Maternity 'Safety Net' Full of Holes

By the time they take their babies home from the hospital--and 99% of births in America take place in hospitals--a large number of the 3.6-million American women who give birth each year find themselves with very large bills that are not covered by medical insurance. This year, the tab for giving birth averages $3,200 for a normal delivery, $5,000 for a Caesarean section and thousands more if complications arise.

These are among the findings of an analysis of data from the Census Bureau's 1984 Current Population Survey and of federal programs conducted by the Alan Guttmacher Institute, a nonprofit public policy research organization affiliated with Planned Parenthood. The findings were published in the June issue of the institute's journal, Family Planning Perspectives:

--The women least likely to have adequate insurance, those in the 18-to-24 age group, represent almost half of all new mothers. One in four of them has no medical insurance at all. Whether married or single, most can ill afford paying the cost themselves; 75% of people this age are starting their working lives and earn $10,000 or less annually, so even if a couple both worked a $5,000 delivery would represent a severe financial hardship.

--A study of hospitals conducted by Vanderbilt University found that childbirth is the reason most frequently cited for admission of uninsured patients and hospital bills that went unpaid. Almost half of unpaid hospital bills of more than $25,000 are for newborns.

Without Adequate Prenatal Care

Fortunately, hospitals do admit maternity patients without money or insurance, but these women are likely to have gone without adequate prenatal care.

--While the majority of working women benefit from private insurance plans, a significant 11% of women who work full time and 16% of those who work on an hourly basis do not have health coverage.

The study also found that the so-called government "safety net" is full of holes for maternity patients. While Medicaid, the joint federal-state program, is supposed to provide medical coverage for poor people, fewer than half of the poorest women of reproductive age--those with incomes of $5,000 a year or less--are covered by Medicaid. Only a third of women in their childbearing years whose family income is between $5,000 and $9,999 are covered.

While Medicaid is required to cover families who qualify for and receive Aid to Families with Dependent Children (AFDC), states have some options as to who and what is covered. California Medicaid, for example, does not cover all low-income pregnant women as do some other states. California covers the fee for a nurse midwife, but does not cover diagnostic or screening services such as amniocentesis or ultrasound, according to the Guttmacher report.

Particular Problems

It does not pay to be an intact family. There is just one category of poor people who are not automatically eligible for Medicaid: a low-income married couple in which the husband is employed.

There are particular problems for pregnant teen-agers whose families will not or cannot cover the cost. A pregnant teen-ager who lives in a family that is not on welfare would have to leave home and set up a household eligible for AFDC in order to receive Medicaid assistance. Many teen-agers are covered by their parents' insurance, but the report points out that reluctance to tell their parents about the pregnancy means that these teen-agers may do without prenatal care for some time.

In addition, more than half of the obstetrician-gynecologists in private practice do not accept Medicaid, a system in which they must accept a state payment that is usually lower than their standard fees as full reimbursement. The average physician's fee for maternity care is $833, according to a projection for 1985 by the Health Insurance Assn. of America. California Medicaid pays $494. Eight states pay less than $300. Pennsylvania pays only $100.

Theoretically, the $478-million Maternal and Child Health Block Grant program is supposed to fill in the gaps in Medicaid in medical care for pregnant women as well as a number of other services to children. Unlike Medicaid, which pays for care that has been given to an individual, this money is awarded to states to support the facilities that serve low-income people. Because there are no requirements for minimum services, no eligibility requirements and no required collection of data about the services provided, "very little is known about who receives what kind of care as a result of the block grant," the report said.

A Dramatic Improvement

For working women, however, the maternity health insurance picture is brighter than ever before. For those employed women who are covered by health plans, insurance coverage for childbirth improved dramatically with the 1978 Pregnancy Discrimination Act which requires employers to treat maternity care the same as other categories of health care. As a result, in 1982, 89% of employees who had health coverage had some form of maternity coverage compared to only 57% in 1955. However, the law excludes small firms with fewer than 15 employees, and about a fourth of these do not provide maternity benefits. A firm that has no female employees does not have to provide maternity benefits for the wives of its workers. People with new jobs are frequently not included in the company plan for a period of time. When women leave their jobs, because of health problems during pregnancy or for other reasons, coverage often is terminated.

The report concluded that current laws and federal programs reflect the will of Congress and "probably" of the public that the health of mothers and infants is important, and that the women who cannot pay for adequate maternity care need to be identified and served.

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