[Senate Hearing 107-747]
[From the U.S. Government Publishing Office]
S. Hrg. 107-747
UNINSURED PREGNANT WOMEN: IMPACT ON INFANT AND MATERNAL MORTALITY
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HEARING
BEFORE THE
SUBCOMMITTEE ON PUBLIC HEALTH
OF THE
COMMITTEE ON HEALTH, EDUCATION,
LABOR, AND PENSIONS
UNITED STATES SENATE
ONE HUNDRED SEVENTH CONGRESS
SECOND SESSION
ON
EXAMINING THE IMPACT OF UNINSURED PREGNANT WOMEN ON INFANT AND MATERNAL
MORTALITY
__________
OCTOBER 24, 2002
__________
Printed for the use of the Committee on Health, Education, Labor, and
Pensions
U.S. GOVERNMENT PRINTING OFFICE
82-564 WASHINGTON : 2003
___________________________________________________________________________
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COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS
EDWARD M. KENNEDY, Massachusetts, Chairman
CHRISTOPHER J. DODD, Connecticut JUDD GREGG, New Hampshire
TOM HARKIN, Iowa BILL FRIST, Tennessee
BARBARA A. MIKULSKI, Maryland MICHAEL B. ENZI, Wyoming
JAMES M. JEFFORDS (I), Vermont TIM HUTCHINSON, Arkansas
JEFF BINGAMAN, New Mexico JOHN W. WARNER, Virginia
PAUL D. WELLSTONE, Minnesota CHRISTOPHER S. BOND, Missouri
PATTY MURRAY, Washington PAT ROBERTS, Kansas
JACK REED, Rhode Island SUSAN M. COLLINS, Maine
JOHN EDWARDS, North Carolina JEFF SESSIONS, Alabama
HILLARY RODHAM CLINTON, New York MIKE DeWINE, Ohio
J. Michael Myers, Staff Director and Chief Counsel
Townsend Lange McNitt, Minority Staff Director
______
Subcommittee on Public Health
EDWARD M. KENNEDY, Chairman
TOM HARKIN, Iowa BILL FRIST, Tennessee
BARBARA A. MIKULSKI, Maryland JUDD GREGG, New Hampshire
JAMES M. JEFFORDS, Vermont MICHAEL B. ENZI, Wyoming
JEFF BINGAMAN, New Mexico TIM HUTCHINSON, Arkansas
PAUL D. WELLSTONE, Minnesota PAT ROBERTS, Kansas
JACK REED, Rhode Island SUSAN M. COLLINS, Maine
JOHN EDWARDS, North Carolina JEFF SESSIONS, Alabama
HILLARY RODHAM CLINTON, New York CHRISTOPHER S. BOND, Missouri
David Nexon, Staff Director
Dean A. Rosen, Minority Staff Director
(ii)
C O N T E N T S
__________
STATEMENTS
Thursday, October 24, 2002
Page
Bingaman, Hon. Jeff, a U.S. Senator from the State of New Mexico. 1
Corzine, Hon. Jon, a U.S. Senator from the State of New Jersey... 5
Green, Nancy, M.D., Medical Director, March of Dimes Birth
Defects Foundation; Richard Bucciarelli, M.D., Chairman,
American Academy of Pediatrics Subcommittee on Access to Health
Care; Lisa Bernstein, Executive Director, The What to Expect
Foundation, New York, NY; and Laura E. Riley, M.D., Assistant
Professor of OB/Gyn, Harvard Medical School and Medical
Director of Labor and Delivery, Massachusetts General Hospital. 9
ADDITIONAL MATERIAL
Statements, articles, publications, letters, etc.:
Nancy Green, M.D............................................. 30
Laura E. Riley, M.D.......................................... 32
Cristina Beato, M.D.......................................... 35
Lisa Bernstein............................................... 36
Kate Michelman............................................... 38
Priscilla Smith.............................................. 40
(iii)
UNINSURED PREGNANT WOMEN: IMPACT ON INFANT AND MATERNAL MORTALITY
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THURSDAY, OCTOBER 24, 2002
U.S. Senate,
Subcommittee on Public Health,
of the Committee on Health, Education, Labor, and Pensions,
Washington, DC.
The subcommittee met, pursuant to notice, at 10:07 a.m., in
room SD-430, Dirksen Senate Office Building, Senator Bingaman
presiding.
Present: Senator Bingaman.
Opening Statement of Senator Bingaman
Senator Bingaman. Why don't we go ahead and get started?
Thank you all for being here.
First I would like to thank Senator Kennedy for allowing us
to hold this important hearing with respect to the health and
well-being both of children and their mothers.
Our Nation ranks 28th in the world in infant mortality and
21st in maternal mortality, according to the data from the CDC.
In infant mortality, for example, our country ranks behind
Spain and Portugal, the Czech Republic and Cuba. There are
numerous studies that have shown the importance of providing
coverage to pregnant women in order to reduce both infant and
maternal mortality. We, as a Nation, would be remiss to not
take the simple but critical step of increasing access to
prenatal and labor and delivery and postpartum care through the
State Children's Health Insurance Program or SCHIP to help
prevent birth defects and prematurity, the most common causes
of infant death and disability, as well as maternal death and
disability.
It is with this in mind that a number of bills were
introduced in this Congress to address these problems by
allowing states the option to expand health coverage to
uninsured pregnant women over the age of 18 through the State
Children's Health Insurance Program or SCHIP. Those bills
include S. 724, the Mothers and Newborns Health Insurance Act
that Senators Bond and Breaux introduced. Senator Lincoln and I
are cosponsors on that. I think Senator Corzine is, as well. He
is just entering at this moment. There is also S. 1016, the
Start Healthy, Stay Healthy Act, which again Senator Lugar,
Senator Lincoln, Senator Corzine, Senator McCain and I all
cosponsored and there is S. 1244, the Family Care Act that
Senators Kennedy and Snowe introduced. All of these try to
address this issue of increasing access to care for pregnant
women.
Throughout the early part of the year the Secretary of
Health and Human Services, Secretary Thompson, issued press
releases and testified before Congress, wrote letters in
support of the passage of legislation to cover pregnant women.
He wrote me on the 12th of April of this year and that letter
said, ``The prenatal care for women and their babies is a
crucial part of medical care. These services can be a vital
life-long determinant of health and we should do everything we
can to make this care available for all pregnant women. It is
one of the most important investments we can make for the long-
term good health of our Nation. As I testified recently at a
hearing by the Health Subcommittee of the House Energy and
Commerce Committee, I also support legislation to expand SCHIP
to cover pregnant women. However, because legislation has not
moved and because of the importance of prenatal care, I felt it
important to take this action.''
Now this action that he is referring to was the issuance of
a regulation to allow the coverage of unborn through SCHIP. The
rule which was initially proposed this past spring and issued
in final form on the 2nd of October, allows states the option
to cover unborn children through SCHIP but not to cover
pregnant women. It came just 2 weeks after Deputy Assistant
Secretary Cristina Beato testified at a hearing here in this
room on Hispanic health that the administration would be
forthcoming with a letter in support of S. 724 and also 1 week
after the administration approved a waiver for the State of
Colorado to cover pregnant women through the SCHIP program.
Colorado clearly faced the choice of taking the State
option of covering unborn children as a result of the new
regulation or the alternative that was more cumbersome and the
more lengthy process of applying for a waiver to cover pregnant
women. According to State officials, Colorado chose the more
cumbersome waiver process because they were unable to implement
coverage for unborn children. There is no insurance program
anywhere on which to model that coverage. There were too many
questions that they could not answer. They were also concerned
by the gaps in coverage for pregnant women that the regulation
caused.
Among other things, since the regulation only provides
states the option to cover unborn children, a number of
important aspects of coverage for pregnant women during all
states of birth--pregnancy, labor and delivery and postpartum
care--are either denied or in serious question. For example,
pregnant women would likely not be covered during their
pregnancy for treatment of some kinds of cancer, medical
emergencies, accidents, broken bones or mental illness. Even
life-saving surgery for a mother in certain circumstances would
appear to be denied.
Further, during delivery, coverage for an epidural would be
a State option and allowed only if the health of the child is
judged to be affected. On the other hand, anesthesia is covered
for Caesarian sections, so the rule could wrongly push women
and providers to perform unnecessary C-sections to ensure
coverage of critical pain relief for pregnant women.
Finally, during the postpartum period women would be denied
all health care coverage from the moment the child is born. As
the regulation reads, ``Commenters are correct that care after
delivery, such as postpartum services, could not be covered as
part of SCHIP because they are not services for an eligible
child.'' Important care and treatment, including but not
limited to treatment of hemorrhage, infection, pregnancy-
induced hypertension and other complications of pregnancy and
childbirth, including life-saving treatment, would not be
covered.
In contrast, the legislation that we have been proposing
explicitly covers the full range of pregnancy-related services,
including postpartum care. This is important as the majority of
maternal deaths occur in the postpartum period and should be
covered.
The legislation is also, of course, about improving
children's health. We all know the importance of an infant's
first year of life. Senator Bond's legislation, as amended in
the Finance Committee with language from the bill that I had
earlier introduced, provides 12 months of continuous coverage
for children after birth. In contrast, the administration
regulation provides 12 months' continuous enrollment to states
but makes the time retroactive to cover the period in the womb.
Therefore, if nine full months of prenatal care are provided,
the child could lose coverage after 3 months following the
child's birth. This obviously would make it difficult to have
coverage for well-baby visits, immunizations and access to a
pediatric caregiver during the first year of life.
Senators Bond and Lincoln and I tried both on October 2 and
then again Senator Corzine and Landrieu joined us on October 8;
we tried to get consent to pass S. 724, the Mothers and
Newborns Health Insurance Act. This was passed out of the
Finance Committee without opposition in July. Unfortunately, on
both occasions our Republicans colleagues objected, citing the
opposition of the administration.
To our surprise, Secretary Thompson had reversed his
position and issued a letter to Senator Nichols on October 8
dropping his support for passage of the legislation by saying
that, in his view, ``The regulation is a more effective and
comprehensive solution to the issue.'' This reversal came
despite the fact that there are, in my view, at least, glaring
gaps in the administration's regulation that are acknowledged
in the rule itself.
Let me at this point just indicate that the administration
was invited to testify by Senator Gregg's office and Senator
Kennedy's office, declined to do so on the basis they had not
been given adequate notice of the hearing. We respect that
position. I very much hope that they will submit written
testimony for us to include in the record, as many other groups
and parties have indicated they intend to.
[The prepared statement of Senator Kennedy follows:]
Prepared Statement of Senator Kennedy
One of the most serious aspects of the health care crisis
that continues to affect so many of our fellow citizens is the
lack of access by large numbers of pregnant women to affordable
health care. Excellent prenatal care is available in this
country, but 14 percent of pregnant women today do not have the
opportunity to benefit from it and over 11 million more women
of child bearing age are at risk of not having such care
because they are uninsured. The lack of prenatal care for these
women can lead to illness and loss of life.
In fact, the United States ranks 21st in the world in
infant mortality and 26th in maternal mortality the highest
rates of any developed nation. These mortality statistics are
unacceptable, and it is even more frustrating is that these
deaths are largely preventable.
We know that timely prenatal care leads to positive health
outcomes for mothers and newborns. Such care assures that
pregnant women receive guidance on proper nutrition and
encourages the elimination of unhealthy habits such as drinking
and smoking. It also prevents transmission of disease from
mother to fetus, and helps to avoid pregnancy-related
complications.
CDC has released data indicating that routine screening for
group B strep in late pregnancy is the most effective way to
prevent its transmission from mother to child during pregnancy.
Screening for diabetes can prevent complications during
pregnancy and birth. Prenatal care can also prevent
transmission of Hepatitis B and HIV from mother to child. These
are all simple steps that can prevent illness and death if
women have access to good health care. Insurance coverage will
give pregnant women access to the care they need to be healthy
before and after birth, and give infants a chance for a truly
healthy start in life.
Many Senators have introduced legislation to provide access
to prenatal care services. Senator Bingaman has proposed
legislation to assure that pregnant women receive effective
care during pregnancy and after birth, and I commend him for
his leadership on this important issue. Senator Harkin and
Senator Snowe are also leaders on this issue, and I commend
them as well. We need to do all we can in Congress to end this
key aspect of the nation's health crisis.
When we provide mothers and their children with access to
good health care, we are investing wisely in the future of our
country.
