AMCHP 2005 ANNUAL CONFERENCE
DELIVERING RESULTS, IMPROVING PREGNANCY & BIRTH
February 19-23, 2005
M. LYNSEY MORRIS: I thought the best way to break this down would be to first spend just a couple of minutes talking about the problem of un-insurance among pregnant women and women of child bearing age. And then I want to talk about Medicaid and SCHIP, which are the two federal programs, federal state share programs. And then I’m going to round this discussion off by talking about tax credits for the uninsured, which is something we’ve been hearing more and more about. I’m coming for the administration and it has, you know, pretty serious implications for what we’re talking about today. And so I’m going to try and keep this interesting. I understand that Federal Medicaid Policy is not the most exciting thing in the world, but I’m going to do my best.
JOSHUA BROWN: Mindy, before you start, can everyone hear okay even in the back of the room, if so we can turn it up a little. Okay?
UNKNOWN SPEAKER: You can turn it up just a little bit.
JOSHUA BROWN: All right.
M. LYNSEY MORRIS: How do I do that?
JOSHUA BROWN: I’m not sure but you can start and I’ll get a tech.
M. LYNSEY MORRIS: Okay, I’ll try to speak more into the microphone. Okay, why is prenatal care important? You all know why it’s important but in terms of Medicaid and access, why is it an important issue? And I have this quote which is, it was taken, and I don’t even remember who said it, but it was during the hearing of the Senate Finance Committee a couple of years ago. “Infants born to mothers receiving late or no prenatal care are more likely to face complications, which can result in hospitalization, expensive medical treatments, and increased cost to public programs.” Now, just for a second, don’t think as an MCH person but think as a member of Congress. And what’s going strike you from this quote are the words, expensive, increased costs to public programs. When members of Congress think about healthcare, they think about it in terms of cost. There tends to by a very myopic view of, you know, safety net programs like Medicaid and SCHIP.
There really isn’t the mentality to think how much could this save us in the long run? Or is we invest in preventive care now, what could we save in the long term? Members of Congress really tend to think about short-term costs. How much will it cost this year to enroll pregnant women? Not, you know, what benefits would prenatal care give to these children who, you know, we could avert more expensive costs later on. And so one of the biggest challenges we really face at a Federal level is trying to expand congresses worldview of what is worth investing in. And so I think the discussion on prenatal care and on, you know, issues related to pregnancy are really where we can see that there’s be kind of a disconnect in terms of investing in preventive care to save money in the long run. And it’s one of the things the March of Dimes has been working on for years.
AMCHP has done a lot of work in this area. A lot of the groups that we work with, but there’s still like I said, a very myopic view of where Federal dollars should be invested. And focusing on prevention is not something that Congress has been willing to do, you know, to the extent that we would like. This chart shows you, this is from the March of Dimes Para stats website. It shows you a breakdown of the concentration of uninsured women of childbearing age, that’s age 15 to 44 in America . In the last few years really since 2000, we’ve seen enormous rates of un-insurance. Since 2000, the number people living in low income families has been increased by eight million. The number of people who are uninsured has increased by five million. And 90 percent of the rise in un-insurance has been among working families. It’s not among people who are unemployed. Some of them are unemployed.
Some of them have lost their jobs, but predominantly it’s people who are in working families and their employer has, you know, stopped providing coverage. And you know, maybe they make a little too much money. Maybe they make more than $25,000 a year and therefore don’t qualify for public assistance. And so, you know, uninsured women of childbearing age, I think when you see the graph you can really see kind of the states that are at the biggest problem. The dark magenta color is where you see the, you know, the strongest concentration. And to break that down by racial demographics, Latino women are overwhelmingly the most over represented in terms of un-insurance. And they’re more than two and a half times as likely as Caucasian women to be uninsured. Thirty-nine percent of Latino women are uninsured in America , 13 percent of Caucasian women are uninsured, 34 percent of Native Americans, 23 percent of African Americans, and 22 percent of Asian Americans. So you can see that this really is, you know, there’s a disparity issue here.
There’s an equity issue very much at play when we talk about un-insurance. Okay. This graph I think is really, is really very telling because one of the things that we’ve been hearing at least at the Federal level and I have seen this as trickling down at the states, is that Medicaid is an expensive program, it’s growing out of control, it’s inefficient, it’s out of control and we’ve got to do something about it. I think this graph kind of proves that wrong. If you look at Medicaid in terms of the growth and per enrollee spending, Medicaid grew at less than half the rate of private insurance. Now, you know, doctors in the room would probably say that a lot of that is due to the abysmal rates of reimbursement in the Medicaid Program and that’s definitely true. That’s part of the reason why Medicaid spending is lower than private insurance. But the overwhelming reason is that administrative costs for Medicaid are cheaper than private insurance. The bottom line is it’s a pretty efficient program.
