The Congressional Budget Office is predicting that under the new Republican health care bill some 14 million people would be without insurance by 2018—with that number ballooning to 24 million by 2026. Among those likely to get shafted: women living just above the poverty line, who could lose their health care in between pregnancies.
That doesn’t bode well for the United States, which already has among the highest rates of maternal mortality for the developed world, and where the rate of women dying from pregnancy-related causes has been on the rise since the late 1980s.
The bill introduced last week by House Speaker Paul Ryan to repeal and replace the Affordable Care Act could hurt a lot of vulnerable Americans, including children. But it chips away indirectly at maternal care in several ways, most notably through cutbacks in Medicaid. The Affordable Care Act opened Medicaid access for 11 million new people, including women without children, by expanding eligibility rules to those slightly above the official poverty line, and by providing federal funding to states to cover the added cost.
The current proposal would end new enrollments under the expansion starting in 2020 (with conservatives pressuring the White House to do so even earlier). That would mean women earning as little as $17,000 per year would no longer be guaranteed Medicaid in many states. Some would turn to the health insurance exchanges, but high deductibles for the cheapest insurance, would likely discourage many from seeking out a doctor for regular visits even if they could afford the monthly insurance fees.
So what’s that got to do with pregnancy and safe births?
Amy Friedrich-Karnik, of the Center for Reproductive Rights, ticked off several screenings important to women who may become pregnant, including for hypertension and gestational diabetes, conditions that can contribute to unhealthy or dangerous pregnancies. Without health coverage, patients are much more likely to put off regular checkups that can catch and treat such issues before a pregnancy complicates things.
That’s especially significant for black women, since they are four times more likely than white women to die of pregnancy related causes, and already suffer disproportionately from these conditions.
“In a lot of communities, black women are in jobs with hourly wage or that don’t offer health care—so they are more likely to depend on … Medicaid,” said New Orleans–based OB-GYN and health advocate, Joia Crear-Perry. As founder of the National Birth Equity Collaborative, which aims to reduce black maternal and infant deaths, she’s working to keep the issue front and center in the upcoming health care debate.
“The whole point of the Affordable Care Act was to move to preventative care. Medicaid expansion and preventative services allow you to get treated before you get pregnant,” she said.
The new proposal would also cap the amount of federal Medicaid funding available per person. Crear-Perry worries some states will attempt to save money by narrowing the eligibility criteria for pregnant women, or limiting the types of services they would have access to.
Her fears aren’t unfounded. Representative John Shimkus (R-IL), recently demonstrated some lawmakers views on the value of care for pregnant women. Shimkus didn’t hesitate to name the federal mandate he’d like to do away with during a recent committee hearing on replacing the current law.
“What about men having to purchase prenatal care?” Shimkus suggested, during a House Energy and Commerce Committee hearing last week.
Shimkus’ comment underscored lawmakers’ lack of understanding of how health insurance pools work. Beyond that, it highlights the challenges ahead for those seeking to preserve and improve maternal care as the country once again plunges into debate over its national health priorities.
“The issue is really that it’s unknown how states will react to all of these changes, because it’s likely they would have to make cuts in lots of places if this bill were to become law,” said Friedrich-Karnik.
The new bill also seeks to defund Planned Parenthood, long a target for religious conservatives. While it doesn’t mention the organization by name, it focuses on abortion providers while exempting hospitals that provide abortions. The proposed change comes despite the fact that the Hyde Amendment has prevented federal funds from going to abortions since 1976.
But the effort to “defund Planned Parenthood” is based on a simplistic understanding of how the group receives money, which gives the mistaken impression that the government is sending Planned Parenthood a regular check. That’s not how it works. Women who receive Medicaid get coverage only for eligible services they receive. They pay out of pocket for the rest. If Planned Parenthood were “defunded,” it would mean these women would lose their ability to use those centers for various health care services including birth control, cancer screenings, STD testing, and well-woman examinations, none of which, again, include abortion, and most of which help ensure healthier pregnancies.
In theory, women would just go elsewhere, but since many private doctors don’t take Medicaid due to the low reimbursements, and no one in Congress or elsewhere has lined up another nonprofit network close to the scale of Planned Parenthood, these women would likely wind up with fewer options for care, rather than alternative ones.
“If this bill passed, it would eliminate our ability to provide services to Medicaid patients,” said Nicole Safar, director of government relations for Planned Parenthood of Wisconsin, where 50,000 of their 60,000 patients are Medicaid-eligible. She mentioned one recent patient whose cancer screening found fallopian-tube tumors that could have complicated a pregnancy if not discovered.
Getting rid of Planned Parenthood also poses another risk to healthy births: lack of access to birth control. A 2013 study by the Guttmacher Institute, which researches issues related to reproductive health, found that planning and spacing out pregnancies led to healthier outcomes overall for both babies and their mothers.
The health care bill introduced this week is just the opening act in what is sure to be a highly politicized debate, and may see several changes over the coming weeks, but Ryan is looking to move it quickly through the House. He has said he hopes to bring it to a full vote by March 20.
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