IMPROVING MATERNALHEALTH IN HARRIS COUNTYA Community PlanA Project of Houston EndowmentImproving Maternal Health in Harris County: A Community Plan1

As members of the Steering Committee for theReducing Maternal Mortality planning effort, wesupport the findings and recommendations describedin this document. We are committed to engage in thework, collaboration and advocacy required to achievethe goal of significantly improving maternal health inHarris County.Co-Chair: Dr. Lisa Hollier Co-Chair: David MendezPeggy Boice, Office of Harris County Judge Ed EmmettPatricia Gail Bray, The Menninger ClinicEricka Brown, Harris Health SystemDavid Buck, Patient Care Intervention CenterRepresentative Garnet Coleman, Texas Legislature – District 147Martin Cominsky, Interfaith MinistriesRepresentative Sarah Davis, Texas Legislature – House District 134Alan Detlaff, University of HoustonCouncil Member Amanda Edwards, City of Houston – At Large Position 4Commissioner Rodney Ellis, Harris County Precinct 1Jamie Freeny, African American Health CoalitionCullen Geiselman, Cullen Trust for Health CareChristopher Greeley, Texas Children’s HospitalBrian Greene, Houston Food BankLisa Hollier, Texas Children’s Health PlanKen Janda, Community Health ChoiceOlinda Johnson, Texas Women’s UniversityMandi Sheridan Kimball, Children at RiskDaryl Knox, The Harris Center for Mental Health and IDDElizabeth Love, Houston EndowmentNaomi Madrid, Crisis InterventionGina Manlove, John Manlove Marketing and CommunicationsElena Marks, Episcopal Health FoundationTom McCasland, City of Houston Housing and Community DevelopmentDavid Mendez, Past Board Chair, Houston EndowmentQuianta Moore, Rice UniversityCarol Paret, Memorial Hermann Community Benefit CorporationAlejandra Posada, Mental Health America of Greater HoustonRebecca Richards-Kortum, Rice UniversityShondra Rogers, Texas Health and Human ServicesMichael Shabot, Memorial Hermann Health SystemUmair Shah, Harris County Public HealthPeggy Smith, Baylor Teen Health ClinicAnn Stern, Houston EndowmentMel Taylor, The Council on RecoveryRepresentative Shawn Thierry, Texas Legislature – House District 146Annvi Utter, Houston Independent School DistrictTroy Villarreal, HCA Gulf Coast DivisionRepresentative Armando Walle, Texas Legislature – House District 140Darcie Wells, March of DimesAndrea White, Houston ChronicleStephen Williams, Houston Health DepartmentImproving Maternal Health in Harris County: A Community Plan2

The Research Team, led by Working Partner LLC:Jessica Pugil, Working Partner LLCDonna Alexander, DGA Healthcare ConsultingJune Hanke, Harris Health SystemKimberly Johnson-Baker, UTHealth School of Public Health in HoustonKara McArthur, Working Partner LLCTim Schauer, Cornerstone Government AffairsWith thanks to an excellent intern team: Kemi Olowogbade, Alexandra Schauer, Bret Sinclair and Alexia WilsonAcknowledgmentsMore than 150 experts and community leaders in Harris County generously shared their time, knowledge,expertise and experience through interviews, focus groups, meetings, workshops and other efforts to develop thiscommunity plan. We are grateful for their contributions and commitment to ensuring that Harris County is a placewhere every woman’s pregnancy, delivery and postpartum experience is successful and safe.Members of the Current State and Innovations Working GroupValerie Bahar, Community Health ChoiceAnitra Beasley, Baylor College of Medicine/Harris Health SystemMary Beck, The Council on RecoveryDonna Beecroft, Memorial Hermann HospitalSean Blackwell, McGovern Medical School at UTHealth, HoustonFred Buckwold, Community Health ChoiceRuth Buzi, Baylor Teen Health ClinicAndrea Caracostis, HOPE ClinicNancy Correa, Texas Children’s HospitalCynthia Deverson, Baylor College of MedicineStacy Drake, Harris County Institute of Forensic SciencesCarey Eppes, Baylor College of Medicine/Harris Health SystemJoslyn Fisher, Baylor College of MedicineErica Giwa, Baylor College of Medicine/The Center for Children and WomenJoanie Hare, The Woman’s Hospital of TexasEssi Havor, Houston Health DepartmentPam Hellstrom, Community Health ChoiceMerrill Hines, Harris County Institute of Forensic SciencesJohn Kajander, Houston FirstTanweer Kaleemullah, Harris County Public HealthFran Kelly, Texas Children’s Pavilion for WomenJudy Levison, Baylor College of Medicine/Harris Health SystemAshley McClellan, The Woman’s Hospital of TexasDi Miao, Texas Children’s Health PlanJerrie Refuerzo, University of Texas PhysiciansLia Rodriguez, Texas Children’s Health PlanBeatrice Selwyn, UTHealth School of Public Health in HoustonTerry Simon, The Woman’s Hospital of TexasMary Traub, Baylor College of Medicine/Harris Health SystemImproving Maternal Health in Harris County: A Community Plan3

