How Insurers are Still Pulling Maternity Coverage from Pregnant Women’s Plans

by Melissa Garvey, ACNM Writer and Editor

As of 2014, maternity care coverage in the United States will take a step up. Under the Patient Protection and Affordable Care Act of 2010, health insurance plans will no longer be able to turn away applicants based on the “preexisting condition” of pregnancy. Maternity care coverage will also be mandatory for individual and small-group insurance plans as well as policies sold through state-based insurance exchanges. This is good news.

But until 2014, women will continue to get pregnant. About half will become pregnant unexpectedly and may have the added stress of no maternity care coverage. Plus, more women will try to conceive and discover in the second, maybe even the third trimester, that their maternity benefits have been cut considerably or have become significantly more expensive.

That’s exactly what happened to The Feminist Breeder—a blogger and birth advocate planning a home birth with a certified nurse-midwife under the coverage of Blue Cross Blue Shield. Here’s what happened to her after months of planning to conceive her third child:

…we found out that coverage we signed up for last year isn’t the coverage we actually have now because they keep decreasing it every year, and it’s going to get even worse in 2011. Starting in January, almost NONE of our homebirth expenses will be covered because of a massive deductible increase, and what is covered will cost us a ton more than we anticipated when we made the decision to start trying to conceive last January.

Even more women are blindsided by expenses they never knew to expect. My cousin is staring down the barrel of inflated health care bills because her maternity care will stretch across two calendar years, two deductibles, and two out-of-pocket costs. A recent Washington Post article features a woman paying $400 per month for an individual health plan who thought “it must be a mistake” when she discovered her plan required a special maternity rider in advance of the pregnancy in order to be eligible for childbirth-related coverage.

Where does this leave mothers until 2014? It doesn’t look good.

Access to Midwifery Care Improves Maternity Outcomes

by Tina Johnson, CNM, MS, ACNM Director of Professional Practice & Health Policy

The Patient Protection and Affordable Care Act will bring millions of newly insured citizens into the health care system. In order to meet the country’s needs, leaders are calling for high value, evidence-based solutions. Let’s start with the health condition that affects 100% of all Americans...childbirth! How can we provide high quality, high value maternity care for all women and families? The answers are in the evidence: midwifery care improves maternal and newborn outcomes and patient satisfaction, reduces health disparities, and saves money and resources.

The U.S. grossly outspends every other nation per capita on health care, yet our maternal and newborn outcomes lag far behind those of other developed nations. Childbirth is the number one reason for hospitalization, and its related hospital charges surpass those of any other health condition. Resource-intensive interventions like labor induction, epidural analgesia and cesarean section are overused, often without indication or consideration of alternatives, resulting in increased risk of maternal and newborn harm.

Cesarean section is the single most common operating room procedure in the U.S., and the rate is steadily climbing. Incredibly, in 2007, nearly one-third of American women delivered their babies by cesarean section. Maternal mortality has risen dramatically, and glaring racial disparities in maternal and neonatal outcomes persist.

How can we reverse these disturbing trends? Ensure that all women have access to maternity care providers and practices that support the normal processes of birth. Labor support, freedom of movement, intermittent monitoring, alternative birth settings, vaginal birth after cesarean...all have been identified as evidence-based practices that are underused.

Midwives truly are the experts in supporting healthy vaginal birth in all settings. Midwives caring for low-risk women improve infant mortality rates in both hospitals and birth centers when compared with physicians caring for equally low-risk women. Midwife-led models of group prenatal care reduce preterm and low birthweight rates and improve patient satisfaction. Birth centers provide improved outcomes for even the most at-risk women, reducing preterm birth, low birthweight and cesarean section rates, and reducing costs to our health care system. Skilled midwifery care is the gold standard among nations with the best maternal and neonatal outcomes, and has been identified as essential to reducing maternal mortality worldwide.

It’s time to bring that message back home. The time is now to promote and support midwifery in America—and to follow the evidence.

This post was originally published on the the Center to Champion Nursing in America (CCNA) blog. Visit CCNA to join more conversation about this post.

Quality of US Maternity Care on Track to Improve With or Without Legislation

by Melissa Garvey, ACNM Writer and Editor

As you may have already heard from ACNM Federal Lobbyist Patrick Cooney, health reform legislation has reached a startling, disappointing halt. We are not sure what this means for the numerous provisions that would increase access to midwifery and birth centers.

In the face of this development, I’d like to take time out to raise everyone’s spirits and highlight a few exciting initiatives that are moving full steam ahead, whether or not health reform legislation passes soon. Each initiative has the same mission as many of the Senate’s proposed health reform provisions: to improve the quality of maternity care for US women.