Senator Bingaman. Let me go ahead with our first panel of
witnesses here. We are very fortunate to have Senators Lincoln
and Corzine. Let me just give a very brief introduction to both
of them. They have both been real champions on this issue since
the beginning. Senator Lincoln, as she stated on the Senate
floor a couple of times, is not only a champion of the bill but
an expert on the subject. She is one of the Senate's leading
advocates on the issues of children and women's health. She had
one of the very first pieces of legislation to expand coverage
to pregnant women in the previous Congress, legislation
entitled ``The Improved Maternal and Children's Health Act of
2000.'' In this Congress she has been a supporter of both S.
724 and S. 1016, a cosponsor of both, and successfully helped
push for the passage of S. 724 out of the Senate Finance
Committee in July.
Senator Corzine has been a strong champion of this
legislation, as well. He was an original cosponsor of S. 1016.
He has worked closely with me at every stage of getting this
legislation passed. He has taken the next step of putting his
interest into direct action in New Jersey and is working with
the What to Expect Foundation on helping low-income mothers
receive prenatal care and literacy education to improve their
pregnancies and subsequent parenthood. Based on that work, we
have begun to initiate a similar program in New Mexico and I
want to thank him and Lisa Bernstein both, who will be
testifying on the second panel, for their dedication and
testimony today on this important issue.
Let me call on Senator Lincoln first and then Senator
Corzine on any comments they have and then we will move to our
second panel.
STATEMENTS OF HON. JON CORZINE, A U.S. SENATOR FROM THE STATE
OF NEW JERSEY; AND HON. BLANCHE LINCOLN, A U.S. SENATOR FROM
THE STATE OF ARKANSAS
Senator Lincoln. Mr. Chairman, I am going to allow my
colleague to have a few comments, as he has got to run to the
floor and open the Senate. So I am going to defer to him.
Senator Bingaman. Senator Corzine, we are glad to hear from
you first.
Senator Corzine. I appreciate Senator Lincoln yielding. I
have about a 10-minute open in the Senate and then put us into
recess. So I apologize that I have to leave and come back and I
will join you.
I congratulate you, Mr. Chairman, for your efforts on this
very important subject, and Senator Lincoln and others, because
it is one that we are not giving the right attention to and I
join your comments.
Senator Bingaman. Thank you very much. And when you return
I obviously invite you and Senator Lincoln to participate here
in the rest of the hearing on the panel.
Senator Lincoln, go right ahead.
Senator Lincoln. Thank you, Mr. Chairman. Certainly a
particularly overwhelming thank you to you, Chairman Bingaman,
for allowing me to participate today and for making this
hearing happen. Your dedication to women and children's health
is absolutely exceptional. As a mother and as a senator, I am
proud of the leadership that you have demonstrated time and
again on this very important issue.
As you know, the Senate currently has the historic
opportunity to enact legislation, the Mothers and Newborns
Health Insurance Act, S. 724, which you have commented on, that
could drastically improve the lives and health of thousands of
women and children throughout our Nation. This bipartisan
legislation, which we both cosponsored and helped to pass
unanimously in the Finance Committee this summer, gives states
the option, simply the option, of covering pregnant women in
their Children's Health Insurance Programs. Most importantly,
the bill allows coverage for prenatal care, delivery and
postpartum care.
Mr. Chairman, the statistics you have often cited about
infant and maternal mortality in this great country of ours are
absolutely inexcusable. According to the Centers for Disease
Control and Prevention, the U.S. ranks 28th in the world in
infant mortality. We rank behind countries like Cuba and the
Czech Republic. It is amazing to me that the United States lags
far behind these nations in this area.
Another shocking statistic from the CDC is that the U.S.
ranks 21st in the world in maternal mortality. The World Health
Organization estimates that the United States maternal
mortality rate is double that of Canada.
The chart right here that I have brought to share with you
all today, the graph shows the data from the CDC on maternal
mortality in the U.S. from 1967 to 1999. The data shows that
the rate of maternal mortality has dramatically decreased since
the' 60s but this decrease has leveled off, and you can see as
it begins to flat-line down there.
In 1999 there were 8.3 maternal deaths per 100,000 lives
births in the U.S., far above the CDC's Healthy People 2000
goal of 3.3 maternal deaths. In fact, you can see on the graph
that the maternal death rates have been steady or rising since
the mid-1980s. This means that since 1983 the United States has
made no progress in achieving its own goal of a 3.3 maternal
death rate.
Even more upsetting is that in the United States an
African-American woman's risk of dying from pregnancy or
pregnancy-related complications is four times greater than the
risk faced by white women. This is one of the largest racial
disparities among public health indicators and one that we
really see in Arkansas, where the maternal mortality rate for
African-American women is 12.4. That is 66 percent higher than
the national maternal mortality rate.
I am absolutely ashamed of these statistics. When we are
ahead of every other Nation in almost every other arena I am
ashamed we have not taken a course of action that would prove
to the rest of the world that we truly do value life in this
country and that we want to do all we possibly can to ensure
the healthy delivery of children, as well as the health of
their mothers.
The fact is we know how to address this problem. The
solution lies in prenatal and postpartum care. Studies have
shown that this care significantly reduces infant mortality,
maternal mortality, and the number of low birth weight babies,
not to mention the quality of life of these individuals later
on.
Not only is prenatal care essential for quality of life; it
is also cost-effective. For every dollar we spend on prenatal
care we save more than $6 in neonatal intensive care costs, not
to mention the cost to the woman who is giving birth. Preterm
births are one of the most expensive reasons for a hospital
stay in the United States, not to mention the difficulties
these children have later in life, whether it is learning
disabilities or health care issues and complications. There are
a number of things that give us reason why it is so important
to make this investment in prenatal care.
I cannot emphasize enough the great opportunity that we
have here in the Senate to drastically improve the lives and
the health of women and babies in our country. We must pass S.
724 as soon as possible. The states want to cover pregnant
women under SCHIP and the Federal Government should give them
the option.
Mr. Chairman, I was proud to join you and Senator Bond on
the Senate floor in recent weeks to try and bring up and pass
S. 724 and I am so frustrated that both our attempts to pass
this bill were blocked. It is a shame that some of our
colleagues have made a political issue out of trying to ensure
a healthy start in life for babies and their mothers.
I am disappointed that Secretary Thompson has recently
withdrawn his support for S. 724 in favor of the
administration's final regulation to provide SCHIP coverage to
unborn children. I do know what it is that has all of a sudden
crossed his mind to change his mind about the effectiveness of
the legislation that we have presented back earlier this year.
All of this concerns me because the regulation fails to
cover the full scope of medical services needed by a woman
during and after pregnancy that are recommended by the American
College of Obstetricians and Gynecologists and the American
Academy of Pediatricians. We are not just saying this because
some of us have been through it. We are not just saying it
because our constituents think it is important or that they
want it. We are saying it because medicine and science tells us
how important this is.
I am certainly glad that representatives from these groups
are here today to better explain these clinical standards of
care and why they are critical to improving maternal and child
health.
Many things concern me about the administration's
regulation, Mr. Chairman. First, the regulation specifically
states that postpartum care is not covered. Postpartum care is
essential in treating serious pregnancy-related complications
for the new mother, complications that can often lead to death.
Where does that leave a newborn child?
According to the National Committee for Quality Assurance,
hemorrhage, pregnancy-induced hypertension, infection and
ectopic pregnancy continue to account for more than half of all
maternal deaths. Why would we not want to guarantee insurance
coverage for postpartum care to ensure that women will receive
proper treatment for these complications? Consider our
country's efforts to reduce maternal mortality rates. The
regulation's silence on this issue is extremely disturbing.
Postpartum care is covered by Medicaid and most private
insurance. What if the new mother has a hemorrhage, an
infection, she needs an episiotomy repaired or has postpartum
depression? The administration's regulation would not cover
such services because in their words, they are not services for
an eligible child.
Given this huge gap in coverage and the political
complications of this regulation, I am worried that states will
ignore it and continue to try to provide coverage to pregnant
women through the HHS waiver process, which many states have
already done. But governors and State legislators have argued
that this waiver process is lengthy and cumbersome. They prefer
a State option that is easier to administer and that is
permanent. That is why they support S. 724.
The regulation also causes me to wonder about provider
reimbursement. Under the regulation, doctors will not be
reimbursed for providing care that they have been trained to
provide and likely feel that they are ethically obligated to
provide. In the modern practice of obstetrics, postpartum care
is a critical part of the treatment the woman receives
prenatally and during labor and delivery. With rising medical
malpractice rates, particularly for obstetricians and
gynecologists, these doctors may simply decide to stop serving
SCHIP patients. This regulation may become yet another
disincentive for doctors to participate in public programs
serving low-income populations.
Finally, I must say as a woman I am offended by the
administration's regulation. How they can leave the woman
totally out of the equation when talking about pregnancy is
beyond me, Mr. Chairman. Women's bodies change and they grow
during the pregnancy. Her psyche may change, too. Many of you
husbands have witnessed that and believe me, it is not easy.
S. 724, on the other hand, puts mother and baby on equal
footing by guaranteeing that they both have access to the
recommended clinical care that they both need.
Having given birth to twins 6 years ago, I can personally
attest to the importance of prenatal and postpartum care.
Because I had this care, I was blessed with two healthy boys
and a relatively trouble-free pregnancy and delivery. Both boys
and I were able to come home from the hospital within 2 days to
a healthy beginning for our entire family. I was able to nurse
my children with the guidance of my physicians and the guidance
that I could get in my postpartum care. No one should stand in
the way of encouraging healthy pregnancies for the most
vulnerable women in our country.
On behalf of our Nation's mothers, fathers and their
babies, we in the Senate have the serious obligation to pass
this legislation as soon as possible. If we truly value life,
as we say we do, we will take action on something that will
provide us and those families the ability to do all that they
possibly can to ensure a healthy delivery and a healthy start
for these children.
Let us come together in a bipartisan way and pass S. 724,
legislation that will make a difference not only in a child's
life, a woman's life, a family's life, but certainly, Mr.
Chairman, in our Nation's success.
I thank you again, Mr. Chairman, for holding this hearing
and certainly for your leadership in this arena. I look forward
to hearing the testimony today that will likely underscore the
need for passing S. 724 as soon as possible. And on behalf of
the women and children and families out there, I do encourage
us all not to let this become a political issue but more
importantly, to recognize its importance. Thank you, Mr.
Chairman.
Senator Bingaman. Thank you very much for your very strong
statement. Why do you not join us up here if your schedule
permits? We are anxious to have you participate in the question
and answer part of this.
Senator Bond is the prime sponsor on the legislation and,
as Senator Lincoln has pointed out very eloquently, it is
bipartisan. We have strong support from many of our Republican
colleagues for moving ahead with this bill, S. 724, and we hope
that we are able to do that when we come back into session.
If all the witnesses would come forward, let me introduce
all of the witnesses in a group here and then we will just call
on them to testify.
Dr. Nancy Green is with the March of Dimes Foundation. Dr.
Green is a pediatrician and the medical director for the March
of Dimes Foundation in White Plains, NY. Dr. Green also serves
as associate professor of pediatrics and cell biology at the
Albert Einstein College of Medicine, is a leading national
expert on topics in pediatric hematology, oncology, immunology
and genetics.
Dr. Laura Riley is with Massachusetts General. She is here
on behalf of the American College of Obstetricians and
Gynecologists. Dr. Riley is a nationally recognized expert on
the delivery and care for at-risk pregnant women and is
testifying today on behalf of this American College of
Obstetricians and Gynecologists. She is the medical director of
labor and delivery at Mass General Hospital in Boston, is the
current chair of the Obstetrics Practice Committee at the
American College of Obstetricians and Gynecologists.
Dr. Richard Bucciarelli is with the University of Florida
Department of Pediatrics and is here on behalf of the American
Academy of Pediatrics. He is a long-time authority and advocate
for the American Academy of Pediatrics for the betterment of
children's health. He is a nationwide expert on improving
health coverage and quality of care for children with special
health care needs. He is currently a professor and associate
chairman in the Department of Pediatrics at the University of
Florida College of Medicine and a professor at the Institute
for Child Health Policy in Gainesville, FL.
And Lisa Bernstein is with the What to Expect Foundation.
She is co-founder and executive director of that foundation in
New York City. The foundation takes its name from the best-
selling What to Expect pregnancy and parenting series that was
co-written by the foundation's president, Heidi Murkoff. The
What to Expect series has been described by women across
America as their pregnancy bible. The What to Expect Foundation
is a nonprofit organization dedicated to assisting low-income
women also to share in the knowledge and understanding of how
to have healthy pregnancies and safe outcomes for themselves
and their children through the Baby Basics program, which
provides prenatal education to low-income women.
We have, as you can see from these introductions, a very
distinguished set of witnesses. Dr. Green, why do you not
start? We are eager to hear your testimony.