Members of the Women’s Experience Working GroupDebbie Boswell, Harris Health SystemReiko Boyd, University of Houston Graduate School of Social WorkBarbie Brashear, Harris County Domestic Violence Coordinating CouncilNicole Bromfield, University of Houston Graduate College of Social WorkKristina Brown, Office of State Representative Shawn ThierryNicole Browning, LIFE HoustonCecilia Cazaban, UTHealth School of Public Health in HoustonHailey Darby, GirlTrekHeather DeShone, University of Houston Graduate College of Social WorkAurora Harris, Young InvinciblesElisabeth Holland, Santa Maria HostelConstance Jones, CRJ HealthcareMarsha Jones, The Afiya CenterKay Matthews, Shades of Blue ProjectPat McElliott, The Council on RecoveryKaren Petermann, Avenue 360 Health & WellnessJeneé Pierre-Raven, The Woman’s Earth Nurturing StudioChristine Powell, The Women’s ResourceAngel Randolph, Hope Consulting groupTiffany Ross, Mental Health America of Greater HoustonMcClain Sampson, University of Houston Graduate College of Social WorkIreatha Wardsworth, Michael E. Debakey Veterans Affairs Medical CenterRebecca White, Houston Area Women’s CenterStaci Young, The Women’s HomeOur sincere thanks to the many women, communityhealth workers, midwives, and labor and delivery nurseswho shared their experiences in focus groups. Theirstories were critical to fostering a deeper understandingof barriers to care, and vital in the development ofrecommendations for action.Improving Maternal Health in Harris County: A Community Plan4

“Even one maternal death that ispreventable is too many.”» Lisa Hollier, MD, Chair of the Texas Maternal Mortalityand Morbidity Task Force and 2018-2019 President of theAmerican College of Obstetricians and GynecologistsImproving Maternal Health in Harris County: A Community Plan5

IntroductionThere is broad agreement among stakeholders that the incidence of maternal mortality and morbidity inTexas is unacceptably high, given that these conditions are largely preventable. There is also agreementregarding the need for improved data quality and methods for verifying maternal deaths and complications.The best data on the rate of maternal mortality in Texas comes from a study published in 2018 in theJournal of Obstetrics & Gynecology, which estimates the state’s rate between 14.6 –18.6 deaths per100,000 live births. This puts Texas’ rate in the middle of state rankings; it is noteworthy that the U.S.has the highest rate of maternal mortality among developed nations.The 2018 study also found that while every woman, regardless of her background, is at risk for lifethreatening complications from pregnancy, African American women and women over age 35 bear thegreatest risk for maternal death.Texas Maternal Mortality Rates 2012,Deaths per 100,000 Live Births14.6 Overall Texas Maternal Mortality RateMaternal Mortality Rate by Race and Ethnicity13.6 White27.8 African American11.5 Hispanic20.7 OtherMaternal Mortality Rate by Age8.7 24 years or younger14.4 25-34 years32.2 35 years or older0510152025303540Source: Journal of Obstetrics & Gynecology 2018; 0:1-8Improving Maternal Health in Harris County: A Community Plan6