1. The March of Dimes released a webcast edition of its Symposium on Quality Improvement to Prevent Prematurity, which ACNM cosponsored last October. Registration is free and gives you access to information from expert speakers, including ACNM President Melissa Avery and A.C.N.M. Foundation Secretary Nancy Jo Reedy.
   
   
2. This week, the Joint Commission issued an alert on preventing maternal deaths during and after pregnancy. The alert points out that maternal mortality rates in the United States are not declining, and may be on the rise. Even more disturbing is that for every mother who dies from pregnancy-related causes, 50 more mothers will become very ill due to significant problems during pregnancy, labor, and delivery. This isn’t good news, but it does promote awareness and proposes steps toward improvement. Lamaze International has taken this opportunity to issue its own set of recommendations for preventing maternal deaths.
   
   
3. Childbirth Connection has released findings from its 2009 Transforming Maternity Care Symposium. This was a major effort by numerous stakeholders in US maternity care, including ACNM, the American College of Obstetricians and Gynecologists (ACOG), and the Midwives Alliance of North America (MANA), with the purpose of transforming US maternity care into a wellness, woman-centered model. Their vision document, blueprint for action, and more are now available. I suspect midwife Amy Romano, CNM, will weigh in with more commentary at Science and Sensibility soon.
   

These are just three initiatives among many in progress toward improving the quality of US maternity care. What other initiatives and projects are you keeping an eye on or participating in?

Women Would Be Better Off If Reform Passes

While President Obama and congressional Democrats discuss the public option and the absence of bipartisan support for health care reform, a front-page article in Monday’s edition of Politico proposes that highlighting the particular importance of proposed reforms to women may be the key to successful reform.

Women have a lot to gain if health reform legislation passes. Protections mentioned in the article include:

• Guaranteed maternity care
• Elimination of higher insurance premiums for women
• Protection from being denied coverage due to “pre-existing conditions” like cesarean section or domestic violence
  

Despite these protections that would address gender discrimination in health care, a Kaiser Family Foundation survey found that women are no more likely than men to think they “would be better off if reform passed.” According to the article, the problem is that women simply don’t know what is in the legislation for them.

Senator Sherrod Brown (D-Ohio) shared his perspective on just how monumental health care reform would be for women:

"Brown described the elimination of gender discrimination in health care as an historic advance comparable to landmark legislation prohibiting unequal treatment between men and women in employment, education and sports."

Do you know what’s in health care reform legislation for women? Learn more in an update from ACNM Federal Lobbyist Patrick Cooney or listen to his audiocast.

Midwives Included in Health Care Reform

National Midwifery Week (October 4-10) starts this Sunday, and we have some wonderful news to kick off the week. Equitable reimbursement for certified nurse-midwives (CNMs) under Medicare is now included in both the House and Senate health care reform bills!

The midwifery equity provision made it into the Senate bill last night after Senator Kent Conrad (D-ND) introduced it as part of an amendment in the Senate Finance Committee.



In the coming weeks, the Senate bill and the House bill are expected to come up for vote in both chambers and are widely projected to pass. As it stands now, the only thing between CNMs and 100% reimbursement for their services under Medicare appears to be President Obama’s signature.

While this is a major step forward for the midwifery community, ACNM’s parallel effort to win inclusion of certified midwives (CMs) under Medicare and Medicaid was not successful. We’ve already identified additional strategies for continuing to pursue reimbursement for CMs.

Meanwhile, hats off to Senator Conrad for introducing the amendment and to Senator Blanche Lincoln (D-AR) for saying, “Without a doubt, the certified nurse-midwives in Arkansas have done a tremendous job and I want to thank Sen. Conrad for moving forward with that.”

Let the National Midwifery Week celebrations begin!

What do Midwives and Women Think about Health Care Reform?

In August, ACNM endorsed the House health reform bill, H.R.3200. This week we're watching closely as the Senate Finance Committee is finalizing its own version of the legislation. These are controversial pieces of legislation. So, tell us what you think! Let’s voice our opinions and share informative resources to fuel the discussion. Is health care reform good for women, midwives, Americans? What do you like about the unfolding legislation? What don’t you like about it?

Here are few resources to get the conversation started:

• Why Reform Matters from the National Women’s Law Center talks about health care reform as it relates to women and families.
  
• The Kaiser Foundation explains the basics of health reform, tracks public opinion, and provides several interactive resources.
  
• The Media Consortium features independent journalism on health care reform.
  
• The Association of Women’s Health, Obstetric and Neonatal Nurses and the National Association of Community Health Centers have informative health care reform position statements and resources.