STATEMENTS OF NANCY GREEN, M.D., MEDICAL DIRECTOR, MARCH OF
DIMES BIRTH DEFECTS FOUNDATION; RICHARD BUCCIARELLI, M.D.,
CHAIRMAN, AMERICAN ACADEMY OF PEDIATRICS SUBCOMMITTEE ON ACCESS
TO HEALTH CARE; LISA BERNSTEIN, EXECUTIVE DIRECTOR, THE WHAT TO
EXPECT FOUNDATION, NEW YORK, NY; AND LAURA E. RILEY, M.D.,
ASSISTANT PROFESSOR OF OB/GYN, HARVARD MEDICAL SCHOOL AND
MEDICAL DIRECTOR OF LABOR AND DELIVERY, MASSACHUSETTS GENERAL
HOSPITAL
Dr. Green. Thank you, Mr. Chairman. Good morning
I am Dr. Nancy Green. I am the medical director at the
March of Dimes Birth Defects Foundation. The mission of the
March of Dimes is to improve the health of babies by preventing
birth defects and infant mortality, so this is an issue that is
near and dear to our hearts.
I am pleased to be here today to discuss with you the
importance of providing all pregnant women access to health
insurance coverage and therefore access to a comprehensive set
of basic maternity services. Lack of health coverage continues
to be a significant problem for many Americans. Particularly
troubling are the statistics on women of child-bearing age.
11.5 million women or nearly one in five women of child-bearing
age went without health insurance in 2001, a higher rate than
for other Americans under age 65. That means that some 28
percent of uninsured Americans are women of child-bearing age
and several of you know that that lack of coverage is not
equally distributed across our country. Women of Hispanic
origin, Native Americans, African-Americans are
disproportionately affected by this lack of health insurance.
Numerous studies have shown that having health insurance
coverage affects how people use health care services. In a
report issued earlier this year by the Institute of Medicine,
researchers concluded that, and I quote, ``Like Americans in
general, pregnant women's use of health services varies by
insurance status. Uninsured women receive fewer prenatal care
services than their insured counterparts and report greater
difficulty in obtaining the care that they believe they need.''
We know how important prenatal care can be. In its report
on pending legislation, the Senate Finance Committee stated
that, ``Recent studies have shown that infants born to mothers
receiving late or no prenatal care are more likely to face
complications which can result in hospitalization, expensive
medical treatments, and increased cost to public programs.
Closing the gap in coverage between mothers and their children
will improve the health of both while reducing costs for
taxpayers.''
At the March of Dimes our overarching goal is to improve
the health of mothers and their children. To further this goal,
the foundation has worked throughout this Congress to obtain
support for a modest incremental step to improve access to
health service for uninsured pregnant women by amending the
SCHIP program.
Mr. Chairman, S. 724, which includes provisions from your
bill, S. 1016, the Healthy Start, Stay Healthy Act, would bring
the SCHIP program into alignment with every other Federal
health insurance program, all of which extend coverage to
pregnant women and their babies. The provisions of S. 724 that
are particularly important to advancing the mission of the
March of Dimes include number one, allowing states the
flexibility to extend SCHIP coverage to pregnant women 19 years
and older and number two, automatically enrolling their
newborns in the program and providing them with coverage for 12
months following birth.
Mr. Chairman, on several occasions throughout the year we
were pleased that HHS Secretary Thompson endorsed legislation
to achieve these important objectives. However, the March of
Dimes is disappointed to learn that the administration has
apparently withdrawn its support for legislation and instead
will rely on a regulation that permits states to cover unborn
children.
We are deeply concerned that this regulation fails to
provide the mother the standard scope of maternity care
services recommended here today by my colleagues at the
American College of Obstetricians and Gynecologists and the
American Academy of Pediatrics. Of particular concern, the
regulation explicitly states that postpartum care is not
covered. When a new mother goes home following delivery the
March of Dimes wants to be sure that she is healthy enough to
support herself, to breast-feed, to care for her newborn, and
to participate in her family's life.
S. 724 has broad bipartisan support and the National
Governors Association has called on Congress to give states
this option. In addition, 26 national organizations have
endorsed this initiative.
In short, S. 724 would give us and other organizations
committed to improving the health of women and children the
opportunity to work in states across the country to expand
access to comprehensive basic maternity services, as
recommended by obstetricians and pediatricians.
On behalf of the March of Dimes, thank you for your
commitment to improving the health of children and their
families and for this opportunity to testify on the issues of
critical importance to pregnant women and infants.
Senator Bingaman. Thank you very much.
[The prepared statement of Dr. Green may be found in
additional material.]
Senator Bingaman. Why do we not just go right down the
table here? I think that is probably just as logical as
anything else.
Dr. Bucciarelli, why do you not go right ahead?
Dr. Bucciarelli. Thank you, Mr. Chairman. Mr. Chairman,
members of the committee, I am Richard Bucciarelli, a
practicing neonatologist at the University of Florida,
testifying today on behalf of the American Academy of
Pediatrics.
As a practicing neonatologist, I am the physician that
often takes care of the babies that are born too small, too
sick to sometimes survive or even live up to their full
potential. I am a former chairman of the American Academy of
Pediatrics Committee on Federal Government Affairs and serve as
the chairman of the Academy's Subcommittee on Access to Health
Care. And on behalf of the Academy, I would like to thank the
committee for the opportunity to present this statement.
Mr. Chairman, the Academy commends you and your colleagues
and thank you for your leadership and determined efforts to
dramatically reduce the number of uninsured children and
pregnant women in this country. We look forward to actively
working with you to bring health care coverage to all of our
Nation's children and pregnant women.
The American Academy of Pediatrics is an organization of
57,000 pediatricians dedicated to the health, safety and well-
being of infants, children, adolescents and young adults. A key
principle for the Academy is that all children and pregnant
women have the right to access age-appropriate quality health
care.
Toward that end, the Academy is pleased to testify today in
support of the Mothers and Newborns Health Insurance Act of
2002, S. 724. This legislation would give states the option of
covering pregnant women with their State Children's Health
Insurance Program and very importantly, it appropriates the
additional funds to states to provide these necessary services.
The Academy believes it is critically important that pregnant
women receive the full range of medical services needed during
their pregnancy and the postpartum period. These services are
spelled out in the Guidelines for Prenatal Care, Fifth Edition,
which was developed jointly by the American Academy of
Pediatrics and the American College of Obstetricians and
Gynecologists. These guidelines describe the components of
prenatal care that are needed by both the fetus and the
pregnant woman to ensure early identification of risk factors
and appropriate treatment of maternal fetal conditions.
As we all know, the administration published a final rule
expanding SCHIP coverage to unborn children. The Academy is
concerned that as written, this regulation falls dangerously
short of the clinical standards of care outlined in our
guidelines, which describe the importance of all stages of a
birth--the pregnancy, delivery, and postpartum care. The
Mothers and Newborns Health Insurance Act ensures that pregnant
women can receive the critically important full range of
prenatal and postpartum care.
This legislation, unlike the recently published rule,
recognizes the important impact of the mother's health on the
fetus. There is no doubt, for example, that maternal diabetes
can directly affect the fetus and lead to increased mortality
and morbidity and would be covered. But what about a mother
with asthma in need of coverage to pay for her medications?
Denial of coverage could result in a severe asthmatic attack,
pneumonia, and could deprive the fetus of oxygen and lead to
even premature delivery.
Or what about the mother with a severe infection of the
gums of the mouth, gingivitis, and dental caries? How is this
related to the fetus? Well, there is an increasing amount of
data to indicate that chronic infection of the gums and bad
dental health greatly increase the chances of a premature
delivery with its increased morbidity, mortality and cost. And
these are just two examples that demonstrate the importance of
covering both the fetus and the pregnant woman with appropriate
health benefits.
One of our biggest challenges we face as a Nation, and we
have an opportunity to address that here today, is reducing the
number of uninsured children and pregnant women in the United
States. We believe the Mothers and Newborns Health Insurance
Act takes an important step to decrease the number of uninsured
children by providing 12 months of continuous eligibility for
those children born to mothers under this act. It has been
demonstrated that intermittent coverage compromises continuity
of care, delays necessary therapy, and adds administrative
costs for outreach and reenrollment efforts.
Additionally, this provision prevents newborns eligible for
SCHIP from being subject to enrolment waiting periods, ensuring
that infants receive appropriate health care in their first
year of life. This legislation ensures that children born to
women already enrolled in Medicaid or SCHIP are immediately
enrolled in the program for which they are eligible. These
provisions would provide presumptive and continuous eligibility
for children covered under the act, guaranteeing essential
uninterrupted access to health care throughout their first year
of life, for it is within that first year of life when parents
need the most assistance in dealing with their new child. It is
within that first year of life that immunizations, timely
immunizations, are most critical. And it is within that first
year of life that making the correct diagnosis and initiating
the appropriate therapy is so important.
We must make health care for America's children and
pregnant women available, accessible and affordable. Providing
children, adolescents and pregnant women access to quality care
with an emphasis on prevention is truly an investment in our
Nation's future. Thank you very much.
Senator Bingaman. Well, thank you very much.
Ms. Bernstein, why do you not go right ahead?
Ms. Bernstein. Mr. Chairman, members of the committee, I am
honored to come before you today to urge passage of S. 724, the
Mothers and Newborns Health Insurance Act of 2001.
First, let me just tell you a bit of how I have come to be
here and why the What to Expect Foundation was formed. The What
to Expect Foundation takes its name, as you have heard, from
the best-selling What to Expect pregnancy and parenting series
that was written by the foundation's president, Heidi Murkoff,
and her mother, the late Arlene Eisenberg.
This series of books has helped over 20 million families
from pregnancies through their child's toddler years. ``What to
Expect When You're Expecting'' is often referred to as
America's pregnancy bible. According to a USA Today poll, it is
read by 93 percent of all mothers that buy a pregnancy guide.
The What to Expect series of books are not only the three best-
selling parenting books in the country; they are among the
best-selling books in the country on any topic. This week
``What to Expect When You're Expecting'' is number three on the
New York Times Bestseller List.
But I am sorry to say, as many parents as the What to
Expect books have helped, they have missed many more. As we
know, our Nation's infant mortality rate is higher than 28
other countries. We are right behind Cuba. And even if a mother
could afford to buy a prenatal guide she might not be able to
read it. The literacy rate in the United States is a continuing
problem. Today 21 to 23 percent or adults or some 40 to 44
million people across the country read at less than a fifth
grade level.
Thus, the birth of the What to Expect Foundation, a new
nonprofit organization dedicated to helping mothers in need
receive prenatal health and literacy education so they, too,
can expect healthy pregnancies, safe deliveries, and can learn
to become parents. We believe that a woman, when she becomes a
mother, needs to learn how to read because a mother who can
read can raise a child who can read.
The Basic Basics program provides prenatal education that
takes into account the special health, economic, social and
cultural needs of low-income women and gives prenatal providers
culturally appropriate health literacy tools and support.
By 2003 we will have provided over 200,000 women across the
country with the Baby Basics program in English and Spanish and
we are now building Baby Basic model health literacy sites at
prenatal clinics across the country.
While researching the Baby Basics book and program I had
the opportunity to speak to hundreds of pregnant low-income
women and the doctors, midwives, nurses, outreach workers,
educators and social workers that care for them. From across
the country I heard the pregnancy stories of the country's
poorest women. Some of them were also the stories of just every
woman--swollen feet, indigestion, back pain. Others were about
hopes and fears that cut across income and education. Will I be
a good mother? Will I know how to hold a child? Will I be able
to provide for my baby?
But too many of these stories broke my heart. Teens who
were pregnant because they wanted someone to love and to love
them. Women pregnant with no health insurance, who worked long
days for little income and hah to take off unpaid time to sit
in a hard chair for hours waiting for an unscheduled five-
minute free appointment at a crowded clinic. Women who saw a
doctor for the first time the day their water broke because
they could not afford care.
Secretary Thompson did an important thing and is to be
congratulated when he realized that many pregnant women could
not afford prenatal care. One look at the infant mortality rate
and he did look for ways to fix it. He also realized that
SCHIP, a dramatically successful program for families, had the
funds and the ability to reach out to help in our constant
battle against infant and maternal mortality. And I applaud him
for finding a stopgap measure that was within his domain to
help states provide prenatal care quickly and efficiently by
extending the care to the fetus, with an implicit understanding
that this was a quick fix, one that would be remedied by
legislation.
Now, frankly, I am confused. In his recent letters to you,
Senators, he seems to have changed his mind, saying such
legislation is no longer needed; his quick fix is enough. But
the quick fix put forward by the administration is not really a
fix at all because now we have created even more problems.
After we have spent so much time and money promoting prenatal
care, we have gone and created an entirely new funded medical
program called fetal care because fetal care and prenatal care
are not the same thing. Please let me tell you why.
