In 1988 North Carolina had the nation’s highest infant mortality rate. The state decided to tackle this tragedy in a variety of ways. One approach, championed in a bipartisan effort by Republican Governor Jim Martin, was to expand Medicaid coverage to pregnant women earning up to 185 percent of federal poverty level and creating a package of programs within Medicaid to ensure good maternity care and a safe delivery.
Pregnant women who qualify now get excellent care in Medicaid and we have made some progress with our infant mortality rates. The legislature is now set to roll back that progress.
One of the Senate budget provisions moves Medicaid eligibility for pregnant women down from 185 percent of federal poverty level to 133 percent of federal poverty level (about $15,000 in annual income). The rest of the provision is a poorly constructed attempt to provide political cover for this mean spirited move.
From committee discussions it’s clear that legislators think they are moving these women who currently qualify for Medicaid into private insurance on the new health benefits exchange. Some Senators suggest the women will then qualify automatically for subsidies and the state will cover the remaining, unsubsidized, part of their premium using Medicaid funds. Out-of-pocket costs for these pregnant women, the Senators say, will be capped thanks to Obamacare.
The problem with all of this is that Obamacare was not constructed with the idea that legislators would try to kick our state’s most vulnerable group of people out of Medicaid. In fact, health reform was built around an expansion of Medicaid. The claims made by Senators about what will happen to pregnant women are untrue. This “program” created by the Senate budget is an unworkable solution to a nonexistent problem.
Many women, for example, will either not qualify for premium subsidies in the exchange or not qualify for the state premium assistance. Let’s say a woman makes $17,000 a year with part-time work and buys a substandard insurance policy from her employer. We don’t have final rules about what constitutes “minimum essential coverage” but initial proposals do not require maternity care. So let’s assume the plan does not cover maternity care. Now the woman becomes pregnant. Her employer coverage does not cover her needs. She no longer qualifies for Medicaid. She could buy subsidized coverage in the exchange but she would still be required to pay thousands of dollars out-of-pocket. And, because she has “minimum essential coverage” at work, she is excluded from the new state program.
Also, it’s not true that her out-of-pocket costs are capped at $2,200 as some Senators claim. Out-of-network care, for example, does not count toward the cap. Neither do the costs of uncovered services. The questions about what it would mean to move these pregnant women to private insurance plans are too numerous to list. Here are just a few: Could a woman lose her private insurance plan? Could a provider refuse to treat a woman if she did not have her co-pay at the time of service? Does the woman get to pick her own exchange plan or does Medicaid choose for her? If a woman is “rated up” for having used tobacco products will the state cover that portion of the premium? Again, these are only a few of the many questions that should be asked. The provision, as I say, is unworkable.
The most disturbing part of the provision is that Senators did not take time to understand its shortcomings or to make it viable. It’s clear that they just wanted to kick pregnant women off of Medicaid and stick some political cover into the budget. They also get to try and score meaningless rhetorical points against Obamacare. But the conclusion is clear: if this proposal is in the final budget, more pregnant women will go uninsured and our efforts to improve infant mortality rates will suffer.
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