Persistence Pays for Minnesota Midwife

by Brielle Stoyke, CNM, Minnesota Chapter Legislative Contact

Senator Al Franken and Brielle Stoyke, CNM

In December 2007, I was invited to a fundraiser for Al Franken. Franken was running for a Minnesota Senate seat. I went that night thinking maybe there would be an opportunity to talk to him directly about S. 662, the Midwifery Care Access and Reimbursement Equity Act, just in case he was elected. I didn’t get to talk to him long enough to mention midwifery, but I got my photo taken with him, which I tucked away for later.

He ended up winning the Senate seat, and I attended his celebration party in St. Paul. He had only been in office a few days and did not have a full staff yet. I didn’t even get near him that night, but was able to get the name of his new legislative health aide. So, I went home and e-mailed her about being a midwife, and specifically about S.662, and was sure to attach the photo of Franken and me from the 2007 party. Next, I e-mailed many of the CNMs in MN urging them to ask the senator to cosponsor S. 662.

Just a few weeks later, I was in my hometown of Duluth, MN, where I was offered an extra ticket to an event that Senator Franken was attending. I went with some friends, and we arrived an hour early. The venue staff were not seating yet, so we went across the street for a drink. When we arrived, we were pleased to find a private party in honor of the senator. I instantly recognized the staffer from the celebratory party in St. Paul and was talking with her, when I noticed a lull at the senator’s circle. So, I approached him and told him that I was a nurse-midwife from St. Paul and that I wanted him to cosponsor S. 662. He asked about the bill, and I told him it would increase reimbursement rates to midwives under Medicare. He looked puzzled. So, instead of explaining the details, I told him that I had been in contact with his legislative health aide, that S. 662 would provide equal pay for equal work, that his Senate partner Amy Klobuchar had signed the bill already, and that the bill had no opposition. He then asked me about my training, and I was proud to tell him I had a master’s degree in nursing, with a focus on midwifery. Right then one of my friends approached us with a camera and captured ‘my moment’ with the Senator on camera again! I followed up with his legislative health aide later that week and sure enough, he signed onto S. 662 just six short days later!

What did I learn from this experience? Success comes after persistence and teamwork. Never let an opportunity pass to talk to your legislator about what you do and why midwives deserve equitable reimbursement. Thanks to my fellow MN midwives for following up as well, and thanks to Senator Franken for supporting our bill!

Washington State Stacks Financial Incentives in Favor of Vaginal Birth

The state of Washington is taking an innovative step toward tackling rising cesarean section rates by eliminating the profit motive. Beginning this month, the state’s Medicaid reimbursement for uncomplicated cesarean sections dropped from approximately $3,600 to about $1,000—the same reimbursement provided for complicated vaginal birth.

Because the cost of vaginal birth is lower than the cost of c-section, the new payment structure rewards health care providers for supporting vaginal birth rather than for performing c-sections. Nearly half of all births in Washington are reimbursed through Medicaid, so the change is expected to have far-reaching effects. In fact, the state has already received calls from hospitals requesting assistance to revise the protocols they use to decide when a cesarean section is necessary.

A recent Crosscut.com article by Carolyn McConnell explains why this is an excellent way to improve maternal and infant health. It’s also in line with #5 and #7 of ACNM’s Seven Key Principles for Health Reform.

What do you think? Would you like to see the rest of the country adopt Washington’s new strategy?

Nurses Stand with Obama; Are Midwives Next?

by Dawn Durain, CNM, ACNM Vice President

I was trying to find some news coverage on the Sonia Sotomayor hearings on Wednesday afternoon, when suddenly there was President Obama on the White House steps surrounded by women! This being an atypical sight, I quickly unmuted. As it turned out, the people accompanying the president were mostly nurses and members of the Congressional Nursing Caucus—nurses in the Rose Garden! Nurses were being praised by the president for their dedication, ability to convey complex information to patients, and skills in caring for women in labor and their nervous husbands—all of this from the personal experiences of President Obama no less.

The occasion of the speech was, of course, to mark a significant step by Congress toward health care reform. I encourage you to read the Senate and House legislation and the president’s speech for yourself. I find the recognition of the work of nurses refreshing—more refreshing than the recent spate of TV shows featuring nurses for sure! I found myself hoping for the impossible though. Would the president mention nurse-midwives when he spoke of his experiences when his daughters were born? He didn’t. Would he mention the importance of nurse practitioners, certified nurse-midwives (CNMs), and certified midwives (CMs) as primary care providers when he spoke of the need for coordinated health care? He didn’t do that either. But, the legislation he referenced does, thanks to the hard work of our ACNM staff and midwives around the country who are talking and talking and talking to their representatives in Congress. Wednesday felt like a giant step forward. And maybe next time the White House will invite a midwife to the Rose Garden!