This September Secretary Thompson, Senator Kennedy and
Senator Hatch, along with our foundation's president, Heidi
Murkoff, spoke at Robert Wood Johnson's Covering Kids
celebration honored SCHIP's fifth anniversary. Mothers and
fathers explained how Child Health Plus helped their family.
These were working families with two jobs working double
shifts, to keep their families afloat.
One family, suddenly unemployed, had no idea how they were
going to pay for their daughter's continuing diabetes care
until they found out about SCHIP. Another hard-working mother
spoke about SCHIP paying for surgery that saved her boy's life.
These parents were heroes to their children and to the
audience. With the help of SCHIP, they have provided for their
families. Because SCHIP had been carefully crafted, marketed
and promoted as help for working families and children, these
parents were able to retain their dignity and were proud of
their ability as parents to provide the health care their child
needed when they needed it. Just as offering prenatal care to a
woman can help her afford to do the best for her unborn child,
it is friendly help that is offered with dignity and can be
accepted with pride.
Offering fetal care? That is a slap in the face. This new
regulation makes clear that fetal care is about the fetus
first. Extras, like epidurals and pain medication, will only be
available if a case can be made that they are for the health of
the fetus. Fetal care offers the mother no dignity, devaluing
her life, which she has risked by sharing her body with an
unborn child.
Prenatal care acknowledges that there are two things that
grow when a woman becomes pregnant. First, of course, there is
the fetus, growing to become a healthy baby. And second, no
less importantly, there is the woman, who must also grow. She
must grow to think of herself as a mother, a parent, a
provider. Inextricably linked in a dance as old as creation,
mother and child grow together, both nurtured with love and
care.
Fetal care unbinds those ties, breaks those bonds. It is
about the government choosing fetuses over women, providing the
fetus with all of its health care needs while saying to the
woman we cannot help you.
Prenatal care provides a woman with the comprehensive
health coverage she needs to have a baby. It cares for her body
and her health. It helps her stay strong so she can be strong
as a mother. It provides for her needs before and after the
delivery and gives her the chance to recover so she has the
strength and the health to nurse her precious new bundle.
Fetal care tells mothers that once they have had the baby,
they are on their own. Like Cinderella after the ball, once the
baby is delivered, no more fairy godmother. Suddenly her health
care is gone. No glass slipper. Even her 48 hours guaranteed
hospital stay is out of the picture.
Prenatal care is about family values. It helps create
parents. It does what Early Head Start, Head Start, Healthy
Start and Even Start do so well. It gives parents the strong
shoulders they need to make sure no child is left behind. It
fosters optimism.
Fetal care throws the parent out with the bathwater. It
fosters pessimism and an early pervading sense of failure. From
the start, it fails to acknowledge that a parent is a child's
first and best teacher. To me, fetal care fosters foster care.
Prenatal care fills hospital wards with healthy babies.
Fetal care fills hospitals with wards of the State.
Senators, so many good things can happen when a woman gets
proper comprehensive prenatal care, as you have heard from my
colleagues. The What to Expect Foundation links prenatal care
to literacy training so women learn how to read and learn how
to read to their babies. Healthy Start and other programs
across the country are linking prenatal care to all kinds of
positive self-esteem-building social programs--parenting
skills, job training, long-term housing planning, financial
planning.
We have trouble in this country getting women into prenatal
care. Why would we ever want to put any barriers to prenatal
care up?
Secretary Thompson has done an honorable thing by opening
the door to prenatal care for thousands of women each year but
imaginary barriers, liberal barriers, conservative barriers,
unintended barriers, no matter what we want to call these
barriers, regardless of their politics or their intent, they
are unnecessary barriers to care.
I am here to tell you that hundreds of providers,
practically every doctor, midwife and nurse across the country
agrees that this fetal care quick-fix must not stand as a
barrier. And every mother, including this mother, and the
mothers who have told millions of mothers across the country
what to expect, agree. Our job is to knock down the barriers.
Passing S. 724 will remove those barriers. Then we can roll up
our sleeves and get back to work because only a healthy parent
can provide a healthy future for a healthy child. Thank you.
Senator Bingaman. Thank you very much.
Dr. Riley, you are the clean-up hitter on this panel. We
are anxious to hear from you, too.
Dr. Riley. These are hard acts to follow.
Thank you, Mr. Chairman, and members of the HELP Committee.
As an obstetrician-gynecologist, I welcome the opportunity to
speak with you this morning on behalf of the American College
of Obstetricians and Gynecologists, 45,000 partners in women's
health care. I look forward to discussing measures that will
increase access to medical services for pregnant women.
I would first like to thank you, Senator Bingaman, for your
leadership on this issue. I would also like to thank and
acknowledge Senators Lincoln and Corzine for appearing before
the committee today and for their commitment to uninsured
women.
My name is Dr. Laura Riley and I am an assistant professor
of obstetrics and gynecology at Harvard Medical School and the
medical director of labor and delivery at Massachusetts General
Hospital in Boston. I also chair the Committee on Obstetric
Practice at ACOG.
I am pleased and honored to speak before the committee
today on an issue that is extremely important to me. The focus
of today's hearing is to discuss how being uninsured can impact
maternal and fetal morbidity and mortality. For uninsured
pregnant women, lack of prenatal and postpartum services can
have devastating and lasting effects on both the mother and her
fetus. There is no question that increasing access to prenatal
care and appropriate postpartum services is of the utmost
importance.
Unfortunately, one of great barriers to this care remains
lack of insurance. I believe passage of Senate Bill 724, the
Mothers and Newborns Health Insurance Act of 2001, would help
us achieve this important goal. ACOG strongly supports S. 724,
a bipartisan comprehensive bill that permits states to extend
health coverage to pregnant women, enabling them to have full
access to a range of services, including perinatal and
postpartum medical care, and urge the Senate to quickly pass
this legislation. ACOG, along with the Academy of Pediatrics,
spells out recommendations for prenatal and postpartum care for
the mother and the fetus in Guidelines for Perinatal Care,
Fifth Edition. If we pass S. 724, we can deliver this care to
many underserved and uninsured women.
I would like to take a moment to comment on the Department
of Health and Human Services' recently issued regulation that
allows states to provide prenatal and delivery benefits under
the SCHIP program to mothers and the fetus, regardless of the
mother's immigration status. We appreciate the administration's
interest in expanding prenatal coverage to uninsured pregnant
women. Their efforts to extend access is appreciated. However,
this regulation, as it stands, raises some questions.
We at ACOG believe that it is unrealistic to exclude the
mother and provide services solely to the fetus. It is
impossible to separate mother-baby pairs and expect a good
outcome for either of them. Our three principal concerns are
the need for postpartum care, the need for essential components
of prenatal care, and the logistical problems of implementing
the administration's proposed legislation.
ACOG is very concerned that mothers will not have access to
appropriate postpartum services. The rule clearly states that
``Care after delivery, such as postpartum services, could not
be covered because they are not services for an eligible
child.'' Physicians regard postpartum care as essential for the
health of the mother and the child.
Covering the fetus as opposed to the mother also raises
questions of whether certain services will be available during
pregnancy and labor if the condition is one that principally
affects the woman. Postpartum care is especially critical for
women who have preexisting medical complications and for those
whose medical conditions were induced by their pregnancies,
such as gestational diabetes or hypertension. Even women with
uneventful deliveries and recoveries can develop conditions
postpartum that require extra visits or even surgery. A woman
may go home feeling well and return with problems.
I recently treated a 20-year-old Hispanic woman 8 days
after an apparently uncomplicated vaginal delivery. She
complained of 2 days of severe headache. Her blood pressure was
200 over 115 and upon arrival to the hospital, she suffered a
grand mal seizure. There are many more stories like this, some
even more tragic. Clearly when new mothers develop postpartum
complications, quick access to medical care is absolutely
critical.
I would also like to touch upon a population that may be
most at risk for developing complications during and after
pregnancy and why we must ensure that obstacles do not prevent
them from seeking care. African-American women, Hispanic women
who have immigrated to the United States, and American Indian
and Alaskan native women are at greatest risk for maternal
mortality.
The statistics are startling. CDC notes that African-
American women are four times as likely to die of pregnancy
complications compared with white women and American Indian and
Alaskan native women are nearly twice as likely to die. In a
14-year national study of pregnancy-related deaths in the
United States, CDC found that the pregnancy-related mortality
ratio for African-American women was 25.1 deaths per 100,000
live births and 10.3 deaths per 100,000 live births for
Hispanic women, versus six per 100,000 live births for white
women. Poverty and lack of insurance clearly and certainly play
a significant role in these alarming statistics. We are
concerned that women without postpartum coverage, the very
women that need the most help and who experience the highest
rate of maternal morbidity and mortality, will be
disproportionately affected.
As I have stated before, prenatal and intrapartum services
are essential. It is inconceivable that there are diseases that
affect the mother principally and have no overall effect on the
fetus. Diseases such as diabetes and hypertension clearly have
defined fetal effects. Maternal obesity, which requires
nutrition counseling, behavioral interventions, and anesthesia
consultation, is not a health condition limited to the mother.
For example, another patient of mine in her 8 month of
pregnancy arrived in the emergency room clutching her head with
pain and developed confusion over time. A CT scan revealed a
large brain tumor. Yes, this is a maternal condition but you
can imagine that the effects of neurosurgery and postoperative
pain management all had an impact on her developing fetus.
Finally, Mr. Chairman, I want to share our concerns about
the implementation of the administration's regulation and the
impact it will have on OB-GYN practices. Already the health
care system prevents physicians from spending needed time with
patients. Skyrocketing medical liability premiums, onerous
regulatory paperwork, and continued Medicare payment cuts can
dramatically undermine our ability to serve our patients. All
of these factors have combined to limit access to care and we
urge Congress to support efforts to address these issues, as
well.
I fear this regulation will create even more bureaucracy
and red tape for physicians. For my patient who was 8 months
pregnant with a brain tumor, figuring out which components of
her care would be covered by such restrictive services would be
an impossible task. Because this regulation also limits
coverage to services directly related to the health of the
fetus, OB-GYNs will be unsure whether medically necessary care
can be covered. In most cases physicians will simply provide
the care and deal with the coverage issues later, knowing that
a tremendous amount of staff time and effort will be expended
to recover minimal payment.
Furthermore, pregnant women may wonder if even they have
the ability to access coverage for nonobstetric conditions or
injuries and decide simply to not seek treatment. This
uncertainty about coverage will discourage physicians from
participating and deter women from seeking appropriate
necessary care.
Mr. Chairman, in closing, I urge the Senate to quickly pass
S. 724. I also encourage the administration to support
enactment of this bill to expand coverage to uninsured pregnant
women, ensuring access to comprehensive prenatal and postpartum
coverage. It is the right thing to do. Thank you.
Senator Bingaman. Thank you very much.
[The prepared statement of Dr. Riley may be found in
additional material.]
Senator Bingaman. I thank all four witnesses for just
excellent testimony.
Before we start some questions let me defer to Senator
Corzine for any comments or statements that he would like to
make.
Senator Corzine. Thank you, Mr. Chairman. Again let me
congratulate you and compliment you on your leadership on this
issue throughout this year and over a long period of time.
Universal access to health care is certainly something that I
think all of us would like to see but if we do not have the
ability to provide that, providing it to the Nation's children
and pregnant women is something that I think all of us can
believe needs to be done.
I have a lengthy statement I will put into the record but I
do want to reemphasize that we are creating controversy where
there need be none. We are creating confusion, as we just heard
Dr. Riley talk about, for our medical community where there
need be none. And we are creating an unbelievable conflict
between the health of the mother and the health of the fetus
that need not be done. So I hope that we can resolve this and
move forward quickly with respect to it.
I thank the witnesses for their testimony. It is far more
articulate than I can be with regard to this, but this is
something that I think the Nation ought to put high on its
agenda and address quickly.
Senator Bingaman. So thank you very much to all of you and
your excellent testimony.
Thank you very much, Senator Corzine, for your strong
advocacy of this legislation here throughout this Congress.
Let me start with a couple of questions and then defer to
Senator Lincoln and Senator Corzine for questions they have.
First I wanted to allude to a very disturbing statistic that I
am well aware of and that is that when you look at the various
states in the Nation as to who has the biggest problem with
regard to women of child-bearing age lacking appropriate
insurance, my State of New Mexico is first in the Nation. There
are 32 percent of the women of child-bearing age in New Mexico
who do not have insurance coverage. Second to New Mexico is
Texas. Twenty-eight percent of the women of child-bearing age
there do not have any insurance coverage.
So it is a very serious problem and, of course, the
statistics in our State I think add to or contribute to the
very unfortunate national statistics that several witnesses
have referred to.
