The Affordable Care Act

Mamas on Bedrest: What to Look For When Shopping For Health Care Insurance

March 13th, 2013

Hello Mamas,

I am newly single and find myself in the precarious position of needing health insurance. (Or will need it shortly!) To be honest, I had no idea where to begin! As a health care provider, I am keenly aware of the importance of adequate health care coverage. As I type this I have a family member who is without coverage and newly diagnosed with a rare form of cancer. Strange stuff pops up and it is imperative that you be prepared.

Health care coverage in the United States is a hotbed issue. With the passage of the Affordable Care Act in 2011, health care coverage is available to many more Americans, yet there are still many people who do not have adequate health care coverage. Additionally, far too many people play what I like to call “Health Care Roulette”. I see this primarily in younger, healthy people who feel that shelling out a couple of hundred dollars each month is a ludicrous expense, but also in families where they struggle to keep a roof over their heads. The young figure they  aren’t on medication, have no illnesses and they mistakenly believe that they are at very low risk. This is a sad, risky line of thought. Young folks are often the ones who jet away on ski vacations, take exotic adventure vacations, hike, bike and engage in other vigorous activities in which unexpected accidents can occur. A broken bone requiring surgical reduction and setting can run thousands of dollars. If you are uninsured, you are responsible for that medical bill. And let’s not forget ourselves, Mamas on Bedrest, in this category. How many of you really anticipated going on bed rest? Yet as many of you are well aware, without health insurance, a hospital bed rest stay or even a complicated labor and delivery can put a family thousands of dollars in debt or worse-bankruptcy. So with all of that in mind, I set about finding reasonable, affordable health care or myself.

I consider myself very lucky. I happened to mention my plight to my accountant and she had some ready resources for me. As I am self employed, I will be able to deduct all of my health care expenses off of my taxes, including the cost of  the policy. But even better than that, she referred me to a very reputable, knowledgeable insurance broker who has set me up with an incredible health care plan. She herself is single and self employed. We are only a couple of years apart in age, so she pretty much set me up with a plan that she would use for herself. I am quite happy with what she has offered me. Here are the highlights.

Co-Payments- I opted for a plan without co-payments. First and foremost, I rarely go to the doctor. I go annually for my gynecological exam and otherwise only go perhaps for a physical examination or an urgent illness/injury. By using providers within the network, I will be assured of a fixed cost for the visit (covered by the insurance). If I go “out of network” I will have a fixed payment for the office visit and will be responsible for any additional charges. But in general, I can apply what I pay to my deductible and later recoup some costs. Also, opting for no co-payment keeps my premium.

Deductibles-I got a pretty good deal here as well. As a single person in relatively good health (got dinged a bit for my age!) I have a reasonable deductible and it will integrate prescriptions into that deductible. My deductible is also my maximum out of pocket expense. Deductibles can be tricky and I highly advise getting some help here. My broker really gave me good information on this and I am quite pleased with her advice.

HSA Account – Being self employed and a Health and Wellness professional, having a health savings account is a must for me. Along providing me with a way to save up funds in the event of a catastrophe or even if I choose to do some alternative treatments, there are tax advantages or business owners. HSA’s are also available if you have a high deductible health insurance plan, so ask your insurance agent if you are eligible for an HSA. While this may not help you now, it would be a great way to pay for a midwife or birthing center or treatments (such as a birthing tub) in the future, which are often not covered by conventional insurance plans.

Supplemental Accident Coverage-This coverage provides added benefits in the event of an accident; you know the type-you break your leg while skiing in Switzerland? This additional coverage will enable you to be flown home and pay for some medical expenses and not be hit with a gastronomical bill. It won’t cover everything, but it will make a dent and provide much needed cash immediately.

Life, Dental, Vision Insurance-I also have the option of adding these coverages to my policy. Yes, they come at additional expenses, but their monthly payments are far less than paying for expenses out of pocket. Again, check with your insurance broker/agent for more details.

I realize that this topic may seem out of line with Mamas on Bedrest, but in actuality it is very pertinent. I can’t tell you the number of mamas who call me when they find out that Maternity care is not a covered benefit of their insurance policy and they need to purchase an additional rider. (Like that’s going to happen if they are already prescribed bed rest!). It’s really important that you look at your insurance policies from time to time, I recommend yearly at the enrollment period, and make sure that you have all the coverage that you and your family need. Many people view health care insurance as an expensive luxury. But if you get without adequate health insurance coverage, it can mean the difference between exemplary care with the best treatments possible and just getting by.



Mamas on Bedrest: Mamas With No Money and No Insurance

January 23rd, 2013

I live in Texas, not by choice but by circumstance.

