An Independent’s Guide to the Iowa Legislators’ Election:
Pregnant Women without Health Care Coverage
– A New York Times Exposé Waiting to Happen

“What Killed Harmon Ball-Stribling?” is a New York Times article from Aug. 11, 2024, that details the death of a Mississippi Delta pregnant woman who “lived in a rural health care ‘desert,’ a county with no obstetrician or certified nurse midwife and no hospital that delivered babies.” She had health insurance. “Her story is a case study of how powerful social, economic and environmental forces conspire” against women like her.

Next year in Iowa, an estimated 1,270 uninsured women with incomes between $32,500 and $56,250 (215% to 375% of the federal poverty level) will become pregnant and will not be able to obtain health-care coverage via Medicaid or privately. (Private insurance via the federal Health Insurance Marketplace will not be available for them until January 2026.)

This new development occurs because an Iowa law passed and signed this spring, which expanded Medicaid coverage for women from three months to 12 months postpartum, also disqualified newly pregnant women within the above income levels from obtaining coverage through Medicaid. Unfortunately, these women do not qualify for early enrollment in the Marketplace’s insurance plans, as pregnancy is not a “qualifying life event.”

These women have no safety net. The Iowa Division of Insurance has told insurance agents that the is no provision for early insurance issuance, and the Iowa Department of Health and Human Services has twice told me that there is no governmental option for health-care coverage for these women.

The United States has the highest maternal mortality rate despite the most health-care spending. Over 80% of these deaths are likely preventable. Women who do not receive prenatal care are three to four times more likely to die from pregnancy-related complications. Infants born to mothers who do not receive prenatal care are three times more likely to have a low birth rate and five times more likely to die in infancy. It is only logical that newly pregnant women without health-care coverage will be at increased risk of morbidity and mortality due to aggravated mental illness, given that “mental health is the leading cause of death of pregnant women and new mothers in the United States,” according to a JAMA Psychiatry’s Special Communication and confirmed by Iowa Department of Health and Human Services staff.

The perfect storm is completed by the ongoing progression of obstetrical deserts in rural Iowa. Denison and Newton gave up obstetrical services in their cities in the last two months.

This set of circumstances occur at a time when Gov. Kim Reynolds in her 2024 State of the State Address to the Iowa Legislature said, “To continue building a robust culture of life, we must also do everything in our power to ensure new moms and their families – especially those who are struggling – have what they need to make ends meet.” She also said, “Let’s do more to help moms, babies and their families get off to a good start.”

Similarly, Iowa Department of Health & Human Services Director Kelly Garcia said on an Iowa PBS program, “All day, every day, Erin. That’s our job. We work with Iowans who need to navigate the eligibility (health-care coverage) process every day.”

How do we solve this situation? Six options, at least, have been determined:

1. Make pregnancy a qualifying life event for purposes of the federal Health Insurance Marketplace, allowing early health insurance access by federal rule.
2. Make pregnancy a qualifying life event for purposes of the federal Health Insurance Marketplace, allowing early health insurance access by federal law.
3. Return Medicaid eligibility to pregnant women in this income category.
4. Make Iowa a state-based Exchange and then make pregnancy a qualifying life event for purposes of allowing early health-insurance access.
5. Expand Iowa’s Children Health Insurance Program (HAWK-I) to include this set of pregnant women. (Six states enroll pregnant women in CHIP-funded coverage.)
6. Expand HAWK-I to cover unborn children. (Fifteen states, including Minnesota and California, provide separate CHIP coverage to approximately 327,000 unborn children.)

At a Sept. 20 meeting, Iowa Department of Health & Human Services staff indicated that they had no options available to their department to help these women except to encourage “all Iowans to secure health-insurance coverage ahead of any health-related issue.” Department staff said it required a legislative “fix.”

Given that the Iowa Department of Health & Human Services recommended that interested Iowans turn this issue over to the Iowa Legislature, and as an avowed independent voter in Iowa who believes that the Legislature serves the will of the electorate, I believe every state legislative candidate in Iowa should be asked at meet and greets, candidate forums, editorial board meetings and debates how he or she would pursue solving this problem quickly to prevent harm to these 1,270 women and their 1,270 unborn children.

If such a question is asked and answered, please communicate that response to your friends, family and other Iowans. Let’s help Iowa avoid harm to our fellow citizens and avoid a New York Times exposé. Remember that Harmony Ball-Stribling had health insurance; these women will not.