Let me just ask any of you, starting with Dr. Green, I
think the concern that I have had and a major motivation for
introducing the legislation I introduced in this Congress and
supporting Senator Bond's legislation, along with my
colleagues, has been trying to deal with this problem of high
mortality of newborns, high mortality of women in the delivery
process. This legislation seemed to be the most effective thing
we could do at the national level to try to deal with this.
Is there something else? Is there something other than
passage of this type of legislation that would also be a
significant contributor to solving this problem? I think we are
sort of looking to you as experts to tell us what can be done
to deal with these problems. I did not know if any of you have
insights as to whether this is the most effective thing or
whether there are others that we ought to be pursuing, as well.
Dr. Green, did you have any thoughts on that?
Dr. Green. Thank you. I think a number of the states have
already identified that between Medicaid and SCHIP coverage,
that is a lot of families affected who can be covered
effectively by those programs. In fact, many states have
increased the threshold for eligibility for SCHIP to 185
percent and in some states 200 percent of the poverty level.
So I guess the theme of my suggestion would be the increase
in coverage both from Medicaid and through SCHIP and to that
end then, this bill would be serving.
Senator Bingaman. Let me put a chart up that we have that
tries to show the problem in my State. I asked Bruce Lesley,
who has been the great champion on this, to put this chart
together. The thatched part up at the right starting after age
18 is the area that we are trying to cover through this
legislation. Medicaid does cover people up to 185 percent of
poverty in my State. The SCHIP program covers anyone up to 235
percent of poverty through age 18 but then after that, of
course, there is no coverage once a person is 19 years old, so
we believe that this is an option that should be available to
our State to pick up.
Dr. Green. The March of Dimes commissioned a study from
Emory University to estimate the potential number of eligible
pregnant women who could be covered by this legislation that
gives states the option to enroll income-eligible pregnant
women in the SCHIP program. Those estimates are 41,000 women
nationwide would be eligible for coverage under this bill.
The Congressional Budget Office has recently released some
estimates of their own--about 30,000 newly eligible pregnant
women could be covered. So between 30,000 and 40,000 women
could be affected by this regulation. That is a lot of
families.
Senator Bingaman. Right. Very good.
Let me ask Dr. Riley, you went into some depth about the
problems that you see with trying to sort out what is covered
under this new regulation that has been issued and Senator
Corzine just referred to that sort of needless complication
that we are adding to the system for physicians and all.
Two, I think that you mentioned are diabetes and
hypertension, questions about whether those kinds of things
would be covered. Would you want to elaborate on that at all as
to how you think obstetricians would make those decisions?
Dr. Riley. I think that obstetricians are going to have a
tough time deciding what component of treatment for
hypertension is going to get covered because it directly
relates to the fetus, yet this part is really for the mom's
long-term health.
Hypertension may not even be the best example. I think a
very good example is my patient with the brain tumor. I mean
the brain tumor was not going to affect her fetus directly but
certainly the neurosurgery that we did and lowering her core
body temperature probably had some effect on her fetus.
I think that there are definitely going to be some medical
illnesses that complicate pregnancies for which you cannot
separate the mother and the baby. You may not be able to define
the fetal effect but there is probably a fetal effect. I do not
think that we want to allow physicians to then be more confused
and start making arbitrary decisions about what treatment they
will give and what treatment they will not give.
Senator Bingaman. Dr. Bucciarelli, did you have any
thoughts on this? You are in the business of providing
pediatric care.
Dr. Bucciarelli. Right. I agree with agree Dr. Riley. When
we go into a delivery room or we go in consultation with the
perinatologist, we are working on a unique situation in which
there are two lives that are inexorably bound together and
there is virtually nothing that I can think of that would
affect the mother and not directly or indirectly affect the
fetus.
One of the examples given earlier is if a mother breaks an
arm, how does that affect the fetus? Well, the stress, the
hormones that are put out when somebody has that kind of injury
cross the placenta and those kinds of hormones, small peptides,
greatly affect blood flow and very commonly blood flow to the
brain, which is what we are trying to preserve. We have babies
that are born with a completely normal delivery process that
have devastating defects in the long run, probably because of
these kinds of things, stresses in the mom that we are not
aware of.
So I just cannot think of anything that would go on in a
mom that would not directly or indirectly affect the fetus and
I would agree with Dr. Riley that separating those two would
make it so difficult to take care of these patients.
Senator Bingaman. Senator Lincoln, go ahead with any
questions you have.
Senator Lincoln. Thank you, Mr. Chairman.
Well, a little bit to expand on that, when you talk about
that you cannot think of anything that would be different or
where you could separate those two, my understanding of the
regulation is that it would be left up to the states. So
basically you are going to have different states deciding what
is covered, what is not, different care given to mothers
depending on where they live and where they seek services and
all of a sudden you are going to have physicians again trying
to make these decisions. Is this a procedure that I follow the
clinical guidelines, which you all obviously have clinical
guidelines, or do I follow another path or another pattern
because I want to take care of both of these but I cannot do it
and get reimbursed or get paid for services in that way.
To me, that sounds enormously confusing and I cannot
imagine that physicians, particularly in light of some of what
Dr. Riley has brought up in regard to liability that we have
seen with obstetrics and gynecology and other difficulties that
they have, I mean what do you all see in terms of the
confusion, the logistical complications that this would present
and finally, I guess, perhaps the lack of reimbursement or the
knowledge of that for whether it is prenatal or postpartum
care? How his that going to affect the willingness of providers
to actually serve or participate in these SCHIP programs?
Dr. Riley. I think that it will lead to more and more
physicians not participating at all. It is too much paperwork.
It is too much confusion. You leave yourself open to a great
deal of liability, giving half the care you should give. I
think that people will just say I do not want to take care of
this segment of the population.
Then again it will get us right back to where we started
from, where there is lack of access.
Senator Lincoln. It is so counterproductive to what we want
to accomplish.
Dr. Riley. Absolutely.
Senator Lincoln. Dr. Bucciarelli, I know I delivered at a
university hospital and I can remember my father, who is a
wonderful man but he is a basic dirt farmer from East Arkansas.
I had never seen my father cry until I went up to the neonatal
intensive care unit with him, took him up to see one of our
twins, who had to spend about 24 hours under some oxygen from a
pneumothorax, and we were very fortunate. I went full term. The
boys were big, good size babies and all of that, but right next
to Bennett was a twin. They were born at, I think, like 24
weeks, 25 weeks, maybe even 23 weeks, and one of the twins
survived; one of them did not.
It was incredible to see that baby and as I said, I had
never seen my father cry until he looked at that child. The
comment that he said, which was not only is that amazing to
see, but he said that poor individual is going to have
complications all his life.
When we talk about the lack of prenatal care and we talk
about how important it is for the health of the family and the
child we are not just talking about delivery. We are not just
talking about postpartum. Can you kind of expand on some of the
things, too, when you have a delivery without the adequate
prenatal care and without the adequate postpartum care, what do
we see in developing pediatrics and in children down the line
in terms of developmental disabilities and other health care
complications, even the statistics on incarceration, when you
are talking about those kinds of situations?
Dr. Bucciarelli. Well, there can be a life-time loss for
the family and the child. Certainly the age group that you
refer to have a high mortality and those that survive often
have some disabilities, from mild to very severe. But, you
know, although I marvel when I am in the NICU, as well, at the
advances that we have made but I am absolutely convinced that
we get handed a healthier baby and it makes my job easier
because of what is happening in obstetrics and gynecology and
the prenatal care, the intrapartum care gives me a child that
is healthier and allows me to use the technology that is
available.
So 10 years ago we had a lot of the technology we have
today but that child would not survive. The difference is the
prenatal care, the ability to treat these kinds of conditions
of high blood pressure and disability, so the obstetrician
hands me a baby that is screaming, pink, and almost ready to
feed.
May I just make one other comment that I think you alluded
to? That is the issue of breast feeding. That is so important
in the outcome of children, that they get the right kind of
initial exposure to immunoglobulins to decrease the amount of
infections, to allow their gut to develop appropriately. And we
have made great strides in our country in having women breast
feed and that is purely a postpartum service. You do not talk
about breast feeding in prenatal care, maybe a little during
the delivery, but it is a postpartum service and without
coverage for lactation consultants and without coverage of the
physician's time to talk to the mother about breast feeding,
breast feeding in our country will disappear very, very rapidly
and it will be a tremendous loss to the health of our children.
Senator Lincoln. That is so true. I can remember asking to
be able to see a lactation consultant and they said, ``What?''
It is interesting.
Miss Bernstein, thank you so much for such a moving
statement. I have to say that I was one of those millions of
women who had ``What to Expect When You're Expecting'' on my
shelf. I have read it and I was very interested to see my
husband, who happens to be an OB-GYN, how much he enjoyed
reading it. We did read it together. It was something that
provided us, I think, a great perspective on many of the
different things we would see. He certainly knew the medical
aspects but for me it was a tremendous help when I was carrying
my sons. But, as you've said, not all women have been so lucky
to be able to read the book or get the kind of prenatal care
that they need.
In my home State of Arkansas there are about 97,000 women
of child-bearing age, between 15 and 24, who do not have health
insurance. We rank 35th in the Nation in this regard and when
you look at Senator Bingaman's chart there, we only cover 133
percent of poverty in Medicaid and we go to 200 percent of
poverty with SCHIP.
But you talked a bit about the effects that providing
health care to only the fetus would have on mothers. I would
like for you maybe to share with us from your experience with
Baby Basics programs and the people that you have met, maybe
describe some hypothetical situations concerning pregnant
women. Or maybe you have some situations that you have in mind
that you have seen that you would like to share, some low-
income, maybe some that do not speak English, perhaps.
Ms. Bernstein. I think this brings kind of an answer to
Senator Bingaman, also, that I would like to talk about. One of
the things that I have noticed about access to care, to early
childhood care and prenatal care, is that a lot of people do
not know what does exist for them. A lot of mothers come in
late because they do not know their rights. They do not know
what is available.
One of the things that I have watched with SCHIP that is a
marvelous program is that families do not know it is for them.
They do not know that they can get this and it is not until by
accident they hear--I mean I have heard stories of people
hearing about it on the radio by accident and realizing, oh,
wait, I fit into that.
One of the things I think we should think about is when
this is successful, which I hope it will be, how we can use
this as a continuum of care because women do go in for prenatal
care and you do not sign them up for SCHIP; they do not find
out about it. With this, we have expanded the entry to the
SCHIP program. You get pregnant women in there and you get them
signed up with their children and then you have expanded the
SCHIP program to reach the thousands of families that we have
been unable to reach.
I think that what I have learned from doing this Baby
Basics program, and I will tell a story that Heidi Murkoff and
I watched happen together. We are at Reikers Island at a
parenting program and this was really the impetus for starting
the program. We gave out copies of ``What to Expect When You're
Expecting'' to pregnant mothers in prison, who dove into these
books. They looked like every middle class mother I have ever
seen who immediately wants to know everything that is going on
inside their bodies because an alien life is growing. It is a
shocking and exciting and a marvelous time and you want to know
everything.
A woman at the end walked up. She was emaciated except for
a swollen belly and it was pretty clear that she probably had
been just incarcerated and was there for drug use and was
probably getting the best care she had ever had because she was
in prison. She asked Heidi, ``They told me I need to have an x-
ray of my tooth and I just read in the book that it's going to
hurt the baby. Should I have one?''
And we could not help but stop and say this woman probably
was not eating, she was probably doing crack cocaine. This was
a few years ago. She loved her baby. She had no idea--she came
from a different world than I came from. She did not know what
to do to help her baby. She did not know what it was going to
take to have a healthy pregnancy. Once we started giving her
the information, once we started showing her what she needed to
do, she was as eager as any mother.
Much of it is about access, about education. The things
that we think come naturally that you know, whether it is
nutrition, whether it is basic hygiene, if you did not grow up
with that, you do not even know to begin there. To deny that to
a mother is an awful thing to do to the mother because she
wants to make that baby healthy. The more help and the more
information you can give her, the more that she will take
control. She will become a parent, which is really what our
goal is.
That, I guess, is the point of what I am saying, is the
more that you take that control away from the mother, the less
that she will grow to take that responsibility. And I think
that is what our goal should be, is to create parents, not just
healthy babies, but to create parents who can give their babies
that health.
Senator Lincoln. That is a continuing thing.
Thank you, Mr. Chairman. I may have another one but I would
like to give my colleague over there an opportunity.
Senator Bingaman. All right, Senator Corzine?
Senator Corzine. Thank you, Mr. Chairman.
