The Medical and Insurance Risks of C-Sections

These days, it is easier for a woman to undergo a major abdominal surgery–a C-Section–than to deliver a baby vaginally. C-Sections are now the most common surgeries performed on women in the United States. In part that is because many doctors and hospitals refuse to perform vaginal birth after cesarean (VBAC). More than 90% of births following C-sections are surgical deliveries, and the International Cesarean Awareness Network (ICAN) has found that, of 2,850 hospitals called, 28% don’t allow VBAC, up from 10% in 2004. Another 21% do not have an official policy on VBAC, but do not have any doctors that will perform them, rendering them inaccessible, as well.

If VBACs cost less and allow the mother to heal quicker, why is this the case? Yes, there is a real threat of uterine rupture, which can cause maternal or infant fatality, but this occurs in 0.7% of VBAC cases. 1 in 2,000 babies will die or suffer brain injury.

In 1999, the American College of Obstetricians and Gynecologists changed their VBAC guidelines stipulating that surgeons and anesthesiologists should be “readily available” during a VBAC to “immediately available,” due to a number of high-profile uterine ruptures. Because of malpractice suits, insurers have raised costs so they are unaffordable for some doctors. Other doctors see a potential 24-hour delivery as a loss of other patients, and prefer an hour-long Cesarean.

But this does not come without both health and insurance risks to women. Risks associated with repeat C-Section are routinely overlooked, but they are real. Placenta accreta, where the placenta attaches abnormally to the uterine wall, has increased thirtyfold in the past 30 years.

And women who have had C-sections, whether they have elected to do so, have been pressured by doctors, or have had emergency C-sections due to fetal distress, now find themselves uninsurable in some cases, or subject to higher premiums in others, a C-Section now acting as a pre-existing condition.

Peggy Robertson, who has had a C-section, was denied coverage from Golden Rule Insurance Company, and was told if she had been sterilized after the procedure, or if she were over 40 and had given birth two or more years before applying, she might have qualified for coverage. Golden Rule also explained that if they could cover her with the exclusion of paying for another Cesarean in three years, they would, but in Colorado that is considered discriminatory. Somehow, not covering a woman who has had a Cesarean, is not.

The number of women looking for insurance outside group plans and the number of women having C-sections is only increasing, meaning more women will find themselves in Ms. Roberton’s position. “Obstetricians are rendering large numbers of women uninsurable by overusing this surgery,” said Pamela Udy, president of ICAN, by pushing for C-sections, whether the first time, or in lieu of VBACs. Women now find themselves having surgery they might not want, and with insurance companies that will not cover the cost.

Perhaps most disturbing about this C-Section epidemic is that women can be red-flagged if they answer “yes” to having been denied coverage before, even if they applied without knowledge of the C-Section stipulation. And medically, many women are steered towards doctors’ preferences, rather than being provided with accurate medical information. Childbirth Connection, an NYC based maternal-care advocacy group, has found that 57% of women who had had C-Sections and gave birth again  in 2005 were interested in a VBAC but were denied the option of having one.

For more, click for the Time article here and the New York Times article here

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Wisconsin’s New Medicaid Bill

On February 19, Wisconsin Governor Jim Doyle, a Democrat, signed a bill that places a new levy on hospital revenue. The bill allows the state to claim hundreds of millions more for Medicaid patients in reimbursement from the federal government. Notably, not one Republican in either chamber voted for the measure.

The bill calls for securing $900 million in new federal revenue over the next two years to support the Medicaid rate increase for hospitals through implementation of an assessement on hospital revenues. It will reduce state taxpayer support for Medicaid by upwards of $300 million through 2011, and provide targeted supplemental payments to rural hosptials, adult level 1 trauma centers and pay-for-performance initatives.

Under the new bill, the Department of Health and Human Services is required to spend the portion of the hospital assessment revenue allocated to pay for hospital services under the Medical Assistant Program on:

• increased reimbursement for eligible hospitals that are reimbursed on a fee-for service basis
• payments to health maintenance organization that the HMOs must use to increase reimbursement to eligible hospitals
• an increase of $2.7 million in supplemental payments to certain rural hospitals
• $8 million in supplemental payments to hospitals that satisfy criteria established by the American College of Surgeons for classification as a level 1 adult trauma center
• supplemental payments to hospitals based on performance, under a methodology developed by DHS

The $634 Billion Question

In his 10-year budget plan, President Obama proposes to further tax increases on the wealthiest for affordable and accessible healthcare for every citizen. This includes stricter limits on benefits of itemized deductions by the wealthiest families. The increase in revenues–around $318 billion dollars in ten years–would account for half the $634 billion reserve fund to address changes in healthcare. The other half would come from cost savings in Medicare and Medicaid, including Obama’s proposal to increase drug companies’ discounts to Medicaid from 15.1% to 22.1%.

