Courtney Darby holds her son, R'Jay Jones, as she talks about postpartum Medicaid expansion at Family Health Center in Laurel, Miss., Tuesday, March 8, 2022. Many mothers in the state cannot afford medical care when their Medicaid coverage ends 60 days after giving birth. Credit: Eric Shelton/Mississippi Today

A few weeks after Courtney Darby gave birth to her daughter Deysha, she got a letter in the mail notifying her that she would soon lose her health insurance through Medicaid. 

Deysha, born in December 2008, was Darby’s first baby, and she was still wondering when she would feel normal again. She wanted to ask her doctor about the back pain that lingered and the nagging worry that she was doing everything wrong. 

But her job at a grocery store didn’t provide health insurance, so without Medicaid coverage, she was left to do her own research and hope for the best. 

“It was too soon,” said Darby.

Earlier this year, about two months after her son R’Jay was born, Darby got a very different letter. It told her that Medicaid would continue to cover her healthcare, thanks to federal rules that extend health insurance coverage during the COVID-19 pandemic. 

As a result, Darby can make an appointment to see a doctor whenever she needs. She has been able to get medication and therapy to treat postpartum depression and anxiety.

But on Wednesday, leaders in the state House killed a bill that would have ensured new moms like Darby could get Medicaid coverage for a year postpartum even after the federal public health emergency ends. When that happens — likely later this year — many of the 60% of pregnant women in Mississippi who are covered by Medicaid will be forced to go without healthcare starting two months after giving birth.

Even some states that have not expanded Medicaid eligibility, like Georgia and Tennessee, have passed measures to let new moms keep their coverage for at least six months. Alabama is set to extend coverage to a year postpartum. 

Just over 39,000 Mississippians are currently covered by Medicaid because they are pregnant or postpartum, according to the state Division of Medicaid. When the emergency declaration ends, communications officer Matt Westerfield said, states will begin reviewing current beneficiaries on a rolling basis. 

People like Darby, who gave birth more than 60 days ago, will lose coverage unless they qualify in another category, such as disability. And people who give birth after the declaration ends are likely to get no more than 60 days of coverage postpartum.

After Senate Bill 2033 failed, Darby was stunned.

“I don’t understand it,” she said. “I mean, it’s just mind blowing that you know — it’s like, have some compassion. Have some heart. At least try to show that you care.”

House Speaker Phillip Gunn cited his opposition to Medicaid expansion, though the bill would not have expanded eligibility for Medicaid. The Associated Press asked Gunn whether extending postpartum coverage saved lives. 

“That has not been a part of the discussions that I’ve heard,” Gunn said.

To Darby, the consequences of the extension are intimately familiar, and the stakes are high: her life, and the lives of her children. 

“That’s kind of a savior to me,” she said of Medicaid coverage. Now, she waits and wonders when it will run out. 

Courtney Darby holds her son, R’Jay Jones, as she talks about postpartum Medicaid expansion at Family Health Center in Laurel, Miss., Tuesday, March 8, 2022. Mississippi is among 12 states that has not expanded Medicaid access under the Affordable Care Act. Credit: Eric Shelton/Mississippi Today

During her pregnancy with R’Jay, Darby regularly drove 20 miles from her home in Heidelberg to the OB-GYN clinic at the Family Health Center in Laurel. Once a month, then twice, and then every week, she reported to a squat brick building near downtown. The waiting room was always crowded with pregnant women.

Family Health Center is a federally qualified health clinic (FQHC), which means it relies on federal grants and donations as well as reimbursement from Medicaid and Medicare to operate. 

Dr. Rashad Ali, who has led the center since 2006, is proud to describe its mission: To provide quality healthcare for the underserved and the uninsured. Ali, an OB-GYN, delivers 200 to 250 babies a year, and one of those in 2021 was R’Jay. He estimates about 70% of the pregnant women he sees are enrolled in Medicaid. 

The five counties served by Family Health Center are prime examples of the importance of FQHCs. Clarke, Jasper, Jones, Smith and Wayne Counties are rural and poor. About one in five adults lacks health insurance, a little higher than the state average. 

Shelly Roark, a women’s health nurse practitioner at Family Health Center, said Medicaid coverage during pregnancy and after gives her patients a chance to get care for underlying health issues like chronic hypertension, kidney disease and diabetes, which can be exacerbated by pregnancy. 

The state’s 2019 maternal mortality report, which reviewed all 136 maternal deaths during pregnancy and up to a year postpartum from 2013 to 2016, found that heart conditions and hypertensive disorders were the most common causes of death. The report also found that Black women are three times likelier than white women to die of a pregnancy-related cause.

In the weeks after a baby is born, new parents are focused on learning how to be responsible for another person’s every need.

“You’re not worried about yourself,” Roark said. “After that two months, you can start focusing more on yourself. That’s when we really need to provide the care.”

With extended Medicaid coverage during the pandemic, Roark can make sure that happens, referring new moms to specialists and connecting them with mental health practitioners. 