I do not really feel like asking the question I am going to
ask after that statement because I think that is really getting
at the heart of the matter of how we bring our kids into the
system and how we frame their futures and their lives, but let
me ask a bureaucratic question. Dr. Bucciarelli or Dr. Green
may be the appropriate source.
The administration argues that states can apply for waivers
in this process. New Jersey is a State that has done this.
Checking with the people who are responsible, it was difficult.
Dr. Bucciarelli, Florida's Healthy Kids program, I guess, has
done the same. Do you think this will be a procedure that will
flow smoothly and easily under the regulations and therefore
this legislation is unneeded or what will be the difficulties,
the stops, the road blocks? Aside from the other issues about
confusions that come into doctors' minds, what will be the
confusions in the states and the conflicts? Any of the
panelists can comment on that.
Dr. Bucciarelli. Well, in regard to the waivers, we have
had experience in filing other waivers in the State of Florida.
They were very complicated. They took a long time before we got
through. It was, I think, a significant waste of money and time
in administration in doing that. When something like this can
be done by legislation as an option, purely as an option,
without having to go through all that process, to me, it makes
more sense to allow the states to take an option to be able to
move that, instead of going through the waiver process.
Dr. Green. I would like to add an additional comment to
that important statement just made. That is that with the
legislation, then Federal funding becomes available to the
states and, as we all know, states are not exactly flush these
days. So I think when we talk about something as critical as
health care coverage for our vulnerable citizens, then the
additional financial incentive from the Federal support of the
program through the legislation would be enormously important.
Senator Corzine. I suspect we all understand the difference
between authorization and appropriation and it is even more
difficult when you are applying for waivers where there is
lacking an authorization.
One other slight difference. Aside from the judgmental
issues that I think really get at the heart of a controversy
that need not be, do I understand it correctly that the
administration's program only attends to the newborn child for
3 months, as opposed to a year, which is the element that is
involved in the legislation? What are we missing as we look
after our children in the start of their life along these
lines? Anyone on the panel.
Dr. Bucciarelli. Certainly there is a tremendous amount of
information that says the first year of life is critical to the
child's health and further development and the American Academy
of Pediatrics for some time has been a proponent of presumptive
eligibility and continuous eligibility through that first year
of life to allow immunizations to be done on time and the other
kinds of well visits for not only screening but diagnosis and
treatment of conditions. Certainly within the first 3 months a
lot of that will be known but after that it certainly will not.
And as I understand the legislation, it is a year coverage but
it could go back to early pregnancy or conception, so 9 months
of the year is covered at that time and then there are only 3
months afterwards.
I think a good example, if I might, is the issue with
hearing impairment. Most states have a requirement to do
hearing screening and they are done in the newborn period. But
to be able to diagnosis carefully and treat a hearing
disability, you have to do that several months later. It is
critical that that be done before 6 months of age because if it
is not done before 6 months of age, there are long-term losses
with reading, language, that may never be recovered.
So if you screen the baby in the newborn period and it is
covered but it is not covered after 3 months and they are on
and off or they fall off for a variety of administrative
reasons and never come back, you have wasted time and effort in
screening that child. Plus, without the proper diagnosis and
treatment, we have lost an opportunity to allow a child to
develop to their fullest potential, and that is a serious loss.
Senator Corzine. Anyone else want to comment?
Dr. Riley. I would just add yet another example that comes
to my mind because it is my area of research but the diagnosis
of HIV infection in a newborn is a difficult one to make. You
might start to make the diagnosis at birth but then really you
have to repeat the studies at 4 months of age to be absolutely
sure that you have made the correct diagnosis. Certainly these
are children, just a small segment of the population, but these
are children that the care in the first year of life really
will determine how well they do and it is not a case of how
well they do but whether they live or die and I think that it
would be horrible to go backwards on all the strides we have
made in medicine for this group of children.
Senator Corzine. Let me ask sort of a medical question. Is
it typical that children have all their immunizations applied
in the first 3 months?
Dr. Bucciarelli. No. In fact, at that point we are just
beginning to get into the immunizations that would go on. Most
of the primary immunizations are done at the end of the first
year but even after that there are other immunizations that are
important. So that continuous coverage, continuous eligibility,
is critical to make sure children do get the series of
immunizations they need and that they get them on time.
Senator Corzine. Thank you, Mr. Chairman. I think we see
some of the reasons why this is so important.
Senator Bingaman. Well, thank you very much.
Let me just ask another question or two here and then if
either Senator Lincoln or Senator Corzine have more, we will
obviously hear those.
I wanted to put up a chart that is very hard for anyone to
read from the back of the room. If you can read that, we
certainly will give you some kind of award. I have given each
of the witnesses a copy of this. What we have tried to do here
is to set out aspects of the regulation, first of all, and then
of the legislation, as well, in several areas where we think
the legislation provides coverage and provides benefits that
the regulation does not. I wanted to just mention what those
are.
Obviously coverage of prenatal care and labor and delivery,
that is clearly covered under our legislation. The coverage is
mixed, as we have discussed here, under the regulation.
Coverage of postpartum care is clearly covered under the
legislation, not covered under the regulation by its own
language. Prohibition on waiting periods for pregnant women,
that again we have made provision in the legislation to ensure
that there are no waiting periods involved. Obviously if you
are pregnant you need care; you do not need to wait 6 months or
a year.
Prohibition on cost-sharing for pregnant women. Again we
have made it clear in the legislation that states would not be
permitted to require any cost-sharing. And then this issue
about whether or not the child would be eligible for coverage
or covered for the first 12 months of life and we think that is
an important benefit of the legislation.
Finally, the one Dr. Green has mentioned here and Dr.
Bucciarelli I think maybe, as well, that our legislation does
provide funds. We have identified ways to fund this additional
coverage, which I think should be a substantial benefit to
states because no such funding is provided in the regulation.
Let me just ask again on this waiver issue, it strikes me
as sort of perverse that we are saying to states, which I think
is the administration's position--I had a conversation frankly
with Deputy Assistant Secretary Claude Allen on the phone where
his position was if states want to provide this coverage to
pregnant women, it is not a problem; they can just seek a
waiver.
It strikes me first of all that it is a little perverse to
have a legal structure where if you want to provide coverage to
pregnant women you have to get a waiver; the provisions of law
that normally apply need to be waived. This is not an
experimental kind of a program, as I understand it. I mean we
are pretty clear that these benefits are real; they have been
real for a long time.
The regulation says the secretary's ability to intervene
through one mechanism--that is, a waiver--should not be the
sole option for states and may, in fact, be an inferior option,
which I think is certainly a clear statement, a correct
statement. Then it says waivers are discretionary on the part
of the secretary and time-limited while State plan amendments
are permanent and subject to allotment neutrality.
I would also just point out for the record here that the
National Governors Association is on record. They have issued a
policy that states, ``The governors call on Congress to create
a State option that would allow states to provide health
coverage to income-eligible women under SCHIP. This small shift
in Federal policy would allow states to provide critical
prenatal care, would increase the likelihood that children born
to SCHIP mothers would have a healthy start.''
So I do not know if any of you have other comments on this
notion that the waiver is a good option. It does not strike me
as a very good option for states to go in and say please waive
the applicable laws and let us cover pregnant women.
Have any of you focussed on that to any greater extent than
this? No one seems to--Ms. Bernstein, did you have any comment?
Ms. Bernstein. I was going to say that I think if you did a
survey of middle class mothers across the country, they all
think that prenatal care is paid for for everyone. I think that
most people in this country who do not live in fear of getting
health coverage have no idea that we turn people away every
day. The thought of a waiver is that same way of thinking. This
is a right. Prenatal care should be something that is provided
for in this country and to have to get a waiver to be allowed
to do it is bad wording. It is embarrassing, I think.
Senator Bingaman. Well, I thought the wording in your
testimony to the effect that fetal care involves throwing the
parent out with the bath water, I thought that was a good way
to put it.
Ms. Bernstein. Thank you.
Senator Bingaman. Let me call on Senator Lincoln for any
additional questions she has.
Senator Lincoln. Thank you, Mr. Chairman.
Dr. Green, following on that question, I think it is
interesting. I kind of wanted to find out where the March of
Dimes was and how active they are at the State level or are
there any plans to be active to encourage states to expand
coverage to pregnant women in what we have talked about here? I
mean we know that the waiver--I agree with the chairman that
the waiver process and what we are talking about there is
pretty counterproductive to what we really want to be doing but
it is an option that if you are faced with, whether you use the
regulation that the administration is giving us or you go for
the waiver, which is the most productive to encourage states to
go toward?
Dr. Green. Well, the March of Dimes has a chapter, at least
one chapter in every State, in Puerto Rico and in the District
of Columbia and I think that you are aware, Senator Lincoln, of
the energy emanating from these chapters at the State level
with respect to advocacy.
Senator Lincoln. Absolutely.
Dr. Green. So I think that the March of Dimes is active in
this program on two levels. One is certainly if states did not
have the option to expand SCHIP to encompass pregnant women,
then our chapters would be very active in trying to help those
State legislatures to apply for this waiver program.
Senator Lincoln. If they do not have S. 724.
Dr. Green. If they did not have S. 724, exactly. As you
have heard, it would be enormously expensive in terms of
resources, time, energy. In fact, we would prefer to have
passage of S. 724 so that we can focus our attention on another
level of this kind of issue, namely getting parents, getting
women, getting children enrolled in the programs that already
exist because, as we have heard in the news, many states do not
have complete implementation of their SCHIP program because
families do not know about it, there are lots of barriers,
language, literacy, logistics.
So our chapters are prepared to help states apply for
waivers but we would really rather help the communities get the
coverage that they deserve. We will do both if we have to.
Senator Lincoln. Right. But what I am hearing you say is
that if you have the choice--if the legislation that we are
talking about today is not made into law and states are not
given that option to make that choice, then the March of Dimes
would not encourage states to take up the option of covering an
unborn child. They are going to encourage states to take the
more difficult option because it is more comprehensive, because
you know that the outcome for the child, for the mother, for
the family, for the community and the Nation are all going the
be better if we get more comprehensive care.
Dr. Green. That is absolutely right, that access to
coverage for children and pregnant women is one of our major
foundation priorities, so we will certainly work with states to
apply for those waivers and we applaud Colorado for their
slogging through the process.
Senator Lincoln. Just one comment, Mr. Chairman, and I will
be finished. There has been a lot of talk about the
availability and the knowledge, the education of people about
what is available. We did try a couple of years ago with some
legislation which we did pass to try and make the SCHIP program
a little bit more available in the sense that we could
publicize it and get better ways of getting the message out
there, whether it is one-stop shopping or making sure that we
have brochures and information out there in the appropriate
places, like pediatricians' offices or in other places, as
well, in our DHS offices and other things.
So we have tried to do some of that but if you have other
suggestions, please let us know because we do not need to stop
there. We know we have not completed what we need to do, but we
have made an initial step. So I would encourage you to continue
that dialogue with us.
Thank you, Mr. Chairman.
Senator Bingaman. Well, thank you and again thank all of
the witnesses. I think it has been very useful testimony and we
will obviously have an opportunity when Congress comes back
into session once again to pass this legislation. I know
Senator Lincoln and I and Senator Corzine and Senator Bond will
be making that effort again and we hope that we can succeed
with the legislation before Congress adjourns.
Thank you very much and that will conclude the hearing.
[Additional material follows:]
ADDITIONAL MATERIAL
Prepared Statement of Nancy Green, M.D.
Mr. Chairman, I am Nancy Green and I am the Medical Director for
the March of Dimes Birth Defects Foundation. I am pleased to be here
today to discuss with you the importance of providing all pregnant
women access to health insurance coverage and a comprehensive set of
maternity services. I want to salute you, Mr. Chairman, and seventeen
of your colleagues for sponsoring legislation that would give states
the option of covering income eligible pregnant women 19 and older
through State Children's Health Insurance Programs (SCHIP). We would
like to especially thank Senators Bond, Lincoln and Corzine who
recently joined you on the Senate floor to discuss the need for S. 724.
President Franklin Roosevelt established the March of Dimes in 1938
to fight polio. The March of Dimes committed funds for research and
within 20 years Foundation grantees were successful in developing a
vaccine to prevent polio. The March of Dimes then turned its attention
to improving the health of children through the prevention of birth
defects and infant mortality. As you might expect, providing coverage
to both pregnant women and infants is a policy priority and especially
pertinent to the advancement of our mission because in January we will
launch a $75 million multi-year campaign to address the growing problem
of prematurity.
Today, the Foundation has more than 3 million volunteers and 1,600
staff members who work through chapters in every state, the District of
Columbia and Puerto Rico. We are a unique partnership of scientists,
clinicians, parents, business leaders and other volunteers and we work
to accomplish our mission by conducting and funding programs of
research, community services, education and advocacy.
