Mississippi faces multiple maternal and infant health concerns that undermine the long-term wellbeing and safety of Mississippi mothers and children. The Commonwealth Fund’s scorecard, State Health System Performance, ranked Mississippi last among all U.S. states in overall health and second-to-last in reproductive care and women’s health.¹ Congenital syphilis rates have skyrocketed throughout the state, which can lead to a myriad of physical and developmental diseases and morbidities.² The state’s preterm birth rate is the highest in the nation, and Black pregnant women are most at risk to have preterm deliveries. Mississippi has both the highest infant mortality rate and the highest maternal mortality rate in the nation.^1,3 The March of Dime’s Maternal Vulnerability Index lists 71 of the 82 Mississippi counties greatly vulnerable to experiencing poor, adverse pregnancy outcomes and pregnancy-related deaths.³ These adverse outcomes have detrimental effects on the infant’s and mother’s health and wellbeing, yet they are preventable and treatable with appropriate care.

One of the most critical mechanisms to prevent and remedy adverse pregnancy outcomes and risks is adequate early prenatal care. Prenatal care entails health education, diagnostics, and disease prevention support and practices by healthcare professionals to ensure the best outcomes for the mother and infant during and after pregnancy.^4,5 Research has found that consistent prenatal care throughout pregnancy is associated with a lower risk for unfavorable birth outcomes appearing.⁶ Early prenatal care, which is initiated during the first trimester, has been shown to improve the quality of pregnancies, the identification of potential health risks, and the prevention of birth complications.⁷ Especially for pregnant women who need to manage high blood pressure, diabetes, or diseases like congenital syphilis, first trimester care is critical to the wellbeing of the mother and infant.⁸

As many Mississippi women have limited access to healthcare services prior to pregnancy, prenatal care may be the first opportunity for many women to identify risk factors and implement interventions to prevent infant mortality, preterm births, and low infant birthweight. Despite healthcare professionals recommending early and continuous prenatal care throughout one’s pregnancy, a significant portions of Mississippi women—largely, Black, Hispanic, and Native American women—receive delayed, insufficient, or no care, putting them at great risk of experiencing several adverse pregnancy outcomes.⁶ Inadequate prenatal care lead to severe and costly adverse pregnancy outcomes.

A lack of prenatal care is associated with a multiple-fold increase in infant mortality and a greater prevalence of low birthweight and preterm delivery rates.⁶ Lack of prenatal care is associated with higher maternal mortality rates.⁵ Studies have discovered congenital syphilis-related outcomes are more prevalent among communities who initiated prenatal care later and returned inconsistently for check-ups throughout their pregnancy.⁹ So, how can Mississippi ameliorate its current maternal and infant healthcare issues? Implementation of a Presumptive Eligibility for Pregnant Women (PEPW) policy may be an important part of the answer.

Presumptive Eligibility (PE) is a state-implemented policy to provide immediate, temporary coverage to families meeting basic Medicaid or CHIP eligibility criteria while they wait for a full determination of eligibility. Without PE, Medicaid programs can take up to 45 days to process, review, and approve applications, leading uninsured families worried if they could receive the needed care in a timely manner or be able to afford that care if found ineligible.¹⁰ Therefore, PE helps potentially eligible people and families receive needed care quickly. When an individual makes an initial visit to a hospital, trained employees assist the individual to complete a PE application. If found to meet PE criteria, the hospital provides the individual information about the length of PE coverage, the benefits and covered services of PE, and encouragement to apply for full Medicaid coverage. PE coverage begins on the day of hospital determination. If a Medicaid application is submitted by the final day of the following month from the date of determination, PE covers medical expenses until the state makes an approved or denied determination for full Medicaid coverage.¹¹ There are several challenges that must be considered when broadening presumptive eligibility access. If patients are enrolled presumptively and later determined ineligible, there have been concerns that states would be responsible for 100% of the expense. Fortunately, federal matching funds are still available for services already rendered.¹² Implementation in the outpatient does require additional training of clinic staff, and operational changes do create an administrative burden for the state Medicaid program, but these have been successfully addressed by the many states that have adopted this waiver.