Some critics of the plan argue that everyone wants affordable healthcare, but, as Representative John A. Boehner (R-OH) says, “Is increasing taxes during an economic recession […] the right way to accomplish that goal?”

For more, including environmental policy revenue reform, click here

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Reform Proposals

President Obama’s fiscal 2010 budget proposal includes a 10-year $630 billion reserve fund for healthcare reform. This will be paid for half by raising taxes on individuals earning more than $250,000 a year, and half by Medicare and Medicaid payment reductions and policy changes. The $630 billion dollars is seen as a “down payment” as more money will be needed in the future to keep the reforms efficient.

The Medicare payment reductions include cuts to Medicare Advantage plans via incorporation of a competitive bidding program, reducing hospital patient readmission rates, comibing payments for some post-acute care services, and, vauge as it is, reducing “fraud and abuse”.

The budget plan, to be released today and expanded in April, will include eight health reform principles to deal with cost, coverage, and quality of healthcare. They are:

• protecting the financial health of Americans via reform
• ensuring health care coverage is affordable
• ensuring coverage is available to all
• ensuring coverage is portable
• ensuring individuals have a choice of health plans and providers
• investing in prevention and wellness
• improving patient safety and quality
• ensuring reform is undertaken in a fiscally sustainable manner

Gail R. Wilensky, a former administrator of the Medicare & Medicaid programs, says that Congress could begin incremental reforms this year, such as altering Medicare payments to focus on improved quality. Later in his term, Obama could work on the number of uninsured, as he has already signed legislation expanding access to healthcare for children by reauthorizing the State Children’s Health Insurance Program.

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The Pre-Existing Condition Problem

In 44 states, insurance companies are legally allowed to deny coverage, or charge more, to individuals with pre-existing conditions. Today, most Americans receive health insurance through an employer’s group rate, which cannot deny or charge more to those with pre-existing conditions. However, with the climbing unemployment rate, the number of Americans who get their coverage in individual or family rates will climb, as well. This will leave many with pre-existing conditions either untreated or in debt because of the higher rates.

Adding an infant or another medically expensive individual to a group rate can cause premiums to rise for all employees. So when her employee Kathy Fisher had a son, Nicholas, Shelly Yanoff of Philadelphia Citizens for Children and Youth (an organization that, ironically, works to get health insurance for children) decided to put Nicholas on an individual plan assuming it would be cheaper. Because of a jaundice at 5 days old, Aetna rejected him, claiming, “We couldn’t price a policy in a range that anybody could actually pay for. If we can’t price affordably, we don’t accept”.

The rejection of a five-day-old highlights the problems, specifically involving pre-exisiting conditions, with our health system. As President Obama said at Tuesday’s joint session, we need “quality affordable health care for every American”. To achieve this, we must end rules that allow insurance companies to exclude inviduals based on pre-existing conditions. A costly decision, but a necessary one.

Fore more, click here

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Maternal health and the well-being of our communities

Last week, we posted on a conference on Capitol Hill at which congressional leaders unveiled a comprehensive framework for women’s health in national health care reform.  Kimberly Seals Allers, over at Womens eNews, has looked in-depth at the central importance of maternal health in the well-being of not only women, but our families and communities.

By targeting women, you reach millions more, says Dr. Vivian Pinn, director of the office of research on women’s health at the National Institute of Health. “Women are the portal to family and community health. When we talk about maternal health, we are talking about improving families and communities. This is one of the most important things we can address for the health care of the whole country.”

The author discusses how care for early-born babies can cost up to 15 times as much as full-term newborns, not to mention the lifelong ailments and disabilities that result from poor prenatal and maternal care.  It’s yet another example of the costs of the system’s inadequate focus on preventative, routine care.

A disturbing figure, the United States ranks 41st out of 171 countries on maternal mortality rates.  Perhaps more disturbing, however, are the racial disparities hidden behind the statistic of 13.1 maternal deaths per 100,000 births.  While the number is only 9.3 for non-Hispanic white women, it is 34.7 among non-Hispanic black women.  Eleanor Hinton Hoytt, president and CEO of the Black Women’s Health Imperative and dedicated advocate for health care rights of women, girls and communities of color, says, “Women are suffering from the breakdown of their reproductive systems and if this does not become an agenda item on health care reform, women will continue to not have the support of the country.”

It has become clear that better maternal health cannot begin with conception, or even the childbearing years of a woman’s life.  Public health and medical experts are advocating a “life continuum” approach that will consider women’s reproductive health throughout their lifetimes, from childhood to old age.

