These four states, along with Florida, are currently trying to fend off health reform in the only way the Supreme Court left open--by declining federal aid to expand Medicaid, the government program that provides insurance for certain categories of low-income individuals: infants, elderly, the disabled and pregnant single women.
In the wake of the Supreme Court's June decision on the Affordable Care Act, the GOP governors of Texas, Florida, South Carolina, Louisiana and Mississippi--all politically opposed to "Obamacare"--were quick to "secede" from the government's offer to extend Medicaid to anyone living below the cut-off of 133 percent of the federal poverty line.
That's a large expansion for a state such as Texas where a working parent today must make less than $5,000 a year for a family of three--less than 26 percent of the federal poverty threshold--to be eligible for Medicaid, according to the Kaiser Family Foundation's State Health Facts website.
An estimated 3 million people nationwide will be left uninsured by the Supreme Court's decision to make Medicaid expansion voluntary, according to estimates by the Congressional Budget Office. It didn't perform a state-by-state analysis, but the Urban Institute estimated that Texas alone could leave 1.3 million uninsured.
Some of the women who will lose out are those whose incomes--while low--are still above that kind of cutoff.
While Medicaid covers all pregnant women who make less than $20,000 annually, these women often have no coverage before or between pregnancies because parents in many states are held to higher income thresholds. Childless women usually aren't covered at all.
Pregnancy-related health issues, meanwhile, don't conform to these financial rules. Many of these ailments are connected to the care and treatment of general and underlying problems such as diabetes and obesity.
"A lot of the problem that happens with pregnancy happens between pregnancies," said Dr. William Sappenfield, a maternal health expert and professor at the University of South Florida.
Expanding Medicaid has the potential to provide insurance to many low-income women who fall outside income requirements or are excluded because they aren't pregnant, elderly, disabled and-or don't have children.
"Medicaid is a critically important program for low-income women," said Usha Ranji, associate director for women's health policy at the Kaiser Family Foundation. But "many don't qualify because they don't fall into one of those categorical boxes."
Excluded women--whether pregnant or not--are widely believed to be at health risk just by virtue of the numbers of women in their states who aren't making it through pregnancy or childbirth.
That's because in every part of the world, deaths linked to childbirth or pregnancy are increasingly viewed as a sentinel for overall ailing female health.
"Public health experts do use maternal mortality as a bellwether indicator of the health of women in a population," said Dr. Lisa Hollier, a specialist in maternal-fetal medicine at Baylor University in Waco, Texas.
The changes are being introduced amid a wealth of data indicating that the number of mothers dying in America during or shortly after pregnancy is consistently growing. The rate of maternal mortality in the United States has more than doubled, rising from 6.6 deaths per 100,000 live births in 1987 to 16. 1 deaths per 100,000 live births in 2009 – the highest among developed nations, according to estimates gathered by the Maternal and Child Health Bureau of the Health Resources and Services Administration of the U.S. Department of Health and Human Services.
The Atlanta-based Centers for Disease Control and Prevention (CDC) attributes some of that rise--but not all--to changes in the way information about the premature deaths of mothers is collected and counted.
The "maternal mortality rate" is a narrow and specific gauge.
It only captures those deaths that occur within 42 days after a pregnancy's end. The U.S. pregnancy-related mortality rate–calculated differently and including deaths up to a year after a pregnancy's end – was around 15.1 between 2006 and 2007.
These deaths are far from inevitable. In 1998, a CDC report said, "more than half of all maternal deaths can be prevented through early diagnosis and appropriate medical care."
An Affordable Option
Currently states extend Medicaid to restricted groups of people under a patchwork of income limits that are often far beneath the new federal offer.
Medicaid expansion would be the most affordable option under health reform--better than insurance exchanges--for those low-income individuals who don't currently qualify, said Karen Davenport, director of health policy at the Washington-based National Women's Law Center.
Davenport said that some of the governors may be posturing ahead of the election in November and could change their minds after that.
But in Texas, Gov. Rick Perry has already proved his determination in a similar situation. His state is now fighting a lawsuit brought by Planned Parenthood after Texas banned affiliates from receiving state funds.
The federal government, claiming that Texas is violating federal law, has withdrawn all federal funds from the state's Women's Health Program.
There are "grave concerns about how that will affect Texas women," Hollier said, as well as the potential for "a lack of coverage affecting maternal health going into a pregnancy," although she said it was too early to comment on the specific impact.
The Lone Star state uses a broad maternal death measure-- closer to pregnancy-related--that finds 24.6 deaths per 100,000 live births as of 2010, far above the national average. One-in-10 women have diabetes and 50 percent of women in the state are overweight.
Texas had the highest rate of uninsured in the country, at 27.6 percent of respondents – over a quarter -- according to a Gallup poll from March 2012.
Mississippi's 2010 rate – which uses the same coding as Texas -- was even higher at 30 deaths per 100,000 live births, similar to 2008 and 2009 numbers, according to data compiled in a report by the Mississippi State Department of Health.
In coverage levels, Mississippi was right behind Texas in the Gallup poll, as 23.5 percent responded that they had no insurance.
Louisiana, South Carolina
As of 2008, Louisiana's pregnancy-related deaths were at 26.1, according to the Louisiana Pregnancy-Associated Mortality Review report. The report was produced in 2012 and was the first of its kind for the state, which also had one of the highest maternal mortality rates in the country between 2003-2007.
Louisiana ranked 10th in the number of uninsured, at 20.4 percent, according to Gallup.
In South Carolina, the maternal mortality rate rose "sharply" between 2006 and 2008 and was "a cause of concern," according to the 2010 Needs Assessment report from South Carolina's Mother and Child Health Bureau. In 2006 there were 9 maternal deaths; in 2008 there were 20, which measures out to about 31.7 deaths per 100,000 live births.
Brenda Martin, director of the bureau, said the number of deaths went down in 2009 and continued to decrease in 2010. In 2010 there were 14 deaths; using the number of live births as reported by the state, it's a rate of about 24 deaths per 100,000 live births.
However, South Carolina's rate is based on a definition that limits includable deaths to those occurring up to 42 days after the pregnancy's end. Current rates for Texas, Louisiana and Mississippi use a definition that includes deaths occurring up to a year afterward.
Florida, which is also bucking Medicaid expansion, saw a brief climb in pregnancy-related mortality in 2009 that the CDC ultimately attributed to a spike in flu-associated deaths, likely the swine flu, and women using illicit drugs seeking delayed care. Between 2005 and 2008 the rate hovered between 13.3 and 15.1 percent.
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