Additionally, a review of statewide maternal health issues conducted by the Texas Health and HumanServices Commission in 2018 was able to identify the most common causes of maternal-related deathsin Texas. Between 2012 and 2015, the top causes of maternal deaths included: drug overdose, with themajority being due to overdose of illicit or licit prescription drugs; cardiac events, including heart attacksand heart failure after delivery; homicide; suicide; and infection/sepsis.Top Causes of Maternal Death in Texas, 2012-2015Percent of Total Maternal DeathsDrug Overdose17%Cardiac Overview of Maternal Health Issues”, March 2018, DSHS PresentationMaternal mortality rates are only part of the story; that is, maternal deaths are a tragic outcome related to amuch bigger problem. Every maternal death started as a complication, and life-threatening complicationsare as much as 50 times more common than maternal death.MaternalDeathyritIniasecrngSeevSevere Maternal MorbidityMaternal MorbidityUncomplicated DeliveriesUnexpected complications of pregnancy or labor and delivery that result in significant, negative short- or longterm consequences to a woman’s health are termed Severe Maternal Morbidity.Maternal mortality and severe maternal morbidity can be prevented. The state Task Force as well asmany other communities across the U.S. that are working to reduce the incidence of pregnancy-relateddeaths found that prenatal care and safety procedures at delivery can make a critical difference in women’shealth outcomes. Further, addressing social and economic factors – through increasing access to healthinsurance, contraception, mental healthcare, substance abuse treatment and other community supports –can make positive improvements to women’s health.Improving Maternal Health in Harris County: A Community Plan7

Concerned by these trends, Houston Endowment convened a Steering Committee of leaders from awide range of backgrounds – including healthcare, behavioral health, social services, research, business,government and philanthropy – to learn more about maternal health in Harris County and to develop acommunity-wide effort to reduce the rate of maternal mortality. The goal of the planning process was todevelop a comprehensive, long-term strategy that incorporates clinical, community-based and systemschange strategies; capitalizes on existing initiatives and funding streams; tests innovative methodologies;and embraces advocacy when necessary.Houston Endowment engaged an expert team led by Working Partner, LLC, to facilitate this one-yearplanning effort. Together, the six-member team contributed expertise in women’s health, maternal health,policy and advocacy, strategic planning, evaluation and community-based research, as well as deep, localknowledge of Harris County and its resources and challenges. The team compiled data to inform thedevelopment of the recommendations through multiple approaches: Research on rates of severe maternal morbidity in Harris County and Texas; Research on effective practices being implemented by providers and managed care organizations inHarris County; Analysis of innovative evidence-based approaches used in other communities, states and countries; One-on-one interviews with healthcare and social service providers (including individual privateproviders, community health clinics and large hospital systems), payers and community advocates; A survey and focus groups with women; and Meetings with the Steering Committee for guidance on information gathering and collaborativelyassessing findings from the research.Throughout, the research process was guided by two Working Groups – one focused largely on thehealthcare system and the other focused on women’s experiences. Together, these groups were made upof more than 80 local healthcare and social service experts and community leaders who advised on theprocess, added context and local knowledge and provided feedback on research findings. The WorkingGroups reviewed and assessed every best practice and recommendation that had been identified throughthe research process. The recommendations that follow represent a consensus of what Working Groupand Steering Committee members want to achieve to improve maternal health in Harris County.Recognizing that the causes of maternal morbidity and mortality are multi-faceted and complex – crossingclinical, community, cultural, socioeconomic and behavioral lines – the research process was intentionallycomprehensive. With the guidance of Steering Committee Co-Chair Dr. Lisa Hollier, Medical Directorof Obstetrics and Gynecology at Texas Children’s Health Plan and 2018-2019 President of the AmericanCollege of Obstetricians and Gynecologists, the Steering Committee identified a cycle of women’s healthto frame research and planning efforts.Led by the research team, and in partnership with Dr. Cecilia Cazaban, MD, DrPH, Co-Director of theCenter for Healthcare Data at the University of Texas School of Public Health, the Steering Committeefirst examined the general health – physical and mental – of all women of child-bearing age in HarrisCounty. This information informed the scale of risk for maternal mortality and severe maternal morbidityamong all Harris County women who might become pregnant.Dr. Cazaban and her team then examined hospital discharge data from 2008-2015 to determine trendsin severe maternal morbidity (SMM) across Texas and Harris County. This research proved particularlyinformative, as it revealed that the rate of severe maternal morbidity in Harris County is not only higherthan the Texas and U.S. rate; it is increasing. Between 2008 and 2015, the rate of severe maternalmorbidity in Harris County increased by 53 percent, greater than the overall increase across Texas of 15percent.Improving Maternal Health in Harris County: A Community Plan8