Health care provisions in the economic stimulus package

Last week, Congress reached a deal on a $789.5 billion stimulus package.  According to the Washington Post, while President Obama admitted some ground was ceded in the negotiating process, most of his priorities were included in the legislation, “including longer-term health care and energy investments.”  The Kaiser Daily Health Policy Report listed relevant provisions of the package:

Provide federal subsidies for health insurance under COBRA that would cover 60% of the cost of premiums for as long as nine months and impose income eligibility limits for the subsidies.  (Note: This is lower than the 65% in the House bill and a shorter time period, as well).

Distribute 65% of $87 billion in additional federal funds for state Medicaid programs under the current formula and distribute the remainder based on growth in unemployment rates in states.

Not included: The compromise stimulus package does not include a provision in the House version that would have allowed states to expand Medicaid coverage to recently unemployed workers.

Potential components of Obama Health Care Plan enjoy popularity

While President Obama’s blueprint for health care reform has yet to be laid out, a poll last week of 2,491 adults nationwide showed that half of those surveyed either “strongly” or “somewhat” support the direction the plan will take.

Key elements of Obama’s health care platform during the election elicited particularly favorable reactions in this online poll administered in late January.  78% of respondents said that allowing Medicare to directly negotiate drug prices with pharmaceutical companies was a “good idea.”  Additionally, six in ten surveyed were in favor of creating a “national health insurance exchange,” which would allow both employers and individuals to choose from an expanded pool of private plans.

Interestingly, support for the plan did not fluctuate significantly on the basis of income.  50% of people making $15,000 – $25,000 a year approved of the plan, compared to 51% of those making over $50,000.  Support for individual components, however, was split predictably along party lines.

Read full coverage of the poll here.

FORUM: National Lessons from State Health Reform

February 25, 2009 from 2pm to 4pm at 2226 Rayburn House Office Building in Washington, DC

RSVP appreciated to: Jessica Yarbrough; jyarbrough@calnurses.org; 202.974.8300

The forum will look into the most recent state health care overhaul. Is Massachusetts a model to follow?

Massachusetts’ reform includes many policy features considered in national healthcare reform including:

• individual mandates
• subsidized private insurance for low-income individuals
• employer “play or pay” provisions
• creation of insurance exchange to promote competition

Panelists include:

• David Himmelstein, MD, Cambridge Hospital Physician, Associate Professor of Medicine at Harvard Medical School
• Sandy Eaton, RN, Massachusetts Nurses Association
• Jamie Eldridge, Massachusetts State Senator
• Peter Knowlton, President of the United Electrical Workers Northeast Region
• Mary Ford, former Mayor of Northampton and Human Services Manager
• Robert Gaw, President, National Association of Socially Responsible Organizations, Health Benefits Administrator
• Arthur MacEwan, PhD, Professor of Economics, University of Massachusetts Boston

On the Issues: Women’s Healthcare

In her article Health Care ‘Reform’ Is Not Enough, Susan Yanow criticizes health care initiatives, most of which look to provide the uninsured with affordable access, but fail to look at the underlying problems with the healthcare system. This is perhaps a suitable allegory for most healthcare today, which treats disease rather than working on prevention.

Ms. Yanow laments that the existing system allows insurance providers to decide who gets care, what providers we can use, and what services will be covered, all of which are based on finance, rather than health. Oftentimes healthcare is based on moral grounds, too, including the Hyde Amendment, which bans the use of federal Medicaid funds for abortion care.

Ms. Yanow claims that the top five healthcare problems facing women today are:

1) Overhead costs deplete funds for services–If we had a single payer program with administrative costs similar to Medicaid, she claims, $20 billion would be saved and redirected towards services.

2) Hospitals are driven by the bottom line–this leads to an abundance of specialized services and a lack of preventative services; in addition, the cost of medical training keeps doctors from primary care or geriatric, which tend to pay less

3) Malpractice policies drive healthcare decisions–this leads to less options for women in terms of birthing choices

4) Hospitals with religious agendas restrict services–18% of hospitals are owned by the Catholic Church, and receive the same funding as non-denominational hospitals, but tend to restrict or deny abortion care, contraceptive services, infertility treatment, and end-of-life decisions

5) Healthcare is not a Central Value–we work to treat disease, not keep people healthy

Ms. Yanow maintains that with healthcare as a right, it must not be dependent on employment status or influenced by pre-existing conditions or religiously-imposed moral values. To be comprehensive, our healthcare must include mental health, dental health, and the choice of those who we feel can best provide for us.

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