Victoria Ferrell Ortiz found out she was pregnant during the summer of 2017. The Dallas resident was finishing up an AmeriCorps job with a local nonprofit, which offered her a small living stipend but no health coverage. She applied for Medicaid so she could be insured during the pregnancy.

"It was a time of a lot of learning, turnaround and pivoting for me, because we weren't necessarily expecting that kind of life change," she says.

But applying for Medicaid didn't come with an instruction manual. She was inundated with forms. She spent days on end on the phone trying to figure out what was covered, and where she could actually go to get care.

"That was a really huge privilege because it took so much time, and then sometimes the representative that I would speak to wouldn't know the answer," she says. "I would have to wait for a follow up and hope that they actually did follow up with me."

More than 471,000 pregnant Texans are currently navigating that fragmented, bureaucratic system to find care. Medicaid provides coverage for about half of all births in the state — but the coverage is so paltry that many people lose eligibility not long after giving birth.

Medicaid covers about half of all births in Texas. During pregnancy, many rely on that Medicaid coverage to get access to everything they need — from doctor's appointments to prenatal vitamins.

But pregnancy-related Medicaid coverage ends just two months after childbirth — and advocates and researchers say that strict cutoff contributes to high rates of maternal mortality and morbidity in the state. They support a bill moving through the current legislative session that would extend pregnancy Medicaid coverage for a full 12 months, postpartum.

What happened when Texas didn't expand Medicaid

Texas is one of 11 states that has chosen not to expand Medicaid to its population of uninsured adults — that's a benefit offered under the Affordable Care Act, with 90% of the cost paid for by the federal government. That leaves more than 770,000 Texans in a coverage gap — they don't have any job-based insurance, nor do they qualify for subsidized coverage on HealthCare.gov, the federal insurance marketplace. In 2022, 23% of women between the ages of 19-64 were uninsured in Texas.

Pregnancy Medicaid helps fill the gap, temporarily. Close to half a million Texans are currently enrolled in the program. The majority are Hispanic and Latinx women between the ages of 19 and 29.

Undocumented Texans and lawfully present immigrants are not eligible, though they can get different coverage which ends immediately when the baby is born.

In states where the Medicaid expansion has been adopted, coverage is available to all adults with incomes below 138% of the federal poverty level. For a family of three, that means an income of $34,307 a year.

But in Texas, childless adults don't qualify for Medicaid at all. Parents can be eligible for Medicaid if they're taking care of a child who receives Medicaid, but the income limits are low. For a three-person household with two parents, they can't make more than $251 a month.

The pregnancy-related Medicaid in Texas is available to individuals who make under $2,243 a month. It lasts through pregnancy and two months after giving birth, covering everything from prenatal visits to postpartum check-ups.

For Ferrell Ortiz, the hospitals and clinics that accepted Medicaid near her in her Dallas neighborhood felt "uncomfortable, uninviting...and a space that wasn't meant for me," she says. But she did find out that Medicaid would pay for her to give birth at an enrolled birthing center.

"I went to Lovers Lane Birth Center in Richardson," she says. And I'm so grateful that I found them because they were able to connect me to other resources that the Medicaid office wasn't."

Ferrell Ortiz was glad she had found a welcoming and supportive birth team. But the Medicaid coverage ended not long after her daughter arrived — just two months after giving birth. She says losing insurance when her baby was so young was stressful.

"The two months' window just puts more pressure on women to wrap up things in a messy and not necessarily beneficial way."

In the 2021 legislative session, Gov. Greg Abbott signed a bill extending pregnancy Medicaid coverage from two months to six months postpartum, pending federal approval.

Last August, The Texas Tribune reported that extension request had initially failed to get federal approval, but that the Centers for Medicare & Medicaid Services (CMS) had followed up the next day with a statement saying the request was still under review. The Tribune reported at the time that some state legislators believed the initial application was not approved "because of language that could be construed to exclude pregnant women who have abortions, including medically necessary abortions."

On March 14, 2023, a CMS spokesman confirmed to KERA that the state's application to extend postpartum coverage to a total of six months is still under review.