Trend of SMM in Harris County and Texas vs. USA (2008-2015)Rate per 10,000Hospital Deliveries250200150100020082009Harris County20102011TexasUSA2012201320142015Linear USADr. Cecilia Cazaban, presentation to Houston Endowment Steering Committee on Reducing MaternalMortality in Harris County, September 28, 2017In addition, the Steering Committee examined the barriers to receiving prenatal and postpartum carein Harris County, including the policies and practices of public and private health insurance, becauseresearch shows that ability to pay is a major barrier to women receiving needed care. Concurrently,the research team interviewed dozens of healthcare and social service providers across the spectrum ofwomen’s health to learn about the practices already being implemented to address maternal mortality andmorbidity. The team then cross-referenced these local innovations with current national and internationalevidence-based best practices.Enrollmentinto CareInterconceptionCareGENERALWOMEN’S HEALTHPhysical & MentalPost PartumPrenatal CareHospital/DeliveryThis planning processused the CDC’s definitionof maternal mortality: thedeath of a woman whilepregnant or within one yearof the end of the pregnancyfrom any cause related to, oraggravated by, the pregnancy orits management.Improving Maternal Health in Harris County: A Community Plan9

“If a woman comes into herpregnancy unhealthy, it isunlikely that she will be able tosignificantly improve her healthduring pregnancy.”» Sean Blackwell, MD, McGovern Medical School at UTHealth, HoustonImproving Maternal Health in Harris County: A Community Plan10

Key FindingsThe purpose of the research process was to identify systematically the forces that account for maternalmorbidity and mortality in the Houston region, in order to help drive strategic recommendations forthe Community Plan to improve maternal health in Harris County. The following are what the planningeffort identified as the most important forces behind Harris County’s high rate of maternal morbidity andmortality, as well as the disparities in how women experience healthcare, pregnancy and birth in HarrisCounty.I.In Harris County, the health of women before pregnancy iscompromised by multiple unmanaged and/or untreated healthproblems. Left untreated, these conditions can be the source ofsevere complications at childbirth or after delivery, threatening thelives of women.Clear and accurate data about the health of women is lacking in Harris County, and indeed, across theUnited States. While experts agree that the rate of maternal mortality is high and must be addressed,researchers are unclear about the actual rate of maternal mortality due to the poor quality of data used toassess the rate. Indeed, throughout the research process the planning team spoke with many healthcareproviders and researchers who noted that data and research on maternal health issues are not only lacking,but are decades behind the level of research being applied to other health issues. As a result, the currentresearch effort is based on the best information available.Understanding these data constraints, two sources revealed an estimate of the general health of womenof childbearing age in Harris County and of how many women are at risk for maternal mortality or severematernal morbidity: The Behavioral Risk Factor Surveillance System (BRFSS) survey results for Harris County. TheBRFSS survey collects data about Texas residents regarding their health-related risk behaviors,chronic health conditions and use of preventive services. The survey relies on self-reported data, butis generally accepted as representative of general health conditions and useful for identifying publichealth problems and developing interventions to address critical health issues. Hospital discharge data on women who delivered a baby in Harris County (years 2008-2015) and hadone or more diagnoses or procedures identified by the Centers for Disease Control as indicators ofsevere maternal morbidity.Based on BRFSS data for the years 2011-2015 among women aged 18-44, the health of women in HarrisCounty is compromised by weight issues, as well as other chronic risk factors, including depression,intimate partner abuse and substance use. Specifically, 55 percent of women reported being at risk for being overweight or obese.16 percent reported having had a doctor tell them they have a depressive disorder.11 percent reported having had a doctor diagnose them with hypertension/high blood pressure.2 percent reported partner abuse before, during or after pregnancy.18 percent reported regularly taking prescription medication before pregnancy.Results of the hospital discharge data analysis are more informative for understanding the health of womenwho are pregnant and how many women are at risk for pregnancy complications or death. Based on thetotal number of hospital deliveries by year (2008-2015) and looking at women who had at least onediagnosis code indicating an incidence of severe maternal morbidity, the rate of severe maternal morbidityin Harris County in 2015 was 238 per 10,000 deliveries (2.4 percent), which was 20 percent higher thanthe Texas average, which was higher than the U.S. average.Improving Maternal Health in Harris County: A Community Plan11