There are problems in Medicaid and no one doubts that. No one doubts that there are places where we could tweak. But when you hear people talk about the ineffectiveness of Medicaid and the inefficiency, it’s just simply not true. The data does not back that up. So, what does Medicaid have to provide in terms of prenatal care? When you hear the word mandatory Medicaid eligibility, what this means is that if a state operates a Medicaid Program, and all states do, Arizona was the last state to add Medicaid in the 80’s. Then they have to provide at least women up to 133 percent of poverty with prenatal care. And you can see that’s 20,000 for a family of three in 2004. And Medicaid covers 33 percent of all births annually, 1.4 million. Now this data is a little bit old. It’s from 2003. The National Governor’s Association is supposed to be releasing data pretty soon, we expect within the next couple of months that updates that number and we think it’s probably going to be a little bit higher than that, of the number of births that are covered by Medicaid.
What kind of services, are included in Medicaid services? Well, if a women is enrolled in Medicaid because of pregnancy, then anything her doctor deems to be medically necessary is covered under Medicaid. She is also covered up to 60 days of post partum care, which is really important because when we start talking about SCHIP, which is a whole different issue, post partum care is really part of the ongoing debate in SCHIP. And another thing that pregnant women can get under Medicaid that other Medicaid recipients can’t get is that states are allowed to provide services such as health education, nutrition counseling, and case management services that they typically cannot provide to other enrollees. So the benefit package for Medicaid patients who are pregnant is actually, you know, a pretty good benefit package.
Now the reason I distinguish between mandatory and optional is because the current administration has proposed a budget proposal that wants to take patients, enrollees, who are in the optional category and allow states to do more flexibility in terms of benefit services that they provide to those, to those enrollees. A state has to cover women up to 133 percent of poverty. They have the option of covering women up to 185 percent of poverty. If they want to cover women at a higher level, which some states do, I think Rhode Island covers women up to like 300 percent of poverty. Then they have to apply for a waiver from the Federal Government, which really isn’t, you know, isn’t a big deal to extend eligibility upwards. But, what would happen if the proposal that’s on the table now to make optional Medicaid enrollees, to give states more flexibility in terms of what they provide. If the proposal is cemented, then what states could do is take these women between 133 percent of poverty and 185 percent of poverty and offer them a limited benefit package or cap the number of enrollments.
Currently Medicaid is an entitlement, which means if you meet a certain, you know, eligibility level than your are entitled to all of the benefits guaranteed. You know, a state could have an option to not give any post partum care to women if they wanted to. It’s just very unclear at this point what, you know, optional flexibility is going to happen if the, you know, administration’s proposal is cemented. Okay. The impact of Medicaid coverage on pregnant women, I think this a pretty remarkable statistic. You know, on, you know, on average there are about 20, about 24 percent of women of childbearing age are uninsured. However, at the time of delivery only eight percent of pregnant women are uninsured. And that drop is due to, it’s due to Medicaid. It’s due to the fact that Medicaid picks up a lot of these women who, you know, otherwise would not qualify.
If you’re just a woman of childbearing age you don’t qualify for Medicaid unless you make, it depends, it differs in every state, but the average is somewhere like 74 percent of poverty. If you get pregnant and you make below 133 percent or if the state has optional eligibility, you could go up to whatever level that state has. Then you can enroll in Medicaid and it’s had a tremendous impact on lowering rates of un-insurance among pregnant women and giving them access to the prenatal care that they need. One of the things that I think is important to remember in this conversation though is that why is it that eight percent of women are still uninsured? If all of these women are probably, I mean, I’m not certain about this but I believe that this is eligible women, eligible. I don’t think it’s the entire population. I think it’s eligible uninsured pregnant women. Why is it that eight percent of them are still uninsured? There are several barriers to enrollment in Medicaid, the first of which is that undocumented immigrants are not allowed prenatal coverage at all, even though, you know, the baby that they’re carrying is a potential U.S. citizen and will be covered under Medicaid, most likely, once it’s born.
