While nearly every state now provides Medicaid coverage for a full year after giving birth, cost concerns and political opposition in some states have prevented the policy from being fully adopted nationwide.

The big picture: The country's maternal health crisis and loss of abortion rights in many states have spurred rapid uptake of a new extended coverage option, even in conservative statehouses that have long resisted the much broader Medicaid expansion under the Affordable Care Act.

• Arkansas, Idaho, Iowa and Wisconsin are the remaining holdouts.

Context: Medicaid is the largest U.S. funder of pregnancy care, covering about four in 10 births.

• States are required to provide pregnancy-related Medicaid coverage for 60 days postpartum. While they've long had the option to seek federal approval for longer coverage windows, Congress in 2021 passed a law making it easier for states to extend postpartum eligibility to 12 months.
• With one in three pregnancy-related deaths occurring between six weeks and one year after giving birth, the policy is seen as a key strategy for efforts to reduce maternal mortality.

Catch up: Most states quickly jumped at the chance to extend postpartum Medicaid coverage.

• "This is the most popular plan option I've seen, at least in the last 20 years of Medicaid," said Joan Alker, executive director of the Georgetown Center for Children and Families.
• The overturning of Roe v. Wade and the expiration of pandemic-era Medicaid coverage protections helped fuel interest in postpartum coverage among states that might have otherwise been skeptical of growing their Medicaid programs, she added.

Where it stands: In Iowa and Wisconsin, governors have called on lawmakers to approve the extended postpartum coverage this year.

• "Building a robust culture of life means supporting mothers and growing families who are struggling to make ends meet," Iowa Gov. Kim Reynolds, a Republican, said in a statement to Axios.
• A bill that Reynolds backs is advancing through the legislature with bipartisan support, according to Iowa Public Radio. However, Democrats have expressed concern over a measure in the bill to lower the income eligibility level for pregnant people.
• In Wisconsin, the state Senate approved legislation in September, but it hasn't advanced in the lower chamber. Assembly Speaker Robin Vos, who previously expressed opposition to the bill, didn't respond to a request for comment.
• A much shorter extension backed by Republican lawmakers in Wisconsin has been rejected by the Biden administration, Gov. Tony Evers, a Democrat, said last month.

The outlook is uncertain in Arkansas, where lawmakers have a limited legislative session this year.

• State Rep. Aaron Pilkington, a Republican who's sponsoring a postpartum coverage bill, said lawmakers had been waiting for a financial impact report on the policy. He's weighing whether to attach his bill to the state's Medicaid budget during an upcoming fiscal session.
• He said he's talked with Gov. Sarah Huckabee Sanders' office but hasn't gotten a commitment to support postpartum coverage expansion.
• A Sanders spokesperson did not answer whether the governor supports the policy but said her "first priority is the health and safety of all Arkansans."

In Idaho, a bill had significant support from Republican lawmakers last year, but the health care committee chair blocked it because it didn't have accompanying cuts to the Medicaid budget.

• The state's Medicaid department this year asked the legislature to approve the coverage expansion, which shouldn't cost additional state funds, an Iowa Department of Health and Welfare spokesperson said.
• "There's the appetite to help moms and kids" in Idaho, said Ivy Smith, a health policy specialist at the advocacy group Idaho Voices for Children. "We're not sure exactly what it's going to look like going forward. But we're confident that we're going to get some movement."

What they're saying: "One of our strategies in these states is to now show them the map" of states that have adopted the coverage expansion, said Taylor Platt, health policy manager at the American College of Obstetricians and Gynecologists.

• "We're not necessarily pulling the shame card, but also being like, 'You know, you're one of the only ones left that hasn't done this.'"