The real cost of pregnancy for the uninsured

By Cristina Fernandez Pereda 

TheUnited States is one of the most medically and economically advanced countries in the world. However, almost three women die every day here from pregnancy complications, according to the Association of Maternal and Child Health Programs.Medical associations link the risk of mortality among pregnant women to their lack of health insurance. One of the most prominent bills pending in Congress this session has been the State Children Health Insurance Program (SCHIP) bill, designed to extend health coverage to uninsured children in the United States. The SCHIP bill, vetoed for the second time by President Bush on Dec. 12, includes a provision that aims to extend coverage also to uninsured pregnant women.The American Medical Association estimated last August that 45 million Americans lacked health insurance. Of those, 12.6 million women of childbearing age are uninsured, making up 25 percent of the uninsured in the United States.

Photo by La Clinica del Pueblo.
Dr. Meredith Joseph works with women at
the Community Health Center La Clinica del
Pueblo, in Washington, D.C.

According to World Health Organization estimates, in 2004 the U.S. maternal mortality ratio was 13.1 deaths per 100,000 live births. The rate has been increasing since 1982: around 1,000 American women are dying of pregnancy-related complications such as diabetes, hypertension, hemorrhages and infections.

Most of these deaths are preventable: pregnancy-related maternal mortality is 3-4 times higher among women who receive no prenatal care compared to women who receive it, as found by the American College of Obstetricians and Gynecologists.

Uninsured women who become pregnant often have no coverage options other than public programs. Individual health insurance rarely includes maternity coverage, and when it does, it often excludes services related to the pregnancy, such as prenatal care or delivery, or requires the purchase of an expensive health policy.

One of the alternatives for uninsured pregnant women is access to Medicaid. However, too many women fall in the gap of making more money than the limit required to be eligible, but still too little to be able to pay for coverage and/or medication they need through pregnancy.

The college of obstetricians supports the need for prenatal care because it helps prevent low birth weight and reduce incidence mortality among infants and mothers.

“Prenatal care has shown very effective so far, but there is an important lack of insurance among women in maternal age that increases for both the mother and the baby their likelihood of dying,” said Tara Straw, Manager of Government Affairs at the American College of Obstetricians and Gynecologists.

Photo by La Clinica del Pueblo.
La Clinica del Pueblo
provides health services
in the Latino Community.

Whether or not a mother has health insurance also affects the future of the child. “There is a direct link between women without insurance during pregnancy and the behavior when, for example, taking their child to the doctor regularly. It’s very important to create the health link from the beginning,” Straw said.

Women with access to medical care in their first trimester of pregnancy are more likely to stay healthier and have healthier babies. Uninsured women are less likely to have access to it and may never have access to peri-natal or postpartum care.

How the delivery is performed is also decisive. The risk of Caesarean infections has increased by 41 percent in the last two years. “Doctors are more inclined to do them because it saves from different complications, but also women choose this practice when they want to have their baby on a specific date,” said Sarah Fahey, Women and Perinatal Health Program Associate.

For the families, the cost of delivery, excluding prenatal care, varies between $7,000 and $10,000, according to the March of Dimes Foundation. On the other hand, a study by The Institute of Medicine found in 2000 that every dollar in prenatal care saved more than three dollars in postnatal care and long-term morbidity costs. This makes half of the hospital charges for infants: $18 billion of $37 billion.

In order to improve the situation of uninsured pregnant women, the SCHIP bill pending in Congress, last vetoed on Dec. 12, 2007 by President Bush, includes a provision to cover them. This provision will affect 1.2 million women in the United States who are going into the program as soon as it is extended and will potentially reduce the number of uninsured.

SCHIP is a joint state-federal effort that currently covers the health expenses of more than 6 million people, mostly children. Democrats in control of Congress have been pushing an extension to this program adding $35 billion to the program and therefore cover 4 million more children. But President Bush will only allow a $5 billion increase in funding. The provision to cover pregnant women will have to wait until Democrats and Republicans reach an agreement that will override any presidential veto.

Recently, experts have highlighted some shortfalls in the SCHIP program. The current set-up might not allow more people into the program and thereby create waiting lists. To address this particular problem, some states may have to create new eligibility rules or expand Medicaid.