As such I watch, with utter disgust, the Texas legislature cut and defund programs that have significant impact on women and children. The mantra here in “The Great State of Texas” is that “We pull ourselves up by our own boot straps and we take care of our own.” The sad truth is that those who can afford boots may in fact be able to pull themselves up by the straps, but for many hardworking Texans, it’s a struggle to make it from day to day and Texas is not doing a very good job of “taking care of its own.”

What many hardworking Texans don’t know is that with the passage of the Affordable Care Act, (ACA) there are federal funds available for each state to utilize so that they can increase the number of citizens who have access to health care. The funds typically go to support Medicare and Medicaid programs. Texas Governor Rick Perry is on the record as vehemently opposing the ACA and has vowed not to accept any federal funds. By rejecting these funds, Governor Perry ensures that some 6.1 million Texans remain uninsured.

Now I am in favor of everyone having his or her own opinion about government and the law. However, I think that when you are in a position of authority and you are making decisions for the general population, you need to step back from your personal views and look at what will be in the best interest of the greater population. Governor Perry and many Republicans vehemently oppose the ACA. However, it is the law and as such, there are provisions within the law that actually benefit a lot of people. In particular, the fact that the federal government has set aside funds so that the individual states can access these funds and use them to insure and care for their constituents is a good thing. Stubbornly denying the funds because you, a wealthy and well insured government official, have a philosophical difference with the government (okay, let’s be frank, the President!), and will as a result deny help to millions of your constituents is deplorable.

So why am I bringing this up on Mamas on Bedrest & Beyond? Because here in Texas, we have a large number of mamas who are either under-insured (their policies don’t cover maternity care) or they are uninsured. Texas also has some of the highest infant and maternal mortality rates in the United States and these rates are even higher for mamas of color. Women should not have to decide between keeping a roof over their heads and whether or not to start a family. The two should not be mutually exclusive. Mamas (and any children that they may have) need health care coverage and Texas Medicaid is struggling. Federal funds could go far in assuring that many hardworking Texans have access to safe, quality health care. A common misconception is that people on Medicaid are slackers, sitting about waiting for a handout. While this may in fact be true of some of the people receiving Medicaid benefits, there are just as many hard working people working low paying jobs that don’t provide (health care) benefits. These folks deserve to have access to quality health care.

But there are some really great folks out there working to ensure that all Texans, but mamas and babies in particular, have access to quality health care. In a bold move, Mamas of Color Rising has started MamaSana, an all volunteer free pregnancy clinic here in Austin. Mamas of Color Rising has also been instrumental in challenging the Texas Medicaid system to do more to support low income/mamas of color; petitioning the Texas Medicaid system to change it’s rules so that Licensed Professional Midwives will be able to attend births for low income/mamas of color and be reimbursed by TX Medicare, they have advocated for mother friendly birth practices for low income women and they have created a movement to ensure that all women have access to the best possible perinatal care, provided by caring health care providers and are aggressively pressing the Texas legislature to support their efforts. You can learn more about Mamas of Color Rising’s work here.

Here in Texas we are going to have to be vigilant and vocal when it comes to health care. We residents, constituents, have to continually press the legislature and the Governor to do the work of the people-and to work for the people. No matter what he may think of the Affordable Care Act or President Obama, Texans need a strong Medicaid program- many mamas and babies depend on it. And it is an ill conceived plan to refuse federal funds based a stubborn, prideful, philosophical difference-which in the end will have no effect on you or the quality of your life, but will greatly impact the lives of millions of others.

Mamas on Bedrest: $5 Billion on Moms and Babies!

January 9th, 2013

$5 Billion dollars.  Yes that’s Billion with a “B”.  That is the amount of money that the United States could potentially save annually on medical costs related to maternity care according to  The Cost of Having a Baby in the United States, new study published by Childbirth Connection, Catalyst Payment Reform and Center for Healthcare Quality and Payment Reform. The study was prepared by Truven Health Analytics and released January 7, 2013.

It’s no secret that the US healthcare system is in deep trouble and if it continues in its current iteration, it could very well bankrupt the entire country in the not too distant future. With the passage of the Affordable Care Act, the federal government made an attempt at reducing costs while at the same time making health insurance more available to more Americans. But it is safe to say that no one thinks that the ACA in its current form will be the answer to all that ails our flailing healthcare system. In an attempt to see where there are potential cost savings, several different agencies (public, private and non-profit) have undertaken studies to evaluate the type and quality of care provided in the United States in different health care arenas. In this study, maternity costs were analyzed in an effort to determine where there are not only potential cost savings in maternity care, but also potential reductions in risks to maternal and fetal/infant health.

