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Recent data indicate that the US is still lagging behind peer countries on maternal health and well-being, with comparatively worsened maternal mortality, preterm birth, chronic disease burden, and unaffordable health care costs among birthing people. Related inequities in severe maternal morbidity, preterm birth, neonatal intensive care unit (NICU) admission, and postpartum readmission only tell part of the story. One in four publicly insured women and one in three Black women report frank mistreatment during childbirth in studies run by the Centers for Disease Control and Prevention as well as independently.
Racial and gender inequities drive these poor outcomes, enabled by histories of enslavement, redlining, racialized policing, and intentional disinvestment in community infrastructure in disenfranchised communities as a result of systemic racism. The tip of this inequity iceberg is lack of access to high-quality, accessible, culturally concordant care and implicit and explicit bias in health encounters for Black and Indigenous birthing people in particular. In recent years, we have looked to value-based payment (VBP) as a solution to address these racially inequitable maternal outcomes and experience.
However, recent efforts in Medicaid maternity care have not yet yielded tangible impacts on outcomes such as those listed above, with no data to demonstrate impact on maternal morbidity as a proxy for mortality, preterm birth, or health before or after pregnancy. The Racial Equity Framework for Assessing Health Policy (REAP) offers a possible explanation as to why existing Medicaid maternity VBP efforts have not meaningfully shifted the outcomes we care most about: disproportionate allocation of benefits away from those more vulnerable to racism and inequities; decentralized and fragmented efforts; and failure to incorporate expertise of racially representative or otherwise marginalized populations.