Legal immigrants, women who are here legally who’ve been here less than five years cannot get public coverage, even if they’re working and paying taxes and are here legally. Eligibility processing is a tremendous problem in many states. Some states exercise an option called presumptive eligibility, which means that Medicaid presumes that they are eligible until their paperwork has been processed and they’ve been, you know, found to be eligible, therefore getting them care earlier on rather than waiting, you know, the two or three months it might take to process their enrollment. But some states don’t have presumptive eligibility. There was an example recently in Colorado where a woman lost her baby at 37 weeks of gestation. Her eligibility was still being processed. It had been what, 37 weeks into her pregnancy and Medicaid eligibility still had not been determined. She lost her baby. She had no prenatal care at all up until that point. And it turns out she was eligible for Medicaid. And a lot of women simply don’t know they’re eligible. A lot of women don’t know, I mean, you know, who walks around knowing the poverty threshold for Medicaid. Not many people. And this is where I think there really needs to be some connection between, you know, MCH programs and Medicaid. They’re lots of points of contact that we could make with women to, you know, to determine their eligibility or to, you know, at how many points women, you know, enter our clinic to receive family cleaning services. You know, if they become pregnant they could, you know, conceivably be eligible for Medicaid and those kind of connections need to be made. Women need to be aware of their entitlements and their rights. Okay.
Now moving on. The second program I want to talk about is the SCHIP program, the State’s Child’s Health Insurance Program. This program was created in 1997 and was intended to cover uninsured kids who were not eligible for Medicaid, kids up to 200 percent of poverty. And it was intended to originally be a program just for children. And it’s a Block Grant to states. Unlike Medicaid, you don’t automatically get CHIP benefits if you meet a certain income threshold the way you do in Medicaid. States are given an allotment and they can disperse that however they want to. Now since 1997 there have been some avenues for states to cover prenatal care through the SCHIP program. The first is through a section 1115 waiver. This is section 1115 of the Social Security Act. But what’s really important to remember is that a lot of states exercise the option to apply for a waiver from HHS so that they can cover pregnant women. Now only three states have done this. What most states who want to cover pregnant women have done is the unborn child regulation.
This was enacted in 2002 and the March of Dimes has been working for a long time to, you know, allow states to cover women through CHIP, pregnant women through CHIP without having to apply for a waiver. Well in 2002 what the department of HHS decided to do is to establish a regulation saying, the unborn child is a potential person who would be eligible for benefits so we’re going to cover the child from conception through the age of 19, which means that the child can be covered while it’s in utero. We weren’t exactly happy with this because you’re covering the child and not the woman, which means that post partum care is not included in this. So we think it’s an incomplete regulation. The upside of this regulation is that a lot of undocumented immigrants, who would otherwise not, you know, women who would otherwise not be eligible for care, can receive care because their child is a potential citizen.
And so it’s kind of been mixed blessing but we still believe and I’ll talk about this in a minute, we still believe that, you know, there needs to be another regulatory change so that states can if they want to, cover not only the unborn child but also the pregnant woman. Okay. If SCHIP were expanded and this is 1999 data, 41,000 uninsured pregnant women would have been covered, which if you look at the graph, it’s really not an impressive up tick. It just would have covered 10.5 percent of all uninsured pregnancies. However, if you look at this graph, this is the number of uninsured women who were income eligible for Medicaid or CHIP in 1999. Eighty point four percent of them could have been covered had they been enrolled for one reason or another. And I talked about the barriers to enrollment but you see that, and I mean, this is, this is an enormous problem among children, it’s a problem among pregnant women, of people who are eligible for these services but don’t get enrolled for whatever reason.
And there are numerous proposals on the table about how to, how to enroll children into the population, you know, work through schools, work through, you know, children’s vaccination. But there are lots of points where children enter the system. You know, children who are potentially eligible enter the system but are not ever, the connection is not ever made for whether or not they could be eligible for SCHIP or Medicaid. And but we really haven’t worked out the right way to get to pregnant women and how to get people who are eligible enrolled in the program. A policy solution to the issue of SCHIP, the March of Dimes has been working on a bill with Senators Lincoln and Lugar, Senator Blanche Lincoln from Arkansas and Senator Richard Lugar from Indiana called “To Prevent Pre Maturity and Improve Child Health Act” and has several provisions in it but one of the things it does is it allows states that option of enrolling pregnant women in their CHIP program without having to seek a Federal Waiver, an 1115 Waiver.
And we also think that they should be allowed to use presumptive eligibility, which means that, you know, before income eligibility has even been determined, you assume that a woman is eligible and get her care immediately. We all know, I mean, I know that you guys know that the earlier you can get a woman into a program and get her prenatal care, the more it increases your chances of having positive birth outcomes. Okay. The last thing I want to talk about is tax credits for the uninsured. And we talked about Medicaid and we talked about SCHIP and those are the Federal Programs. Remember when I was telling you that one of the options the administration wants to pursue is giving states more flexibility with covering optional populations, anybody above a hundred, women and children above 133 percent of poverty. What they want to do is to encourage people to get private insurance, which is a great thing, I mean, it would be awesome if, you know, more people had access to private insurance. We’re talk about it in a minute, why that’s a problem for pregnant women and really for women of childbearing age.