Despite the extensive media coverage of the political showdown between President Bush and Democrats in Congress over the SCHIP bill, the provision to extend coverage to pregnant women hasn’t garnered much public interest.

“This provision hasn’t been included in the public debate because it is not actually considered a big issue. This is helpful; it is good that it’s not controversial. We are happy that they don’t want to change it,” Straw said.

Women’s advocacy groups agree that they want the bill to pass and stay as close as possible to the first agreements reached in Congress. They are also sure that the provision to cover pregnant women has a good chance of success.
However, this provision will only cover pregnant women who are U.S. citizens. Legal immigrants and undocumented women will not be eligible. “There has been some discussion about extending it to legal immigrants, whether after five years in the country they would be eligible for health care, but this hasn’t been discussed anymore after the first veto, and this issue won’t be accomplished by this bill,” Straw said.

Women in this situation have three alternatives: premature care at community health centers, coverage exclusively for the delivery or assistance at free clinics whenever they think there is a complication. Regarding insurance, the National Women’s Law Center states that low-income pregnant women may be eligible for health coverage in four ways:

• Pregnant women qualify for health care coverage through Medicaid if they meet certain income qualifications. According to the Kaiser Family Foundation, 70 percent of those covered by Medicaid are women.
• State programs that use only state dollars to cover populations the federal Medicaid program does not.
• State waivers from the SCHIP program.
• State plan amendments implementing the SCHIP ‘unborn child’ regulation, already approved in the states of Michigan, Illinois, Rhode Island, Massachusetts and Minnesota.

Out of these choices, the current coverage by SCHIP programs offers each state the alternative called the ‘unborn child’ extension, which gives coverage to the fetus and their pregnant mothers who are not themselves eligible. “This creates a problem for doctors when trying to know what kind of treatment they can provide to make sure that their patient is O.K., because some standard treatments are still not included,” Straw said.

According to a statement by the National Women’s Law Center released in March, 2007, the SCHIP ‘unborn child’ regulation has not accomplished its objective to expand coverage for thousands of low-income pregnant women. It requires states “to give services to the ‘unborn child’ and not the pregnant woman; the full range of recommended pre- and post-natal services are not always paid by SCHIP, and are not provided by every state that is participating.”

Photo by La Clinica del Pueblo.
Dr. Joseph attends one of her patients
at La Clinica del Pueblo.

Uninsured pregnant women also go to Community Centers such as La Clínica del Pueblo, in Washington, D.C., with programs that provide them and their children with health care. “We have a very small program, we practice between 40 and 50 deliveries a year, but we created it to answer a big necessity and provide help when it’s needed,” said Dr. Meredith Joseph of La Clínica del Pueblo.

This organization has an agreement with Howard University, also in Washington, to provide coverage according to the families’ income. “Howard is happy for this. Their students can do their practice for free here and we provide care to pregnant women,” Joseph said.

Alternatives such as La Clínica del Pueblo have become the only choice for women who fall between the gaps of legislation and insurance companies’ eligibility requirements but need to ensure their children’s health and their own. Uninsured pregnant women in the United States will have to wait for now until the approval of this SCHIP extension gives them a new possibility.

This story was published on the American Observer on Jan. 23, 2008.

Obesity Society

By Cristina Fernández Pereda 

Nearly half of Americans will be obese by 2015, the Obesity Society predicted at a panel session Wednesday. Public Health experts and congressional lawyers discussed at George Washington University what the next president should do to reduce obesity rates.

“It is an extraordinary difficulty that we face and will continue to face on this issue,” Dora Hughes, Health Policy Advisor to Sen. Barack Obama, D-Ill., said. Even though it is a problem affecting most countries, obesity has spread in the last two decades in the United States more than anywhere else.

Peter Orszag, director of the congressional budget office explained that researchers justify this increase with the lack of balance between the calories one person takes in and the calories he or she burns. “It appears that you can track the increase of caloric in-take to snacking and not to meals,” Orszag said.

He mentioned that obesity is also related to the reduction of exercise among Americans but that “it would be foolish to look only to one side of the problem,” and not consider all the social, economic and environmental factors.

Obesity rates are higher among low-income people with lower education degrees. Laurie Rubiner, legislative director for Sen. Hillary Clinton, D-N.Y., introduced the access to health insurance coverage as one of the problems that obese people are facing in the United States, where 47 million people are uninsured. “Coverage does matter,” Rubiner said.

