In the mid-2000s, the state of Iowa committed to having every Iowan belong to a medical home. To accomplish that effort, Iowa created the Medical Home Advisory Committee. Some of the necessary components for one to be in a medical home include that the individual has health-care coverage and that family physicians, pediatricians and internists are available to care for that individual.

Senate File 2251, which was voted in and signed into law this spring in Iowa, created a positive by allowing mothers covered under Medicaid to stay on Medicaid 12 months postpartum instead of the previous 60 days, but it created a negative by reducing the income eligibility for pregnant women from 375% to 215% of the federal poverty limit. According to the Legislative Service Bureau, that reduction of income eligibility means an estimated 1,260 women per year will not be able to obtain Medicaid health-care coverage, which also means 1,260 unborn children will not be able to benefit from their mothers’ prenatal care. Therefore, these mothers and unborn children would not be able to have a medical home via Medicaid health-care coverage.

But surely you say that such pregnant women (and their unborn children) no longer eligible for coverage through Medicaid would merely sign up for subsidized health insurance via the Health Insurance Marketplace, also known as the Exchange, and then, having obtained health-care coverage, have access to medical homes. Sadly, these women cannot sign up for the Exchange in Iowa unless it is during the open-enrollment period at the end of the year because the exemptions, called qualifying life events, do not include pregnancy.

Marketplace Exchanges come in a variety of forms. There is a federal Exchange, to which Iowa and 29 other states belong; 20 other states have some form of state-specific Exchanges that are allowed to set up different rules regarding the list of qualifying life events.

Iowa cannot change the list of qualifying life events; that Iowans have to live by.

This situation regarding 2,500 individuals not having access to health-care coverage in Iowa for prenatal care occurs at the time of the following factors:

• One, maternal mortality in Iowa from 1999-2019, according to a Journal of the Medical Association article, increased from 10 to nearly 22 deaths per 100,000 births.
• Two, a second medical article quoted a study that said Medicaid expansion decreased maternal mortality by 7.01 deaths per 100,000 births, compared with states that did not expand Medicaid (Eliason, Women’s Health Issues, 2020).
• Three, Iowa in the last 15 years has been found to have rural areas that are obstetrical deserts due to lack of hospitals offering obstetrical services.
• Finally, 2024 is clearly a time of emphasis regarding the unborn child from all political persuasions. Regardless of persuasion, no Iowan nor American wants to leave a pregnant women who is looking forward to the birth of her child without health-care coverage.

What can Iowa do to protect these pregnant women and their unborn children? Four options come to mind:

• One, the federal government (Centers for Medicare & Medicaid Services, or CMS) could change the rules by adding pregnancy as a qualifying life event.
• Two, the federal government could pass legislation to this effect. Such a bill, called the Healthy Maternal and Obstetrical Medicine (Healthy MOM’s) Act, sponsored by U.S. Rep. Bonnie Watson Coleman of New Jersey and U.S. Sen. Sherrod Brown of Ohio, would accomplish that feat.
• Three, Iowa could increase income eligibility for pregnant women, possibly up to 375%.
• Four, Iowa could create its own state Exchange and then designate pregnancy as a qualifying life event.

In summary, the issue is not Medicaid for these pregnant women; the issue is health-care coverage for these women, either by health insurance or Medicaid.

I am on a flight to Washington, D.C., to see which of these or other options are feasible. No one needs a medical home more than a pregnant woman. This situation harkens back to the Virgin Mary searching for lodging on Christmas Eve.