On a personal note, I’d like to give a shout-out to Keisha Walker, one of the nurses President Obama introduced who was there with him. She is a graduate of the University of Pennsylvania Graduate School of Nursing and worked on two projects in my Public Policy class at UPenn. She was passionate about nurses being involved in the political process and about the ability of nurses to have an impact on reproductive health care policy. She is currently at Johns Hopkins as a nurse researcher in their MPH program and clearly still involved in health care policy. Way to go, Keisha! Who is next in line to talk to the president about midwifery?

CNM/CM Medicare Reimbursement Legislation Included in House Health Reform Bill

Senate Medicare bill (S. 662) has 18 co-sponsors and counting!
by Laura Jenson, CNM, MS

So, the best thing about making that first phone call to my representative’s health legislative aide was finding out how easy it is. Sure, I had made quick phone calls in the past to legislators’ offices asking that they support this or that bill, my zip code is 60623, OK, thank you very much, bye! But I had never phoned a health legislative aide (or “health LA” if you want to sling around some jargon) with the intention of having an in-depth conversation about legislation until this winter . . .

When I first spoke with the health LA for my representative, Luis Gutierrez, about H.R. 1101, she wasn’t even totally sure what a midwife was. I honestly kind of stumbled through that conversation and then followed up with a couple of e-mails with letters of support for the legislation from various organizations like ACOG, the ANA, the National Perinatal Association, and the National Rural Health Association. I called her back a couple of times to check in, and then to my great surprise, Rep. Gutierrez’s name showed up a few weeks later on the co-sponsor list for the bill! (Love www.opencongress.org/ – you can get loads of information about a bill; the old standby, http://thomas.gov/ is good, too). It was such a great feeling to see that my little amount of work made a difference, and now I’ve got a new little hobby.

Seriously. Once I started poking around looking for resources, I found that most everything you need is online, and ACNM has put it all in one place. You can go here to find information about the Medicare equitable reimbursement issue that’s so important right now, especially because of the health care reform legislation that’s being drawn up. If you want to find out who your elected officials are, just go here. (I had to go to the USPS site first to find my four-digit zip code extension to figure out who my one representative was.) There are also loads of people on the ACNM Government Affairs Committee (or the “GAC”) who would love to help with any questions you have about this process—e-mail me at laurajenson@gmail.com if you’re interested in finding out who’s in your region.

Why get involved? Because more phone calls means more legislators signing on as cosponsors, and more co-sponsors means our bill has a better chance of being attached to some larger health care legislation. The Medicare reimbursement issue is a top agenda item right now—let‘s make this happen! The legislation has already been included in the House health care reform package (go team!), and now it’s important that it be included in the Senate version. If you’ve read this far, how about taking a couple more minutes to give your Senators a call? Go here to learn more.

Are You In The Know?

Straight from the ACNM Communications Department, here are our top picks for happenings in midwifery for the week:

Authors of an Obstetrics & Gynecology article say they encourage midwifery care and “support future randomized trials to compare” home vs. hospital births. The statement comes in response to a letter from certified nurse-midwife Judith Rooks and Our Bodies, Ourselves Executive Director Judy Norsigian.

A midwife wrote an interesting article for Tuesday’s New York Times entitled “In a Lifeless Birth, a Midwife’s Opened Eyes.”

A fatal Metro collision happened between Washington, DC, and Silver Spring, MD—home of ACNM. Thankfully, the one ACNM staffer in the accident escaped with only a few bruises.

Saturday, June 27, is National HIV Testing Day.

Health reform is still hot, and ACNM is involved. We just posted legislation of interest to ACNM members here.

What else is going on in your world? Feel free to add to our list!

The Article that President Obama is Reading

According to an article in the New York Times, President Obama is singing the praises of Atul Gawande’s “The Cost Conundrum,” which was recently published in The New Yorker magazine. Gawande’s piece investigates the geographic variations in health care cost per person, in particular McAllen, TX—the most expensive place in the US for health care. The piece is certainly impressive, calling attention to the fact that higher spending is often not associated with better health outcomes.

How’s this for a fun fact? When it comes to maternity care and primary care, midwives achieve positive patient outcomes using minimal costly interventions. Want to give us a hand with improving access to midwives? Tell your legislator to support the Midwifery Care Access and Reimbursement Act of 2009 (HR 1101 and S 662).