democrat, but this is an area where pro-lifers are supporting her and this agenda,” he said.
Rose said it made sense that antiabortion groups would support the measure.
“It’s a pro-life bill. We want to save lives,” she said. “ … As I’ve stated to my colleagues, if you’re pro-life you should be able to get behind this.”
Rose said Texas Senate leaders have to consider the fallout from their abortion posture: “If we want women to carry the baby, let’s give them the resources they need to do that.”
The American College of Obstetricians and Gynecologists supports postpartum Medicaid extensions, noting in a statement that while maternal mortality is increasing nationwide, “a growing body of evidence shows that many of these deaths, particularly from preventable causes such as overdose and suicide, occur after pregnancy-related Medicaid coverage ends.”
Pregnant Texans are more likely to be uninsured and less likely to seek prenatal care than those in the rest of the country, and the state has high rates of maternal mortality and morbidity, especially among Black women. At least 52 pregnancy-related deaths were reported in 2019, 27 percent occurring 43 days to a year after pregnancy, according to a report released in December by the state Department of State Health Services. Severe medical complications from pregnancy and childbirth also increased significantly between 2018 and 2020, from 58.2 to 72.7 cases per 10,000 deliveries in Texas, according to the report.
Among the committee’s top recommendations: expanding postpartum health-care coverage to a year.
“People are quickly falling off the pregnancy-related coverage and not getting coverage because the income eligibility threshold is quite low in Texas, and they are not getting private coverage and reporting health concerns they either address in the emergency room or don’t address,” said Kari White, lead investigator with the Texas Policy Evaluation Project at the University of Texas at Austin.
Without extended coverage, she said, “pregnant Texans are really going to fall through gaping holes in the safety net.”