At the March of Dimes, our overarching goal is to improve the
health of mothers and children. This is why we are so concerned about
improving access to health coverage for pregnant women and their
newborns.
the problem of the uninsured
Mr. Chairman, lack of health coverage continues to be a significant
problem for many Americans. The Census Bureau recently reported that 41
million Americans were uninsured in 2001. Particularly troubling,
Census Bureau data commissioned by the March of Dimes show that in
2001, 11.5 million women (18.7 percent) or nearly one in five women of
childbearing age (15-44) went without health insurance a higher rate
than other Americans under age 65 (15.8 percent). That is, some 28
percent of uninsured Americans are women of childbearing age. Hispanic
women in this age group are almost three times as likely as whites to
be uninsured 38 percent compared to 13 percent respectively. Native
American (30 percent), African-American (23 percent) and Asian (20
percent) women were also likelier than whites to be uninsured. New
Mexico (32 percent) and Texas (28 percent) had the highest rates of
uninsured women of childbearing age for the 1999-2001 period according
to the U.S. Census Bureau, compared with a U.S average of 18 percent
for these years.
Since the mid-1980's expanded Medicaid eligibility for pregnant
women has resulted in better rates of coverage for them than for women
in general. The Congressional Budget Office, citing in part March of
Dimes supported research, estimates that about 1.7 million pregnancies
are covered each year by Medicaid. But as the data indicate,
considerable room for improvement remains.
health insurance makes a difference
Numerous studies have shown that having insurance coverage affects
how people use health care services. In particular, the uninsured are
less likely to have a usual source of medical care and are more likely
to delay or forgo needed health care services.
In a report issued earlier this year by the Institute of Medicine,
researchers concluded that ``[L]ike Americans in general, pregnant
women's use of health services varies by insurance status. Uninsured
women receive fewer prenatal care services than their insured
counterparts and report greater difficulty in obtaining the care that
they believe they need. Studies find large differences in use between
privately insured and uninsured women and smaller differences between
uninsured and publicly insured women.'' A study funded by the March of
Dimes and cited by the Institute of Medicine in its report shows that
some 18.1 percent of uninsured pregnant women in 1996 reported going
without needed medical care during the year in which they gave birth.
That compares with 7.6 percent of privately insured pregnant women and
8.1 percent of pregnant women covered by Medicaid.
Mr. Chairman, we know pregnancy represents a significant cost to
young parents. These families, many of whom work in small businesses
that don't provide health insurance, face significant costs even with
the healthiest pregnancies, and for families with a problem pregnancy,
the financial impact can be devastating. Without access to health
insurance, many pregnant women will delay seeing a doctor and getting
the prenatal care they need. As the report that accompanied legislation
passed by the Senate Committee on Finance stated, ``[R]ecent studies
have shown that infants born to mothers receiving late or no prenatal
care are more likely to face complications which can result in
hospitalization, expensive medical treatments, and increased costs to
public programs. Closing the gap in coverage between mothers and their
children will improve the health of both, while reducing costs for
taxpayers.''
The March of Dimes' objective is to reduce the number of uninsured
pregnant women and children and to improve access to medical care. As
you know, the March of Dimes supports elimination of any income
eligibility disparities between mothers and newborns. To meet this
objective, the Foundation has worked throughout this Congress to obtain
support for a modest, incremental step to help improve access to health
services for uninsured pregnant women by amending SCHIP. We support
giving states the flexibility they need to cover income-eligible
pregnant women age 19 and older, and to automatically enroll infants
born to SCHIP-eligible mothers. By establishing a uniform eligibility
threshold for coverage for pregnant women and infants, states will be
able to improve maternal health, eliminate waiting periods for infants
and streamline administration of publicly supported health programs.
Currently, according to the Department of Health and Human Services'
Centers for Medicare and Medicaid Services and the National Governors'
Association, 36 states and the District of Columbia have income
eligibility thresholds that are more restrictive for women than for
their newborns. Encouraging states to eliminate this disparity by
allowing them to establish a uniform eligibility threshold for pregnant
women and their infants should be a national policy priority.
Mr. Chairman, in January and on several occasions throughout the
year, we were pleased that on behalf of the administration HHS
Secretary Thompson endorsed legislation to achieve this important
objective. However, the March of Dimes is disappointed to learn that
the administration has apparently withdrawn its support for legislation
and instead will rely on a regulation issued on October 2, 2002 that
permits states to cover unborn children. Specifically, we are deeply
concerned that final regulation fails to provide to the mother the
standard scope of maternity care services recommended by the American
College of Obstetricians and Gynecologists (ACOG) and the American
Academy of Pediatrics (AAP). Of particular concern, the regulation
explicitly states that postpartum care is not covered and, therefore,
federal reimbursement will not be available for these services. In
addition, because of the contentious collateral issues raised by this
regulation groups like the March of Dimes will find it even more
difficult to work in the states to generate support for legislation to
extend coverage to uninsured pregnant women. We agree with the
Secretary about the value of prenatal care to achieve healthy birth
outcomes. In fact, as recently as January 31, 2002, Secretary Thompson
has said that ``[P]renatal care for women and their babies is a crucial
part of the medical care every person should have throughout the life
cycle. Prenatal services can be a vital, life-long determinant of
health, and we should do everything we can to make this care available
for all pregnant women. It is one of the most important investments we
can make for the long-term good health of our nation.'' We couldn't
agree more. When a new mother goes home following delivery, the March
of Dimes wants to be sure that she is healthy enough to support
herself, to breast feed and care for her newborn, and to participate
fully in her family's life.
solutions
Mr. Chairman, you and your Finance Committee colleagues approved S.
724, the ``Mothers and Newborns Health Insurance Act of 2002,'' in
early July and similar legislation is pending in the House of
Representatives. By including important provisions from your bill, S.
1016, the ``Start Healthy, Stay Healthy Act,'' the Finance Committee-
approved legislation would accomplish these important policy
priorities. By doing so it would bring the SCHIP program into alignment
with every other federal health insurance program all of which extend
coverage to pregnant women and their babies.
The provisions of S. 724 that are particularly important to
advancing the mission of the March of Dimes are:
1. Allowing states the flexibility to extend SCHIP coverage to pregnant
women 19 and older.
States would be able to receive federal financing to help provide
health coverage for income-eligible pregnant women. No waiting period
would apply for participation in the program, and coverage of the
mother would extend for at least two months following the birth of the
child the postpartum coverage timeframe recommended by the American
College of Obstetricians and Gynecologists (ACOG) and the American
Academy of Pediatrics (AAP). Estimates of the annual impact of this
change in law suggest that some 30,000 to 40,000 uninsured pregnancies
could be covered.
2. Automatically enrolling newborns whose mothers are enrolled in SCHIP
and 12 month continuous coverage
Automatic enrollment of newborns is important to avoid gaps in
coverage for medically vulnerable infants. Enrollment of infants born
to mothers eligible for SCHIP should begin the moment the child is
born. This is especially important when a baby is premature, has a
birth defect, or is in other ways medically fragile. In addition to
automatic enrollment in SCHIP, newborns would remain enrolled in the
program for one year. Many of these newborns would be eligible for
coverage under current law, but often are not enrolled on timely basis.
S. 724 establishes continuity of care for infants by guaranteeing
coverage for the first year of life when access to health care services
is particularly important for a healthy start in life.
3. Outreach Improvements
In addition to the positive effects of enrolling pregnant women in
SCHIP, S. 724 includes provisions to improve outreach. Research and
state experience suggests that covering pregnant women is a highly
successful outreach mechanism for enrolling older eligible children.
Several states have found that expanding coverage to uninsured parents
results in increased enrollment of eligible children (including
California, Illinois, Kentucky, Nevada, Rhode Island, and Wisconsin).
conclusion
At the March of Dimes we believe that improving access to health
care for uninsured pregnant women and their infants should be a
national priority. S. 724 has broad bipartisan support in both Houses
of Congress and the National Governors' Association has called on
Congress to give states this option. In addition, twenty-six national
organizations have endorsed this initiative. In short, Mr. Chairman, S.
724 would give us, and other organizations committed to improving the
health of women and children, the opportunity to work in states across
the country to expand access to comprehensive maternity services as
recommended by obstetricians and pediatric practitioners.
Once again, on behalf of the March of Dimes thank you for your
commitment to improving the health of children and their families and
for this opportunity to testify on the issues of critical importance to
pregnant women and infants.
I would be pleased to answer any questions the Committee may have.
Prepared Statement of Laura E. Riley, M.D.
Thank you, Mr. Chairman, and members of the Senate Health,
Education, Labor and Pensions Committee, for holding this important
hearing. As an obstetrician-gynecologist, I welcome the opportunity to
speak with you this morning on behalf of the American College of
Obstetricians and Gynecologist's (ACOG) 45,000 partners in women's
health care. I look forward to discussing measures that will increase
access to medical services for pregnant women.
I would like to also specifically thank Senators Bond, Bingaman,
Lincoln and Corzine, and others, for their strong leadership on the
issue of uninsured pregnant women. Your efforts to enact meaningful
legislation are deeply appreciated.
My name is Dr. Laura Riley, and I am Assistant Professor of Ob/Gyn
at Harvard Medical School and the Medical Director of Labor and
Delivery at Massachusetts General Hospital in Boston. I also chair the
Committee on Obstetric Practice at ACOG. I am pleased and honored to
speak before the Committee today on an issue that is near and dear to
me.
The focus of today's hearing is to discuss how being uninsured can
impact maternal and infant mortality. For uninsured pregnant women,
going without needed prenatal and postpartum services can have
devastating and lasting effects on both the mother and fetus. I have
seen firsthand the consequences of women whose first visit to a
physician is in the emergency room upon delivery. I have also seen the
effects of severe postpartum complications on the health of the mother,
conditions which, unfortunately, disproportionately affect minority
women. Many of these conditions could have been reduced or prevented
had a physician seen them early in their pregnancy. By assuring
insurance coverage, and increasing access to prenatal care and
appropriate postpartum services, we can reduce complications. I believe
passage of Senate Bill 724, the ``Mothers and Newborns Health Insurance
Act of 2001,'' would help us achieve this goal.
ACOG strongly supports S. 724, a bipartisan, comprehensive bill
that extends coverage to pregnant women, introduced last year by
Senators Christopher ``Kit'' Bond (R-MO) and John Breaux (D-LA) and
supported by a number of Senators, including Jeff Bingaman (D-NM) and
Blanche Lincoln (D-AR). S. 724 permits states to expand health coverage
to pregnant women, enabling them to have full access to a range of
services, including comprehensive prenatal and postpartum medical
services, that promote healthy pregnancies and deliveries and healthy
babies. We urge the Senate to quickly pass this legislation.
ACOG has long recognized that a full spectrum of health services is
necessary to ensure uneventful pregnancies, healthy deliveries, and a
postpartum period free of complications. Recommendations for care are
spelled out in Guidelines for Perinatal Care, Fifth Edition, which was
developed jointly by ACOG and the American Academy of Pediatrics.
Guidelines provides a description of the components of prenatal and
postpartum care that are important to both the fetus and the pregnant
woman. If we can pass S. 724, we can deliver this care to many
underserved and uninsured women and reduce instances of morbidity and
mortality.
new schip regulation
Recently, the Department of Health and Human Services (HHS) issued
a regulation that allows states to provide prenatal care and delivery
benefits under the State Children's Health Insurance Program (SCHIP) to
mothers and fetuses regardless of the mother's immigration status. We
appreciate the Administration's interest in expanding prenatal coverage
to uninsured pregnant women. Increased access to prenatal services is
essential in our fight to reduce maternal and infant mortality. There
is no question that as a nation we must do better to address this
incidence.
The Administration recognizes that prenatal care is essential to
ensure healthy pregnancies, however the regulation's approach to
achieve this goal is a cause for concern. In particular, ACOG has
several principle concerns with the rule. We hope to work with both
Congress and the Administration to address these issues.
postpartum care critical
ACOG is very concerned that mothers will not have access to
postpartum services under the regulation. The rule clearly states that
``care after delivery, such as postpartum services could not be covered
as part of the Title XXI State Plan because they are not services for
an eligible child.''
The regulation also revises the definition of ``child'' under SCHIP
to clarify that ``an unborn child including the period from conception
to birth may be considered a `targeted low-income child.' '' Limiting
coverage to the fetus instead of the mother omits a critical component
of postpartum care that physicians regard as essential for the health
of the mother and child. Covering the fetus as opposed to the mother
also raises questions of whether certain services will be available
during pregnancy and labor if the condition is one that more directly
affects the woman.
