JEFFERSON CITY — Sixty days after giving birth, women with health insurance through Show-Me Healthy Babies and MO HealthNet lose their postpartum coverage.
For women who received substance use treatment through their coverage while pregnant, the risk of relapse and overdose increases.
Matt Stinson, a family physician and vice president of medical and behavioral health at the Jordan Valley Community Health Center in Springfield, has seen firsthand the cost of the limited 60-day coverage.
The center had a patient who was high each time she came in for an appointment during her first pregnancy. Her second pregnancy was different. She got counseling and no longer needed medication-assisted treatment, which reduces withdrawal symptoms and decreases the chance of relapse.
After having her baby, she said she was struggling and that she once again needed help. The center was able to get her counseling but was not able to give her medication-assisted treatment due to her expired coverage.
She went home that night and died of a heroine overdose.
Maternal need for extended health care
In 2017, Missouri's maternal mortality rate was 32.6 per 100,000 live births, up from 28.5 in 2016. The 2017 national average was 20.7, according to the Centers for Disease Control.
The Missouri Department of Mental Health served 1,009 pregnant women in substance use treatment during the 2017 fiscal year. Of those women, 35 percent had an opioid use disorder according to Debra Walker, director of public and legislative affairs for the Missouri Department of Mental Health.
Although women receive substance abuse treatment while they're pregnant, it's easy for them to relapse after giving birth, when they are no longer covered.
"A lot of it's about access," said Rep. Martha Stevens, D-Columbia. "These are vulnerable women, being low-income and not having access to health care."
When these women do relapse, they are more likely to overdose due to a decrease in tolerance that occurred while they were in treatment and not using during their pregnancy, said Jaye Shyken, associate professor of obstetrics, gynecology and women's health at St. Louis University and the medical director of the Women and Infant Substance Help Center.
The ideal coverage period would be one or two years after the end of the pregnancy, Shyken said. With the help of medication-assisted treatment, these women would be less likely to relapse after that period.
"The longer the better," Shyken said. "Current thinking about opioids is that this is a brain disease, and it takes quite a while for the brain to sort of readapt. They never reach normality, but they can get closer to normality."
One of the criticisms of medication-assisted treatment is that it's replacing one drug with another. Shyken argued that diabetics are dependent on insulin, and people who are hypertensive are dependent on medication as well.
"Medication-assisted treatment during pregnancy results in the reduction not only in the use of illegal opioids, but also all medications and abuse substances," Shyken said.
Even if legislation were passed that would help women pay for it, some rural communities lack the other necessary resources to provide medication-assisted treatment, said Dina van der Zalm of the Missouri Rural Crisis Center.
One in seven women in Missouri suffer from postpartum depression — but in the Medicaid population it's one in five, said Cynthia Rogers, child and perinatal psychiatrist at Washington University and director of the Perinatal Behavioral Health Service.
"Both postpartum mental health disorders and postpartum substance abuse disorders are fatal," Rogers said. "If you want to effectively treat postpartum substance use disorders, you have to have access to mental health treatment."
Suicide is one of the leading complications of pregnancy. The risk of suicide in the postpartum period spikes at four and twelve months after giving birth, showing a need for coverage that extends past 60 days, Rogers said.
Infant need for extended health care
Between 2006 and 2016, the number of infants born with neonatal abstinence syndrome increased by 538 percent, according to the Missouri Hospital Association. The syndrome occurs when an infant is born with withdrawal symptoms as a result of opioid use by the mother during pregnancy.
Opioids are not the only substance that pose a threat to infants or mothers. Shyken cited the consumption of tobacco, alcohol and narcotics as some of the substances that increase the risks for low birth weight, mental retardation, cardiac abnormalities and other signs in infants.
"It's incumbent upon us to do what we can to try and support them, as opposed to some other approaches that might seek to criminalize moms who have babies with neonatal abstinence syndrome or that are born with substance use related complications," said Rep. Cora Faith Walker, D-St. Louis. Walker has proposed House Bill 1616 to extend Show-Me Healthy Babies coverage for substance abuse treatment up to a year after the end of a pregnancy.
Missouri's infant mortality rate — 6.5 per 1,000 live births in 2016 — is above the national average of 5.9, according to the Centers for Disease Control.
Half of the infant mortality rate is accounted for by neonatal mortality, the loss of an infant within the first 28 days of life, Shyken said.
"Mother and infant health are inextricably linked," Shyken said.
One of the reasons Walker decided to propose her bill was because of the high infant mortality rates in her district. In parts of St. Louis County, the infant mortality rate was over 16 deaths per 1,000 live births, according to Missouri Department of Health and Senior Services data from 2009-2013.
The rate in those areas was higher than in Syria, where it was 14.8 deaths per 1,000 live births in 2017, according to the CIA.
"Something needed to be done," Walker said.
In addition to Walker's bill, three other proposals have received initial hearings in the General Assembly.
House Bill 2120, proposed by Rep. Jay Barnes, R-Jefferson City, seeks to extend MO HealthNet coverage to include substance abuse treatment, including treatment for opioid abuse, for women up to two years after they give birth. To be covered, the women must have a household income at or below 185 percent of the poverty level.
House Bill 2280, proposed by Rep. Marsha Haefner, R-St. Louis, would extend MO HealthNet coverage to include substance abuse treatment for women, including treatment for opioids, for a year after the end of their pregnancy.
"There seems to be a growing recognition and understanding that the opioid crisis and substance use disorders are health issues and public health issues," Walker said. "I think that the spirit and the intent of the bill has widespread support from both sides of the aisle."
The committee mentioned the possibility of combining the bills and proposing one omnibus piece of legislation.
"I will be the first representative to tell you that representatives Haefner, Walker and Stevens have bills in the same area that I think are better," Barnes said when introducing his legislation to the committee. "They're a little bit broader, and I think they are better bills."
The cost of the bills
In Minnesota, officials have found that for each mom that goes untreated, it costs the state about $23,000, Rogers said.
"Treatment is significantly cheaper," Rogers said.
Stinson said during his testimony in front of a House committee that he has seen savings through a program offered at the Jordan Valley Community Health Center.
Of the 48 women in the program who received medication-assisted treatment, 43 of the babies who were born did not require admission to the NICU for neonatal abstinence syndrome, Stinson said.
Through keeping babies out of the NICU, there were savings of about $2.7 million, Stinson said.
"When you think about things like the infant mortality rate right now, the maternal mortality rate, I absolutely think that it makes more sense to invest in treatments for moms as opposed to not treating, and then we end up still paying (for a complicated pregnancy)," Walker said.
The cost of the four bills in general state revenue range from $133,461 to over $16 million in fiscal year 2019, according to the fiscal notes. The costs are expected to increase through 2021 to range from $367,114 to over $40 million.
"I'm trying to be realistic with the current budget crisis that we're in," Stevens said. "Two years (of postpartum coverage) would be wonderful — I'm starting the discussion at one."
The costs in the fiscal notes are still being finalized.
Haefner said the estimated cost doesn't scare her.
"It's an investment. It's keeping families together."