The Potential of Health Care Reform to improve Pregnancy-Related Services and Outcomes
By: Adam Sonfield
Having a child is, quite simply, expensive. Even putting aside the years of food, clothing, shelter, education and all the rest, the basic human functions of pregnancy and childbirth involve, in the U.S. society, thousands of dollars in medical expenses for prenatal care, labor and delivery, and postpartum care for both the mother and the infant. And if there are any pregnancy-related complications, those costs can increase dramatically. Even a short stay for a newborn in intensive care can be expensive enough to bankrupt many American parents, if they must pay out of pocket.
At the same time, there can be dramatic health consequences for mothers and children if they do not obtain the appropriate care. And although there are a multitude of factors behind major health indicators like the rates of maternal mortality and preterm births, it is clear that finacial hurdles-particularly for the uninsured and underinsured-are an important reason why the United States lags behind most other developed countries in the area. According to the 2005 estimates from the World Health Organization and other United Nations agencies, the U.S. maternal mortality rate is higher than the rate in more than 30 other countries, including most of Europe. In fact, as was highlighted in a 2010 report from Amnesty International, the U.S. rates of maternal mortality and severe maternal complications have astually grown worse in recent years.
However, with the passage of the Patient Protection and Affordable Care Act in March 2010, Americans have new reason for optimism about improvements in maternal and child health. Health care reform has the potential to improve access to and use of a wide range of health care services generally, and the law includes a sizable list of provisions focused specifically on pregnancy-related care. Better access to and use of care, in turn, has the potential to address the distressing disparities in maternal and child health found among certain segments of the U.S. population, and between the United States and other developed countries.
Coverage Before Reform
One of the primary impetuses for health care reform, of course, was the large numbers of U.S. residents who lacked health insurance. By the most recent government estimates, about 46 million people in the United States were uninsured, amounting to 17% of the U.S. population younger than 65. That number includes more than 12 million women of reproductive age (15-44), two in 10 women in that age group.
The Coverage to Come
One expected consequence of health care reform is that consederably fewer women will be uninsured prior to pregnancy. According to estimates from the Congressional Budget Office, 32 million fewer Americans will be uninsured in 2019 than would otherwise be the case, as a result of two major coverage expansions slated to become effective in 2014. First, all states will be required to extend eligibility under their Medicaid programs to all U.S. citizens and longtime legal residents in families with incomes at or below 133% of poverty. (Currently, most states have considerably lower thresholds for parents - on average about 65% of poverty - and do not cover childless adults at any income.) Second, individuals and small employers will be able to purchase private insurance coverage through new, state based marketplaces known as exchanges; most of the currently uninsured will be eligible for federal subsidy to make that insurance affordable. Expanded coverage should mean that more women will have a regular doctor or health center they rely upon, and fewer women will need to scramble to pay for care during and after pregancy, or for care for their newborns. It should also mean that more women will be able to plan their preganacies using contraception, ensure they are in good health before conception and obtain early prenatal care - all of which are important factors in maternal and child care.
Beyond its goal of expanding coverage, per se, health care reform includes specific provisions designed to make coverage better for women who are pregnant or trying to become pregnant. Most notably, maternal and newborn care is one of only 10 types of health care services explicitly required by law to be included in what will become widely known as the “essential health benefits package.” That package of services - which will be given greater detail by the U.S. Department of Health and Human Services sometime before 2014 - will be covered for all enrollees in all plans sold in the new exchanges, as well as in any new individual and small group policies sold outside of the exchanges. All told, this mandate should eliminate most of the gaps in the maternity coverage left by the PDA.
The new law also prohibits many of the abusive practices that insurance companies have used to avoid adequately covering pregnant women and infants: Starting in 2014, health plans will no longer be allowed to exclude or limit coverage for care relating to preexisting conditions, or deny health coverage entirely to people because of such conditions. For minors, that protection starts in September 2010. Similarly, plans in 2014 will be barred from charging higher premiums to women than to men, a common practice known as gender rating that is based on the fact that women make greater use of their insurance.
In addition, some key pregnancy-related serices will be available with no cost-sharing. All new private health plans, starting in September 2010, will be required to cover - without any out-of-pocket costs - a series of preventive care items and services as described in preliminary regulations issued by the administration in July, the list of services today includes folic acid suppliments to prevent certain birth defects, STI testing for pregnant women, smoking cessation counseling (also newly required under Medicaid) and a variety of other screenings and vaccinations that are important components of prenatal care, along with all of the preventive care guidelines are issued by the Institute of Medicine.
Potential for Progress
For maternal and child health advocates, this multipronged approach comes none too soon. The 2010 Amnesty International report is but the latest to raise alarms over what some consider a crisis in U. S. maternal health, particularly among disadvantaged women. For example, nearly one-quarter of black women initiate prenatal care late or not at all, according to CDC data, a rate that is more than twice as high as their white counterparts. This disparity contributes to disparate health outcome as well, with black women experiencing at least twice the rates of low-birth-weights births, infant mortality and maternal mortality as white women. Major disparities also exist by geography, income and education.
Many immigrants - both documented and undocumented - are also at a disadvantage, even after health care reform. Although a 1986 federal law requires hospitals to provide labor and delivery care to all women, regardless if immigration status, women without legal status have long been barred from Medicaid and CHIP for their prenatal and postpartum care, and the new law bars them not only from receiving federal subsidies for private insurance, but also from purchasing even unsubsidized insurance through the exchanges. The news is better for legal immigrants, as a 2009 law allowed states to cover pregnancy-related care for recent immigrants under Medicaid and CHIP, eliminating a five-year waiting period put in place in 1996.
Granted, coverage and access are not the only determinants of health care use. Women face a host of other difficulties, ranging from logistical hurdles (e.g., transportation, child care and lack of personal or sick time at work) to quality of care issues (e.g., the need for language services, cultural competency training and night and weekend hours) to social barriers (e.g., low health literacy, immigration concerns, mistrust of providers and discrimination). Moreover, health care use is only one factor affecting individual and community health status, and U.S. health disparities are in large part a result of broader societal inequities, from the availability of jobs and education to the prevalence of crime and pollution. Nevertheless, improved insurance coverage and access to affordable, appropriate health care is an essential first step to help address the nation’s disparities in maternal and child health.