And the vast majority of the uninsured are under 200 percent of poverty and they don’t have access to employer coverage. And so the proposals on the table, you know, that congress and that the administration are really considering with any seriousness, allow Americans to buy into the private insurance market. It assumes that these people are not in Medicaid or SCHIP and it assumes that they don’t have access to employer, based insurance, which is true. And so, you know, how could we help people buy private insurance in the individual market? Well, through tax credits, is what the administration is saying. And so the question for us is, if tax credits are really going to be a legitimate way of enrolling people in private coverage and giving them, you know, insured, and March of Dimes, we really don’t take a position on whether or not Medicaid is better or CHIP is better or private insurance is better. Really what we care about is that women have access to comprehensive care. We don’t care where it comes from, so long as they have quality comprehensive care.
So if tax credits, you know, are a useful way of helping women enroll, then we’re all for it. However, lets look at the private market. Lets assume that a woman has a tax credit and to just briefly tell you, the tax credit proposal that’s been proposed by the administration in the past and that will be proposed again this year, every individual that is income eligible, under 200 percent of poverty, would receive a $1000 tax credit for an adult, and a $500 credit for a child, that’s for a year. So, you know, a two-parent family with two kids would receive a $3000 tax credit. It’s estimated that on average, families who qualify for this tax credit would spend 16 percent of their annual income on health insurance coverage. And that’s assuming that they’re relatively healthy. Prenatal and maternity services are generally not covered under most private insurance policies, you know, as a basic rule. Now, there are 13 states that have mandated that private insurance offer prenatal care. But for most states it’s not true. If it is available, it’s often sold as a rider to your policy and you buy additional coverage for prenatal care.
It’s often incredibly expensive and very limited. If you’re already pregnant, you can’t get service at all. You cannot get insurance. It’s considered a pre existing condition. So, I think individual market policies, giving people tax credits so that they can buy private insurance is great if you’re Josh Brown. If you’re relatively young, relatively healthy, and male, then it’s an excellent option for, it’s a really good option for you. But you know, even if you’re not pregnant, if you’re a young woman of childbearing age, you’re considered at risk of pregnancy. So if I wanted to buy a private insurance and, you know, suspected that at any point in the future I may actually want to have a child, I’d have to buy the rider. It’s incredibly expensive and a $1000 is just simply not going to get me very far. You know, and so it is a good option for some people, but like I said, Congress is very myopic. They think in terms of dollar terms.
Everybody would get that thousand dollars regardless of how healthy they are, regardless of what their risk factors are. And so, you know, you really have to think about whether or not this a good option for insuring women access to prenatal care. I would argue that it’s not. And then the final thing that I want to talk about here is that even women who have employer based coverage right now, we’ve seen a dip in insurance access, in employer sponsored insurance access. And the reason why this is significant is that Congress passed a bill in 1978. This is actually in Title Seven of the Civil Rights Act, which is Title Seven covers, you know, all sorts of employment, employment based discrimination and Civil Rights. And the Pregnancy Discrimination Act says that if you’re an employer with 15 or more workers, than you have to have, you have to offer prenatal care, maternity care.
What we’ve seen is a dip in insurance, in employer sponsored coverage and several researchers, Jonathan Gruber from MIT whose done work with the Kaiser Family Foundation estimates that employer based coverage under a tax credit system would drop even further, if employers know that their workers qualify for tax credit, they may drop employers insurance all together, which means that, not only would these women of childbearing age have to go out and buy private insurance, they won’t have the protection of the Pregnancy Discrimination Act. So they’ll protection that they actually had because of their employer sponsored insurance. Oh, okay, I don’t know how to get that (inaudible). Okay. I want to close it. I have a few, just a couple of remarks to close. I think that when we’re thinking about access to prenatal care, you know, I think that the Medicaid and SCHIP programs serve as a really important safety net function in our society. You know, it was originally created, Medicaid was originally created to offer insurance for people who were on welfare.
And when welfare as we knew it, changed in 1996, Medicaid turned into really a public health assistance program for low-income people. And, you know there needs to be kind of a larger value discussion at the Federal level of do we think that it is the role of Government to help people in this capacity, to help people get access to insurance. If we believe the tax credits, and empowering people to buy their own private insurance is the way to go, then I would say that we have to insure that there is serious regulation. We need to absolutely make sure that women are going to be able to afford coverage that allows them to get prenatal care services because absent that, you know, women are not only going to continue to be, you know, as poorly off as they are with 24 percent of women in my age cohort being uninsured, they’re actually going to receive worse care. They’re going to lose access to important employer protections that they currently have. So, just some things to think about.