The study is presented in an 86 page document.  One of the most remarkable findings is the fact that there are roughly 4 million babies born in the US annually and now a full one third or 33% are born via Cesarean section. This represents a 50% increase in cesarean deliveries in the last decade, and many cesareans performed are not medically necessary. Unnecessary  cesarean sections have been shown to increase health complications for both mother and baby.  But what was found in this study is that cesarean sections dramatically increase the cost of maternity care. According to the study,

“For the commercially insured, the average cost of a birth by c-section in 2010 was $27,866, compared to $18,329 for a vaginal birth.  Medicaid programs paid nearly $4,000 more for c-sections than vaginal births.  If the rate of c-sections were reduced from 33% to 15% (the World Health Organization recommends a c-section rate of 15% or less), national spending on maternity care would decline by more than $5 billion.”

The study also found that the cost of care for mamas increased 40% from 2004-2010 and this did not include costs of infant care, and also noted wide variation in costs from state to state and within states.  According to Harold Miller, Executive Director of the Center for Healthcare Quality and Payment Reform (CHQPR),

“Maternal and newborn care together represent the largest single category of hospital expenditures for most commercial health plans and state Medicaid programs, so reducing maternity care costs provides a major opportunity to reduce insurance premiums for employers and to make Medicaid coverage more affordable for taxpayers.”

Another startling finding (in my opinion) is the fact that the uninsured may be charged. According to the study,

“Uninsured parents could be charged over $50,000 for a baby born by c-section and over $30,000 for a baby born by vaginal birth.  Average provider charges for a c-section in 2010 were $51,125, but commercial insurance plans only paid $27,866, 55% of what an uninsured patient could be asked to pay.”

Other startling findings:

  • Vaginal births cost $18,329; c-sections cost $27,866 (for the commercially insured, 2010) and these costs are substantially more for the uninsured.
  • Medicaid, which pays for over 40% of all births, paid nearly $4,000 more for c-sections than vaginal births.
  • If the current national rate of c-section were reduced from 33% to 15% (the World Health Organization recommends a rate of 15% or less), we could save $5 billion!
  • The cost of maternal care (not including newborn care) jumped an incredible 40% between 2004 and 2010 for the commercially insured.
  • The total commercial payments for care of newborns were $5,809 for babies delivered vaginally and $11,193 for cesarean births.  Total Medicaid payments for newborn care were $3,014 for vaginal births and $5,607 for cesarean births.  Reducing the rate of prematurity among infants could significantly reduce these costs.
  • The largest share of all combined maternal-newborn costs goes to pay for hospital or other facility costs regardless of the type of birth.  59% of total maternal and newborn care costs for vaginal births are used to pay facility fees, and 66% of costs for c-sections are for facility fees.  Similarly, the hospitalization phase of childbirth consumed from 70% to 86% of all maternal and newborn care costs, depending on payment source and type of birth.
  • There is significant variation in cost within and across states.

If the United States is serious about health care reform, obviously maternity care reform has to be at the top of its list! If pulling the US cesarean section rate in line with World Health Organization recommendations would truly result in a savings of $5Billion dollars, we should be seriously looking at ways to reduce the number of cesarean sections performed. Likewise, since hospital fees represent more than 70% of maternity care costs, it behooves us as a nation to consider increasing the availability and accessibility of birthing centers and, for those low risk women, home births. Many other countries utilize nurses and other health care providers to provided additional care to mothers and babies in their homes before and after birth (The models upon which Mamas on Bedrest & Beyond is designed!) which has been shown to greatly reduce the numbers of hospital admissions and care costs. The US has the means, the skills and expertise and the workforce (talking about A LOT of potential jobs here!) to provide such care and hence, further reduce the cost of maternity care and the burden on the US health care budget. If as a nation the US fails to implement of these recommendations, we will continue to face spiraling out of control maternity care costs, and,  more tragically, more perinatal complications, catastrophes and deaths of mamas and babies.

Childbirth Connection is a national not-for-profit organization founded in 1918 as the Maternity Center Association.  Its mission is to improve the quality and value of maternity care through consumer engagement and health system transformation.

Catalyst for Payment Reform is an independent, non-profit organization working on behalf of large employers and other healthcare purchasers to catalyze improvements in the way healthcare services are paid for and to promote better and higher value care in the United States.

The Center for Healthcare Quality and Payment Reform is a national policy center that encourages comprehensive, outcome-driven, regionally-based approaches to achieving higher-value healthcare.