Clinton’s universal health care program released on Tuesday includes coverage for those currently uninsured and emphasizes on the relationship between patients and their doctors. This is a shared concern with Sen. Chris Dodd. “The United States has one of the lowest rates of people keeping the same doctor for more than five years,” Barbara M. Smith, lawyer for the Democrat from Connecticut’s campaign, said.

Along with access to health insurance, panelists agreed that education is a very important factor on the fight to reduce obesity. Orszag explained that vending machines in school might not be helping when trying to educate children about healthy food. “Some studies have shown that consumption is influenced by availability of food rather than taste of hunger,” he said.

“This is really a young person’s problem, we need to hit it at the beginning,” said David Bonior, John Edwards for President Campaign Manager. Like other panelists, Bonior mentioned walking to school, community education on healthy food and physical activity as habits to that should be taught to children to avoid obesity.

Director of STOP Obesity Alliance Christine Ferguson said that thinking about a solution to reduce obesity must consider “how easy do we want to make it for people to eat healthy and lose weight,” referring to different legislation proposals to tax fast-food products or reduce the cost of health insurance for those who lose weight.

Health experts and Democratic presidential advisors agreed that the access to health care will be a very important factor to reduce obesity rates in the United States, along with making coverage mandatory and lowering the prices by insurance companies.

On the other side, Health Policy Advisor for Sen. Mitt Romney, R-Mass., Lanhee Chen argued that “what makes the market work is choice.” He alleged that there are 50 separate legislations on health care in this country and unifying them by making coverage mandatory wouldn’t fit with the current way market works.

“We are going to deal with this for a long time and we need to do a concentrated effort. It is important to understand what actually works, what made some progress and remember that we still have a long way to go,” Don Moran, Health Care Advisor for the Republican candidate Rudolph Giuliani, said.

“There is no other issue Americans care more at the domestic level than obesity,” Douglas Holtz-Eakin. “We should attack this problem with the same power that we attack other problems in America,” he said.

Health: A right for all, a privilege for the few

By Cristina Fernández Pereda

If we want to address the challenges to global health, it is necessary to strength health systems. Without this requisite, we will not be able to give equal health conditions to everyone.

The lessons learned in the past, including aptitudes and strategies developed in the fight against polio and SARS can be used in the treatment of HIV/AIDS and to obtain the Millennium Objectives.

The objectives consist good health conditions for everyone a priority, and making equality in health a part of the development of social justice and making the participation of communities in their health programs.

The progress of these goals will not last if the patterns established for health are not followed. This is especially true of the “3 million goal” which consists to reach up to 3 million people with antiretroviral polio therapy against HIV/AIDS in developing countries by the end of 2005. These objectives should reinforce an extensive network of health programs.

Due to the health reforms of the last decades, health systems need to make more improvements. However, new opportunities emerge. Healthcare is a priority in the international development and the impoverished countries to count on funds for health activities.

The health system includes all the organizations, institutions and the resources that come from all initiatives to improve health. A healthcare system is made up of the institutions, the people, the necessary resources to provide attention to the individual. The link between the functions of public health and the attention to patients is one of the most important features of primary care.

The values and practices of primary healthcare adapted to the current situation can become the basis for healthcare systems. The global personal healthcare crisis, the lack of scientific proofs, financial resources and the difficulties to apply politics to healthcare inequalities are the greatest challenges to healthcare systems today.

In the 90s, the OMS evaluated the health care systems and their development. The OMS made equally accessible primary care and the supply of analytical instruments that become such an undertaking in adequate scientific proofs for developing countries. In rich countries the waste of resources in healthcare systems is noteworthy.

Initiatives like the European Observatory of the OMS on healthcare systems bring important facts about the workings and errors.

However, there are still issues to solve. The Observatory broadcast the changes in European systems, the reforms, and analyze its results and why they function in specific contexts. Moreover, the Observatory keep vigil because the experiences within the European system may extend beyond its borders.

The OMS can only offer investigation lines and help the countries find the best optionc to make their healthcare system adequate to the demands of the population, especially in the countries of the South.

The right to healthcare has become a privilege en some parts of the world. The healtcare systems based on primary care could be the first step to bring equal health benefits to every person.

(En Español)