The state's Maternal Mortality and Morbidity Review Committee is tasked with producing statewide data reports on causes of maternal death and intervention strategies. Members of that committee, along with advocates and legislators, are hoping this year's legislative session extends pregnancy Medicaid to 12 months postpartum.

Lack of health care coverage led to worse outcomes for pregnant people in Texas

Kari White, an associate professor at the University of Texas at Austin, says the bureaucratic challenges Ferrell Ortiz experienced are common for pregnant Texans on Medicaid.

In Texas, maternal health care and Pregnancy Medicaid coverage "is a big patchwork with some big missing holes in the quilt," says White, who is also the lead investigator with the Texas Policy Evaluation Project (TxPEP).

TxPEP studies the various impacts that state policy has on people's reproductive health. A March 2022 TxPEP study surveyed close to 1,500 pregnant Texans on public insurance. It found that "insurance churn" — when people lose health insurance in the months after giving birth — led to worse health outcomes and problems accessing postpartum care.

"People are either having to wait until their condition gets worse, they forgo care, or they may have to pay out of pocket," White says. "There are people who are dying following their pregnancy for reasons that are related to having been pregnant, and almost all of them are preventable."

For example, chronic disease accounted for almost 20% of pregnancy-related deaths in Texas in 2019, according to the latest report from the Texas Maternal Mortality and Morbidity Review Committee (MMMRC). Chronic disease includes conditions such as high blood pressure and diabetes.

The report determined at least 52 deaths were related to pregnancy in Texas during 2019. Serious bleeding (obstetric hemorrhage) and mental health issues were among the top causes of death.

"This is one of the more extreme consequences of the lack of health care," White says.

Black Texans, who make up close to 20% of pregnancy Medicaid recipients, are also more than twice as likely to die from a pregnancy-related cause than their white counterparts, which is a statistic in Texas that has held true for close to ten years with little change, according to the MMMRC report.

Stark disparities such as that can be traced to systemic issues, including the lack of diversity in medical providers; socioeconomic barriers for Black women such as cost, transportation, lack of childcare and poor communication with providers; and even shortcomings in medical education and providers' own implicit biases — which can "impact clinicians' ability to listen to Black people's experiences and treat them as equal partners in decision-making about their own care and treatment options," according to a recent survey.

Maternal health bills moving in the 2023 Texas legislature

Diana Forester, the director of health policy for the statewide organization Texans Care for Children, says Medicaid coverage for pregnant people is a "golden window" to get care.

"It's the chance to have access to healthcare to address issues that maybe have been building for a while, those kinds of things that left unaddressed build into something that would need surgery or more intensive intervention later on," she says. "It just feels like that should be something that's accessible to everyone when they need it."

Extending health coverage for pregnant people, she says, is "the difference between having a chance at a healthy pregnancy versus not."

As of February, 29 states have adopted a 12-month postpartum coverage extension so far, according to a Kaiser Family Foundation report, with 7 states planning on implementing this extension in the future.

"We're behind," Forester says of Texas. "We're so behind at this point."

"I feel like the momentum is there"

Many versions of bills that would extend pregnancy Medicaid coverage to 12 months have been filed in the legislature this year, including House Bill 56 and Senate Bill 73. Forester says she feels "cautiously optimistic."

"I think there's still going to be a few little legislative issues or landmines that we have to navigate," she says. "But I feel like the momentum is there."

Ferrell Ortiz's daughter is turning 5 this year. Amelie is artistic, bright, and vocal in her beliefs. When Ortiz thinks back on being pregnant, she remembers how hard a year it was, but also how much she learned about herself.

"Giving birth was the hardest experience that my body has physically ever been through," she says. "It was a really profound moment in my health history — just knowing that I was able to make it through that time, and that it could even be enjoyable — and so special, obviously, because look what the world has for it."

She just wishes people, especially people of color giving birth, could get the health support they need during a vulnerable time.

"If I was able to talk to people in the legislature about extending Medicaid coverage, I would say to do that," she says. "It's an investment in the people who are raising our future and completely worth it."

This story comes from NPR's health reporting partnership with Kaiser Health News (KHN) and KUT.