More specifically, out of the 71,252 women who delivered in Harris County in 2015, one in five women(22 percent) had at least one condition that put them at higher risk for severe maternal morbidity,including hypertension, diabetes, obesity and mental illness, including depression and other conditions. Reflecting national and statewide trends, severe maternal morbidity rates were highest for AfricanAmerican women while Hispanic women and Asian women had the lowest rates. Women under age 20 and above age 40 were two times more likely to experience complicationsrelated to severe maternal morbidity. Women living in historically underserved communities had higher rates of severe maternal morbiditythan the overall Harris County rate.Rate of Severe Maternal Morbidity in Harris County in 2015, by Zip CodeRate CategoriesBelow TexasBetween Texas and Harris Co.Between Harris and 2x Harris Co. RateAbove 2X Harris Co.II.In Harris County, reproductive health has become disconnectedfrom women’s general health such that it is often not included inwomen’s regular primary care, limiting women’s access to criticalhealth services.Reproductive healthcare is a vital component of women’s preventive and primary care. Yet in HarrisCounty and in many places across the United States, reproductive and sexual health is often fragmentedamong providers. For example, a primary care provider may see a woman for an annual exam and referher to a specialist for a Pap test and discussion of contraception, if contraception is discussed at all.Conversely, an OB/Gyn may see a woman for an annual exam and refer her to a primary care provider forroutine age-appropriate screening. This disconnected care can lead to important findings and importantconversations being missed, and ultimately affect a woman’s health.Improving Maternal Health in Harris County: A Community Plan12

The Impact of Disconnected CareReproductive care isdisconnected fromgeneral health careDecreasedaccess to careand informationNegative impact onpregnancy planningand controlWhen a full discussion of reproductive health and contraceptive options is integrated into a woman’sregular primary care, her ability to plan for pregnancy can be greatly enhanced. For example, one bestpractice being utilized in some health institutions is to ask every woman at every visit, “Would you liketo become pregnant in the next year?” A woman’s response to this question can then lead to a deeperconversation either about how she can work toward a healthy pregnancy in the event the woman wants tobecome pregnant, or, if a woman does not want to become pregnant, about contraceptive care and the fullrange of contraception options available to her, including the effectiveness of each method.However, based on the results of the women’s survey and focus group discussions, it is rare for womento be asked this question, or for women to have an opportunity to learn about and discuss the differentoptions for contraceptive care with their providers. Indeed, many women in the focus groups felt that theydid not have much say in the type of birth control they received. Some noted that they did not like manyof the side effects of their contraceptive and yet were deterred by the high cost of changing birth controlmethods. As a result, many women said they left pregnancy “up to chance.”Together, limited information and/or access to contraceptive care have negative implications for womenwho want to plan their pregnancy and their health outcomes. Based on results of the Pregnancy RiskAssessment Monitoring System survey2 among women who reported in Harris County (2012-2014), 33percent of women reported that their most recent pregnancy was unintended. Unplanned pregnanciesare associated with late entry to prenatal care (an independent risk factor for maternal mortality in Texas)and with worse health outcomes for both the baby and the mother, including increased risk of postpartumdepression and intimate partner violence.III.Barriers to enrollment in publicly funded insurance and confusionabout insurance coverage play a detrimental role in maternalhealth.Women who enter prenatal care late, or fail to receive prenatal care at all, are at increased risk for severematernal morbidity and mortality. However, accessing healthcare is increasingly difficult due to risinghealth insurance costs and other challenges to securing health insurance. For low-income women,accessing Medicaid is critical for a healthy pregnancy.However, in Harris County and Texas as a whole, very low income thresholds for women to qualify forMedicaid and a cumbersome enrollment process often result in delayed access to prenatal care or somewomen never receiving health insurance coverage at all.Determining eligibility for Medicaid can be complex. For a pregnant woman to qualify for Medicaid inTexas: She must be a U.S. citizen or qualified alien, She must be a Texas resident and Her household income can be no greater than 198 percent of the federal poverty level (FPL),equivalent to 3,370/month for a family of three in 2017.Improving Maternal Health in Harris County: A Community Plan13

Medicaid and CHIP-P Eligibility FlowchartWoman Age 15-45Living in Harris CountyYYUS Citizen orQualified Alien*NNNYTaking Careof Children?**NIncome at or Below202% FPLMedicaidIncome ator below202% FPLCHIP-PYNYIncome ator below14% caidNPregnant?Pregnant?Income at or Below198% FPLEmergencyMedicalCondition?Medically Needy?MedicaidMedicaidIncome ator below74% FPLYYNNMedicaidYChart KeyMedicaid EligibleUnder the Age of 21(If Never ReceivedMedicaid as a FosterYouth) or Under the Ageof 26 (If ReceivedMedicaid as aFoster Youth) ****YFormer FosterCare Youth?NIncome ator below16% FPLYNMedicaidNHave Breastor CervicalCancer?***NIneligibleYCHIP-P EligibleIneligible for EitherYYesNNo*MedicaidSee Notes on page 16Improving Maternal Health in Harris County: A Community Plan14