Roark joined Family Health Center in March 2019. During her first year at the clinic, she saw what happened when women were dropped from Medicaid 60 days after pregnancy. 

“Typically, they just don’t show up” to scheduled follow-up appointments, she said.

Because Mississippi hasn’t expanded Medicaid eligibility under the Affordable Care Act, many working parents who could be covered in other states aren’t covered here. In Louisiana, for example, a single parent with four kids qualifies as long as their income is below about $43,000. In Mississippi, that same parent only qualifies if their income is less than $8,100 annually. (And healthy single adults in Mississippi can’t get Medicaid at all.)

During pregnancy, the income rules are much looser: A woman with four kids qualifies as long as her monthly income is below about $5,400. That means many women with insurance through work get additional coverage through Medicaid that makes it possible for them to get better care.

Family Health Center has a sliding fee scale to try to keep services affordable, but any amount can be too much for families struggling to pay for diapers, food, and older kids’ needs. 

Mississippi doesn’t have a paid family leave policy, so for many women, giving birth and taking a few weeks to recover and bond with their baby means losing income completely. By the time they are able to return to work, the bills are piling up.

“I’ve had to be that patient, where it’s like– ‘I can’t come, because I don’t have the money,’” Darby said. 

She wants to keep her kids active in sports and school events, which also costs money. Sometimes, she tries to use Google to find “home remedies” to save herself a doctor’s bill. 

“It’s trying to distinguish between, do you want to try to keep your child on track, help them succeed? Or (pay for) this one-time visit?”

Dr. Rashad Ali discusses postpartum Medicaid expansion at Family Health Center in Laurel, Miss., Tuesday, March 8, 2022. Mississippi is among 12 states that has not expanded Medicaid access under the Affordable Care Act. Credit: Eric Shelton/Mississippi Today

When Darby brought R’Jay home from the hospital, she was overwhelmed. Without the nurses’ help, she felt like she had forgotten how to breastfeed. She worried about catching COVID-19 and bringing it back to her baby. She barely slept, concerned R’Jay would die of SIDS if she didn’t watch over him constantly. 

Was he sleeping too much? Not enough? Was he getting enough milk? Was she doing this all wrong?

“It just got to the point where that deep depression slipped in,” she said. “I really didn’t want to get up and do nothing, but I had to. It was an everyday fight and battle for me: ‘You’ve got to get up, you’ve got to get up. Your children need you. R’Jay can’t do nothing for himself.’”

The feeling wasn’t like a light switch she could turn on and off. It came and went, no matter how much she tried to stop it. It was unlike anything she experienced after her older children were born, and it was hard to explain.

Her doctor prescribed medication and referred her to a therapist, who diagnosed her with severe anxiety and depression. They talk about trying to tackle one thing at a time.

Postpartum depression and other mental health issues are not a small part of Mississippi’s maternal health crisis. The maternal mortality review found that 11% of all pregnancy-related deaths in the state were caused by suicide or drug overdose. And 37% of all pregnancy-related deaths occurred more than six weeks after birth. Several studies have shown rates of postpartum anxiety and depression are rising during the COVID-19 pandemic, as new moms are more isolated and worry about their family’s safety. 

Darby knew she needed help, and she’s grateful she can get it.

“I don’t want to keep it covered to the point that I’m so down and out that I can’t dig myself out of that hole,” she said. “I want to be the best parent that I can be for not only R’Jay, but also my other kids as well.”

Exactly how long Darby’s coverage will last is now unclear. She is taking time off from her job as a teacher to focus on parenting and her mental health, and she thought her Medicaid coverage would provide a measure of stability and consistent access to care. 

The current declaration is set to expire in mid-April, but the federal government told states it would give them 60 days’ notice before any expiration. Since that notice hasn’t arrived, the declaration should be extended at least one more time, which could last until mid-July. 

Depending on when the emergency declaration ends and how long Mississippi takes to reevaluate her eligibility, Darby could lose coverage in several months.

Her doctors at Family Health Center are worried, too. Ali is a former president of the Community Health Center Association of Mississippi, which backed efforts to extend postpartum coverage. 

“It’s not at all uncommon for a woman to have health issues weeks or months after they’ve delivered,” he said. “And if they don’t have money to get treated, what are they supposed to do? On occasion, we find people who had problems in the pregnancy, but after the pregnancy is over, two months later that problem hasn’t gone away, but now they don’t have money or insurance.”

R’Jay, now nearly three months old, cries less than Darby’s other kids did when they were babies. He already likes to talk. Every night from 1 a.m. to 3 a.m., he wakes up, as regular as clocking in to work, she jokes. 

After dozing off in his baby carrier while Darby talked, he woke up with the hiccups. Darby held him against her chest.

“Hiccup means baby grows, they gonna get taller,” she said, looking at her son. She smiled. “I just always say that.”

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Isabelle, an Atlanta native, covers health as part of Mississippi Today’s community health team. Prior to joining Mississippi Today, she was a reporter for the Biloxi Sun Herald and a Report for America corps member.