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writing for godot

Underfunding Labor & Delivery: A National Disgrace That Discriminates Against Women’s & Babies’ Rights

Written by Robert S. Becker   
Thursday, 11 April 2019 13:46

Breakthrough ideas are rare for grassroots activists who grind away, weighing tactics, with eyes forever on the prize. For us, that means protecting local maternity services against “bookkeeping mentalities” at our rural, community-owned, Northern California hospital. Small-town, public hospitals are under siege, punished by austere reimbursements while labor, drugs, regulatory, and maintenance costs skyrocket.

Breaking even is an epic triumph as required Emergency Rooms are cash black holes, way surpassing "optional" obstetric (OB) deficits. That makes dumping OB the ready target, especially since Medicaid/MediCal pays under half of actual costs to deliver healthy babies (private insurers and ACA-only patient cover even less). 
Deranged, but true. Needless deficits thus afflict maternity care, which we at Friends of the Hospital value as a public service, more akin to police or fire departments than profit-dictated “businesses.” 

So last month, our veteran OB warrior stunned us with riveting, conscious-raising questions that made clear and simple byzantine medical payment craziness:

Why doesn’t the massive underfunding of labor and delivery, putting both mothers and children at risk, qualify as discrimination against women and babies? Why don’t national failures to sponsor quality birthing centers constitute a violation of social justice? Why are medical “electives,” say replacing knees or overdone lab tests, favored over life-producing labor and delivery? With the talent, science and technology for world-class excellence, why do payment shortfalls denigrate motherhood and women’s health as second-class?

Wow! Afterwards I went hunting for court challenges applying this logic, that underwhelming reimbursements constitute discrimination against mothers and newborns (plus families). Nothing surfaced, though I knew immediately, whatever the legal niceties, this framework could have immense political force. OB as human right cuts through massive healthcare weeds by simply arguing: if health is a universal right, as ACA and single-payer advocates testify, why must pregnant mothers endure high stress from a surge of rural closures (100 hospitals since 2009) or dangerous travel times that exceed medically-recommended 30 minutes? Is getting born any less of a right than the “life, liberty and the pursuit of happiness” set piece that buttresses our opening national gambit?

A second, significant question arose: why must Critical Access Hospitals (CAH, total of 1350 rural US providers) guarantee an Emergency Room (ER) but not basic OB services? Why don’t CAHs like ours fund the three arenas where life and death events occur daily: OB, surgery and emergency services? Our group exists because we know axing OB sends a terrible demographic/community message to prospective parents seeking small-town living: you’re not welcome.

From bad to worse?

A 2018 NY Times summaryfleshes in the calamity, beyond scary hospital closures:

A study published last year in Health Affairs by researchers from the University of Minnesota found that over half of rural counties now lack obstetric services. Another study, published in Health Services Research, showed that such closures increase the distance pregnant women must travel for delivery. And another published earlier this year in JAMA found that higher-risk, preterm births are more likely in counties without obstetric units.

A greater crisis looms: “430 rural hospitals — or 21% of all rural hospitals in the US — are at risk of closing unless their financial situations improve.”

When professional maternity options vanish, pregnant mothers, especially those with less money, fewer cars, yet excessive travel time, must rush to crowded, overtaxed ERs. Rules dictate mothers in labor cannot be transported. Tragically, few ERs are prepared for birthing complications, as with emergency C-sections.  

How shocked are we how little has improved (aside from the exceptional California) since this NPR/Pro Publica headlinetwo years ago, “U.S. Has The Worst Rate Of Maternal Deaths In The Developed World"? This month Iowa OB/GYN doctor, Marygrace Elson confirmed a worse case: not only does the US have “a rising maternal mortality rate that has more than doubled in the last two decades, it's the worst among high-income nations.” Want another shocker: “Sixty percent of maternal deaths in the U.S. are preventable”? 

But, you wonder, how can having babies be so perilous while noisy, zealots in power glorify procreation and oppose termination? Turns out “pro-lifers,” including this dismal president, talk up “life” far more than they back women, often minorities, who go full term because they want children. What, a blatant contradiction?  You bet. So full of contempt for government, anti-abortion voices veto enlightened state and federal policies (many affordable) that could readily reverse our dreadful national OB numbers. So fixated against Obamacare, they refuse offered Medicaid/ACA funding for them and neighbors.

Ever hear the outmoded, simple-minded chorus: “women have been birthing babies forever.  They’ll figure it out. It’s natural, commonplace, automatic”? Except for countless mothers and babies in our day and age who don’t survive childbirth.

Everything in healthcare is complicated and other factors matter: demographic shifts as young families move to cities, small-town economic depressions (less industry, less private insurance), plus serious national shortages of OB talent test all rural staffing tasks. Dr. Elson: “The number of family medicine physicians providing maternity care is on the decline nationally — the percentage of new family medicine residency grads intending to provide maternity care has approximately halved over the last 20 years.”

In short, childbearing is driven to second-class status, with babies treated more like “nice-to-have,” life-style choices, like plastic surgery. After all, Medicare covers 100% of billings from our local Critical Access Hospital. Dr. Elson again: “Due to low reimbursement for maternity services and the expense of maintaining 24/7 coverage, a rural hospital saves approximately $2 million by eliminating obstetrics.” And they are, -- often worsening overall hospital overall stability as OB-related services also decline.  

Glimmers of good news

So, where’s the silver lining, aside from today's consciousness raising? California has halved maternity mortality by improving pre-natal scrutiny, better identifying potential emergencies (yet without compensation for superior results). Dr. Elson is full of recommendations: sending National Health Service Corps physicians to serve rural communities, okaying more J-1 Visa waivers to attract overseas medical graduates, expanding "perinatal regionalization efforts, across specialties, across disciplines, across health systems, student loan forgiveness programs, tax incentives, and assistance with medical malpractice liability insurance."

The solution cupboard is not bare. Still AWOL are benefits from the touted Dec. ’18 “Improving Access to Maternity Care Act” signed by a president more obsessed with keeping immigrants out than welcoming healthy babies in. 

We must shift the big picture from whether OB “makes money” (never, even at larger hospitals) to whether our core human values endorse keeping mothers safe and delivering healthy babies. Moreover, needless emergencies, even deaths, lead to higher immediate and future costs for everyone. Certainly, universal or Medicare-for-All triumph will re-focus attention on expanding OB options. Would it bust our national budget, now squandering a trillion dollars for “defense,” to simply have OB reimbursements cover real-world hospital costs?

Do we not judge a culture's moral standing by protections awarded its most vulnerable members? Like infants. If so, negligent maternity care represents another American black eye. So much for rightwing rhetoric that lionizes stay-at-home moms and pro-life family values. So much for bragging we’re the richest, bestest country, with the world’s best medical care. Tell that to a mother who needs an emergency C-section or a newborn coming out the wrong way or with breathing problems — and both stuck far from professional facilities. Until a critical mass is pressed to redefine what “pro-life” really means, the just rights of mothers and newborns won't join those “self-evident truths” that patriots claim make America great.

Postscript: thanks to Tanya Smart and my wife, Katy Pye, for fact-checking, editing and expanding  perspectives. your social media marketing partner
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