For Black women, North Carolina has struggled to make progress ensuring successful pregnancies and healthy births. Racial disparities in both fetal and infant mortality persist despite reductions in the overall infant mortality rate. Unfortunately, the Trump Administration’s recent guidelines endorsing work requirements for Medicaid beneficiaries could entrench existing barriers to successful pregnancies.

Poor birth outcomes are often tied to maternal health challenges pre- and post-conception. Negative social determinants of health, like high poverty and the experience of racial discrimination, can cause and exacerbate many health conditions (e.g. hypertension, diabetes, obesity) that lead to poor birth outcomes due to their impact on maternal health behavior and access. That fact is borne out in the experience of Black women in North Carolina. Between 2012 and 2016, babies born to Black mothers were more than twice as likely to die before their first birthday than those born to White mothers (rate of 13.0 compared to 5.4 infant deaths per 1,000 births). Additionally, Black women were more than twice as likely as White women to give birth to a stillborn child (rate of 12.0 compared to 5.2 fetal deaths per 1,000 births + fetal deaths). 

Fortunately, access to health care can help to mediate risk factors in a woman’s life and help to ensure a healthy pregnancy and delivery. A recent study found that infant mortality had the greatest decline in states that expanded access to insurance coverage through Medicaid than in those that did not. Notably, the decline in the study was greatest among Black (non-Hispanic) infants, the population most vulnerable to negative birth outcomes in North Carolina. 

While North Carolina has not expanded Medicaid under the Affordable Care Act, the state’s pending Section 1115 Waiver proposal references a bill known as ‘Carolina Cares’ that would increase Medicaid access for adults up to 133 percent federal poverty. The legislation is aimed at covering adults in the insurance coverage “gap”, which includes more than 20 percent of all women of reproductive age in North Carolina who earn too little to afford coverage in the Marketplace but are currently ineligible to qualify for Medicaid. 

Such an expansion could be key to promoting women’s health and safer births in North Carolina, but the inclusion of premiums and work requirements in the ‘Carolina Cares’ proposal coupled with last month’s guidance on Medicaid work requirements from the Trump Administration would create an additional barrier for low-income women looking for care. A wealth of research has found such requirements wasteful and ineffective. 

While most of those who would gain coverage under the Carolina Cares proposal are already working, a work requirement would add a level of bureaucracy to the program that will act as a barrier to insurance for eligible individuals. For potential Carolina Cares recipients who are unemployed, health problems are often the reason for their unemployment. According to a recent study of the Medicaid expansion population in Michigan, approximately 75 percent of recipients who were out of work suffered from a chronic health condition, such as cancer, asthma, or diabetes. The Carolina Cares legislation exempts individuals “determined to be medically frail,” but the definition of “medically frail” and the determination process remain unclear.

Health insurance is a fundamental intervention to address the health causes of fetal and infant mortality, with particular impact for populations most at-risk of negative outcomes. In North Carolina, that means that Black women and babies have a lot to gain from expanded health care coverage. Work requirements and other proposals that limit access to care are only standing in the way of a promising strategy to ensure a strong start for every child. 

Whitney Tucker, MPH, is the Research Director at NC Child