PE allows states to empower healthcare providers and government agencies to provide to their communities and qualified entities opportunities to be knowledgeable of, have quick access to, and enroll in Medicaid or CHIP health coverage programs.¹³ States have flexibility when creating hospital PE programs to include any additional tests or questions for eligibility; however, they cannot use these additional measures to disrupt or delay PE determination.¹¹

Presumptive Eligibility for Pregnant Women (PEPW) is a form of PE policy aimed towards providing immediate prenatal care access for pregnant women not covered by Medicaid but potentially eligible. PEPW can be implemented to prevent care delays during Medicaid processing. PEPW policies are strictly aimed to cover pregnancy-related care expenses.⁸ With PEPW policies, health departments, health centers, and hospitals can determine if the pregnant person fulfills the temporary eligibility requirements and provide prenatal care during the Medicaid processing period.¹⁴ If the person is subsequently found to be eligible for Medicaid coverage, one is enrolled in the program; if found to be ineligible, then PEPW guarantees providers reimbursement for the temporary care services utilized.¹⁰ For one to qualify for temporary coverage, the pregnant or post-partum individual must have a household income coinciding with their state plan’s income eligibility level and pass any state-implemented tests for state residency, U.S. citizenship, or eligible immigrant status.¹⁵ PEPW is an important mechanism to providing underserved communities the opportunity to receive the benefits of early prenatal care that would otherwise be difficult to obtain.

Studies of implemented PEPW policies within U.S. states show that it can improve the quality of pregnancy outcomes by easing the burdens and challenges that delay or prevent low-income women from receiving prenatal care.⁵ PEPW increases the number of pregnant women enrolling in Medicaid coverage and initiating early prenatal care whilst decreasing the proportion of women who received late, inadequate, or no prenatal care.¹⁴ Those within PEPW coverage show improved prenatal care access and prenatal care retention throughout the duration of the pregnancy.⁷ In evidence documented by the Center for Mississippi Health Policy, a review by the University of Mississippi Center for Population Studies found that "living in states with a PEPW policy can reduce preterm births for women covered by Medicaid. These findings suggest PEPW can blunt the effects of poverty on preterm births. “The link between PEPW and preterm births was statistically significant, but modest.”¹⁶

PEPW is different from Retroactive Medicaid (RM), a policy currently in place in Mississippi. Both policies serve to cover medical expenses for people who are not initially covered by Medicaid; whereas PEPW covers pregnant women’s future prenatal care expenses from time of temporary coverage determination, RM covers only medical expenses performed prior to a Medicaid application. RM provides a 3-month period coverage for medical care expenses before one’s submission of a Medicaid application.¹⁷ For one to be eligible for RM, the individual must be eligible for Medicaid coverage during 3-month period prior to the application and have medical care services be those covered by Medicaid.¹⁸ If one is determined to be eligible for Medicaid coverage, Medicaid will cover all previous acceptable forms of medical care services. Where RM significantly differs from PEPW in its operation is that applicants who are determined ineligible for Medicaid coverage will not have their previous medical care services covered by Medicaid. The applicant is required to pay for these expenses out-of-pocket. Due to this lack of guaranteed coverage for costly medical expenses, RM policies deter uninsured pregnant women in Mississippi from initiating early prenatal care—even if they may be eligible for Medicaid coverage—for they worry they will be unable to finance the costly medical expenses if they are determined to be ineligible for financial aid. In the absence of PEPW, it is common practice in Mississippi for clinics to charge patients up front for prenatal care, until the Medicaid application has been approved. This obviates the utility of RM for engaging women in prenatal care earlier, and serves as a barrier to optimal maternal-child health.

As of 2020, 29 states have implemented PEPW policies. Mississippi is one of 21 states who have yet to implement a PEPW policy and is one of 3 states to also not implement expanded Medicaid eligibility requirements. Mississippi lawmakers have recently increased the duration of postpartum Medicaid coverage to one year, which provides significant support in ensuring maternal and infant health for low-income families following birth.⁸ This change will undoubtedly be critical to improving maternal and infant health within Mississippi, but, without the enhanced access to prenatal care provided with PEPW, it may not be enough to improve Mississippi’s current state significantly. Therefore, it is essential that the state consider the implementation of PEPW policies to encourage early prenatal care access.

The Mississippi Division of Medicaid has indicated that it will not implement PEPW policies without legislative action, thus making our lawmakers responsible to finding a way to implement PEPW.⁸ Lawmakers have the power to pass PEPW policies and even propose different methods to test for presumed eligibility. Lawmakers in the Mississippi House of Representatives had proposed a statute to implement PEPW within Mississippi earlier this year; however, the bill died within the Medicaid Committee.¹⁹

Although PEPW is believed to ameliorate many barriers in people receiving adequate and early prenatal care, it is important to know that PEPW itself cannot create significant improvements in prenatal care. A study performed in Kansas—a state without an expanded Medicaid eligibility policy, like Mississippi—revealed that PEPW was associated with small, insignificant improvements in early prenatal care access.¹⁰ However, implementing PEPW policies along other current federal aid programs, like Mississippi’s RM and post-partum coverage extensions, may help more low-income families to receive and cover early prenatal care.