Medicaid and CHIP-P Eligibility Flowchart Notes:* Qualified aliens include:Legal permanent residents (LPR’s Any person that is not a US citizen who is residing in the US under legallyrecognized and lawfully recorded permanent residence as an immigrant. AKA “Permanent Resident Alien”“Resident Alien Permit Holder” “Green Card Holder”). Asylees. Refugees. Aliens paroled into the US for at least one year. Aliens whose deportations are being withheld. Aliens granted conditional entry prior to April 1, 1980. Battered alien spouses and alien parents of battered children. Cuban/Haitian entrants. Victims of human trafficking.** Children being cared for must be: Eligible for and/or receiving Medicaid. Living with the caregiver. Age 17 or younger, or 18 and going to school full time and expected to graduate before 19th birthday. Caregiver must be a parent, step parent, sibling, step sibling, grandparent, uncle or aunt, nephew or niece,first cousin, or a child of a first cousin.*** In order to qualify a woman must be: Diagnosed and in need of treatment for biopsy-confirmed breast or cervical cancer, a metastatic or recurrentbreast or cervical cancer, or certain pre-cancerous condition. Uninsured and not otherwise eligible for Medicaid, Medicare, or CHIP. Must be screened and diagnosed by HHSC Breast and Cervical Cancer Services (BCCS) provider. Screened for Medicaid eligibility by a BCCS provider, and application must be submitted to HHSC by thesame provider (Woman cannot apply with HHSC on her own).**** If a former foster care youth is not eligible under these criteria they may be eligible for the Former FosterCare Youth in Higher Education (FFCHE) program. Since this program is funded entirely by the state it is notconsidered Medicaid. Must be between ages 21 and 23 and enrolled in a higher education institution.A pregnant woman who is a legal immigrant but not a U.S. citizen can qualify for CHIP Perinatal insurance.For these women, the household income requirement is 202 percent of the FPL; however, CHIP Perinatalcovers only healthcare for the fetus, not for health issues related to the woman.The complexity of eligibility and the low income requirements are part of the reason that Texas has one ofthe largest gaps in medical coverage in the United States. A woman whose income is only slightly higherthan the required percent of FPL must find affordable health coverage elsewhere or pay for her pregnancycare and delivery out of pocket.In addition to the challenge of meeting the eligibility requirements, the process of enrolling in Medicaidcan result in delays in accessing care. Per state protocol, eligible women can receive a determination oftheir eligibility for Medicaid within 15 days of applying. However, women in the focus groups noted thatin reality, it can take much longer before they are enrolled in Medicaid and entered into prenatal care. Twokey issues affect when a woman ultimately receives coverage: Submission of required documentation by the due date: Once a woman submits her applicationfor Medicaid, she has 15 days to submit required documentation. While the documentation is notnecessarily burdensome, it could take some time to get a recent check stub or a letter from heremployer, adequate proof of expenditures and proof of citizenship. However, if the woman doesnot submit her documentation within the required 15 days, she must start the process over again.For women who work, have children and other responsibilities, meeting the 15-day deadline can bedifficult. For some, the challenge can be such a burden that they simply give up, go without prenatalcare and present at an emergency room for delivery. Securing a timely appointment with their prenatal provider. Generally, a woman must have proof ofMedicaid coverage before she can make an appointment with her provider.3 However, many womenreport that it can take up to 45 days before they can get in to see their provider, depending on theavailability of their physician. In cases like these, women can be well past their first trimester beforereceiving prenatal care.Improving Maternal Health in Harris County: A Community Plan15

“If you have private insurance,[the doctor] will sit and talkwith you but if you are onMedicaid, it’s just in and out.”» Woman in focus groupImproving Maternal Health in Harris County: A Community Plan16

Another barrier to care created by the state public health program is the low reimbursement rate given toprivate providers. This has multiple impacts on the care women receive: Currently Medicaid reimburses private physicians for only a portion of the cost of each visit. As aresult, private providers often limit the number of Medicaid patients they can serve, which createschallenges and delays for women seeking a provider who will accept Medicaid. Additionally, the low reimbursement

Improving Maternal Health in Harris County: A Community Plan 3 The Research Team, led by Working Partner LLC: Jessica Pugil, Working Partner LLC Donna Alexander, DGA Healthcare Consulting June Hanke, Harris Health System Kimberly Johnson-Baker, UTHealth School of Public Heal