The best way to address this coverage issue is to pass S. 724,
supported by Senators Bond, Bingaman and Lincoln and many others, and
which provides a full range of medical services during and after
pregnancy directly to the pregnant woman. Early access to prenatal care
can help determine if a mother is at risk, but comprehensive follow-up
care is also vital to avoid further complications. Pregnancy can
sometimes signal the onset of new conditions such as diabetes or
hypertension that require careful attention to the mother and child.
When new mothers develop postpartum complications, quick access to
their physicians is absolutely critical.
Postpartum care is especially important for women who have
preexisting medical conditions, and for those whose medical conditions
were induced by their pregnancies, such as gestational diabetes or
hypertension, and for whom it is necessary to ensure that their
conditions are stabilized and treated. A wide range of diseases may
affect the mother during and after pregnancy, such as cardiac disease,
pulmonary embolism and renal disease; postpartum monitoring is critical
is these cases.
Women can go home well and return with problems. I recently treated
a 20-year-old Hispanic woman eight days after an apparently
uncomplicated delivery. She complained of two days of headache; she had
a blood pressure of 200/115 and, upon arrival at the hospital suffered
a seizure. Another 28-year-old woman had an emergent cesarean delivery.
She went home and returned later with fever and abdominal pain. She
remained in the hospital for 13 days on intravenous antibiotics to
treat bacteria in her blood. She was in too much pain to bond with her
baby for the first three weeks of its life. There are many more
stories, some even more tragic.
We at ACOG believe that it is unrealistic to exclude the mother and
provide services solely to the fetus. It is impossible to separate
mother-baby pairs and expect a good outcome for either of them.
women at risk will there be coverage?
According to the Centers for Disease Control and Prevention (CDC),
``each day in the United States, two to three women die of pregnancy
complications.'' The CDC further notes that ``childbirth remains the
most common reason for hospitalization in the United States, and
pregnancies with complications result in more costly hospitalization.''
Half of all maternal deaths in this country might be prevented through
early diagnosis and appropriate medical care of pregnancy
complications.
African American women, Hispanic women who have immigrated to the
United States, and American Indian and Alaska Native women are at
greatest risk for maternal mortality. CDC statistics note that African
American women are four times as likely to die of pregnancy
complications compared with white women, and American Indian and Alaska
Native women are nearly twice as likely to die. In a 14-year national
study of pregnancy-related deaths in the United States, CDC found that
the pregnancy-related mortality ratio for African American women was
25.1 deaths per 100,000 live births, and Hispanic women was 10.3 deaths
per 100,000 live births, versus 6.0 per 100,000 deaths for non-Hispanic
white women. Poverty and lack of insurance certainly play a significant
role in these alarming statistics.
The Administration is right to target prenatal coverage to reduce
these figures. For many women, especially minority women, however,
complications also arise after giving birth. And the truth is,
postpartum women without health insurance are more likely to go without
care because of economic priorities. The other truth is, sick women who
recently delivered are less able to care for their babies. In this way,
a lack of postpartum care harms mothers and their newborns. The
regulation's omission for postpartum coverage will disproportionately
affect the very women that need the most help and who experience the
highest rate of maternal morbidity and mortality.
As we have stated before, prenatal and intrapartum services are
essential. It is inconceivable that there are diseases that affect the
mother principally and that have no overall affect on the fetus.
Diseases such as diabetes and hypertension clearly have defined fetal
effects. Maternal obesity, which requires nutrition counseling,
behavioral interventions, and anesthesia consultation is not a health
condition limited to the mother. Another patient of mine at 32 weeks
pregnant arrived in the emergency room clutching her head with pain and
developed confusion over time. A CT scan revealed a large brain tumor.
Yes, this is a maternal condition but you can imagine that the effects
of neurosurgery and postoperative pain management all had an impact on
her developing fetus.
implementation concerns
Finally, ACOG also has several concerns about the implementation of
the Administration's regulation and the impact it will have on ob-gyn
practices. Already, the health care system prevents physicians from
spending needed time with patients. Skyrocketing medical liability
premiums, onerous regulatory paperwork, and continued Medicare payment
cuts make everyday practice an endeavor for most physicians. This
regulation will create even more bureaucracy and red tape for
physicians.
As in the last example, figuring out which components of a
patient's care would be covered by such restrictive services would be
an impossible task. Because this regulation limits coverage to services
directly related to the health of the fetus, ob-gyns will be unsure
whether medically necessary care will be covered. In most cases,
physicians will simply provide the care and worry after the fact about
coverage issues, knowing that a tremendous amount of staff time and
effort will be expended to recover even some payment. Furthermore,
pregnant women may wonder if they even have the ability to access
coverage for non-obstetric conditions or injuries, and decide to simply
not seek any treatment. This uncertainty about coverage will discourage
physicians from participating and deter women from seeking appropriate,
necessary care.
enact s. 724
I urge the Senate to quickly pass S. 724 and encourage the
Administration to support enactment of this bill to expand coverage to
uninsured pregnant women ensuring access to comprehensive prenatal and
postpartum coverage. The recently issued regulation, while misdirected
in its approach, creates a policy foundation that makes prenatal care
and healthy babies a priority. We urge Congress to take the next step
and pass S. 724, assuring women's health and their babies healthy
lives.
Prepared Statement of Cristina Beato, M.D.
Mr. Chairman and Senator Gregg, I want to thank you for accepting
our request to include a statement for the record. The Secretary has
asked that I serve as the Administration's witness at hearings covering
women's health issues of this nature, and the following is my prepared
statement.
I would also like to take this opportunity to recognize the members
of the Senate Health, Education, Labor and Pensions Committee for their
continued interest in addressing the needs of low-income pregnant women
and their children. Like their colleagues on the Finance Committee,
they have demonstrated a clear concern that women and children receive
the best this country can offer in the way of health care, and we think
they should be commended for that.
As Congress and this committee seek input and explore ways to
address the lack of insurance for many pregnant women, I want to re-
emphasize HHS' commitment to implement policies that will provide more
women coverage for a healthy pregnancy and safe delivery. The health of
pregnant women and a healthy start for their children is certainly a
goal we all share and that we are all working toward in our respective
roles in government. I want to give some examples of some of the
avenues we are exploring through administrative authority.
Current law gives HHS the authority to provide prenatal and
delivery care to many low-income pregnant mothers and their unborn
children. The Secretary has exercised that authority and, after
conducting a thorough regulatory process, including a public comment
period, a final rule has been published that will allow states to
extend S-CHIP coverage to unborn children and their mothers. The rule
will ensure that pregnant women and children who are currently
ineligible for health care under either Medicaid or S-CHIP are given
the support they need for a healthy pregnancy and delivery. All
children deserve a healthy start in life, and this rule is one more
option states have to fulfill that promise to low-income mothers and
babies.
Under the regulation, we are able to reach a broad population of
vulnerable women and children because we can offer coverage to the
children of immigrants who are otherwise ineligible for any coverage.
The legislative proposal S. 724 would not reach this broader population
of low-income women and children.
A point of consistency across the legislative proposals and the
Administration policy is that the benefits, and hence services covered,
(prenatal and pregnancy related services) are the same, excluding
postpartum care after hospitalization. While eligibility for these
benefits extends through the child rather than the mother under the
rule, the benefits and services covered remain the same. The concern
that mothers would not receive care while still hospitalized
immediately following delivery is addressed in the published rule's
comment and response section, and has again been addressed in
correspondence with Congress and in discussions with key stakeholders
in the effort to improve the health of mothers and children.
The regulation also affords states the opportunity to access
enhanced-match funds without conditioning this access on any
eligibility expansions at the regular match rate. Again, the pending
legislative proposals would condition access to enhanced-match funds
for some states. And, since states already have the option to raise
eligibility at their regular match rate and have not chosen to do so,
we believe the regulation provides them the opportunity to cover more
low-income pregnant women.
In fact, President Bush's fiscal year 2003 budget proposed to
strengthen the SCHIP program by making available to states unused SCHIP
funds that otherwise would return to the federal treasury. The SCHIP
law originally required that states that did not use their full SCHIP
allotment during the previous three years return the unused funds.
Under the President's plan, these unused funds would be made available
for states nationwide to expand coverage to the uninsured, especially
those at the lowest end of the income scale. Congress can be a partner
in this initiative by enacting at least this component of the
Administration's budget.
Adopting the President's proposal on unused SCHIP funds would not
only complement this new rule, but many of the other initiatives in the
Administration's larger effort to give mothers and children a healthy
start and help those who cannot afford health insurance get the health
care that they need. Already, the Administration has made unprecedented
strides in assisting states to expand health care services.
Since January 2001, HHS has approved waivers and plan amendments
that have expanded eligibility to more than 2 million people and
enhanced services for 6 million Americans. In August 2001, Secretary
Thompson launched the Health Insurance Flexibility and Accountability
(HIFA) Initiative to encourage states to expand access to health care
coverage for low-income individuals through Medicaid and SCHIP
demonstrations. The initiative gives states more flexibility to
coordinate these companion programs and offers simplified applications
for states that commit to reducing the number of people without health
insurance. Seven states have approved HIFA waivers: New Mexico,
California, Arizona, Maine, Illinois, Colorado and Oregon.
For example, New Mexico's HIFA demonstration will cover uninsured
parents of Medicaid and SCHIP children, as well as childless adults, in
partnership with employers in the State. Up to 40,000 currently
uninsured individuals may be covered under the demonstration with a
projected implementation date of February 2003. This waiver includes
coverage for prenatal care, labor and delivery and postpartum care.
California's HIFA waiver will cover up to 275,000 parents, relative
caretakers and legal guardians. Arizona expects to expand coverage for
up to 48,000, and Illinois expects 300,000 additional parents will be
covered. Colorado's HIFA demonstration expands coverage to 13,000
uninsured pregnant women. In addition, through the Administration's
Pharmacy Plus Model Waiver Initiative, states are able to expand drug
coverage to low-income seniors and people with disabilities. Five
Pharmacy Plus waivers Florida, Illinois, Maryland, South Carolina and
Wisconsin have been approved so far.
Again, while waivers often result in the expansion of coverage for
health benefits and services, the Administration also has programs that
help communities provide health services to low-income women directly,
including prenatal and pregnancy related care. Most of these services
are administered by the Health Resources and Services Administration
(HRSA) and, in particular, the Maternal and Child Health Bureau (MCHB).
Programs supported through Title V of the Social Security Act (the MCH
Block Grant) provide gap-filling prenatal health services to more than
2 million women each year.
In addition, in FY2001, the Healthy Start program funded 106 grants
to communities with a total of $90 million to improve perinatal health
and improve prenatal care among at-risk populations. In FY2002, Healthy
Start was able to extend services further by funding an additional 12
sites in high-risk communities, expanding outreach, case-management,
and preventive health services.
The MCHB has also begun new programs focusing on reducing risk
factors for adverse outcomes during pregnancy, especially among
vulnerable women. This includes screening for tobacco use, domestic
violence, alcohol use, depression, and substance abuse then referring
as needed.
HRSA-supported Community Health Centers serve more than 3 million
women of childbearing age and provide primary care services, including
prenatal, delivery, and postpartum care, for low-income women who are
likely to lack access to health insurance or other sources of care.
Funding for Community Health Centers has been increased substantially
under a five-year expansion plan initiated by President Bush.
I hope this brief overview highlighting just some of the
initiatives this Administration has implemented and supported provides
a more comprehensive view of our commitment to improving the health of
low-income women and children. I believe that while undertaking a
balanced dialogue and delving into the substance of both the problems
that result when women and children lack access to health care and
current and proposed solutions, we should never lose sight of our
shared goal. On behalf of HHS, I hope that we can work together with
the many organizations that share our vision of a healthier beginning
for children to encourage states to expand coverage under SCHIP to
unborn children and their mothers.
There is still work to be done to meet our universal goal of giving
children a healthy start in life, and we look forward to continued
collaboration with Congress.
Prepared Statement of Lisa Bernstein
Mr. Chairman, members of the committee, I am honored to come before
you today to urge passage of S.724, the ``Mothers and Newborns Health
Insurance Act of 2001.''
First, I would like to tell you how I have come to be here and a
bit about why The What To Expect Foundation was formed.
The What To Expect Foundation takes its name from the bestselling
What To Expect pregnancy and parenting series that was written by the
Foundation's president, Heidi Murkoff and her mother, the late Arlene
Eisenberg.
This series of books has helped over 20 million families from
pregnancy through their child's toddler years. What To Expect When
You're Expecting is often referred to as ``America's Pregnancy Bible.''
According to a USA TODAY poll it is read by 93% of all mothers that buy
a pregnancy guide the What To Expect series of books are not only the
three bestselling parenting books in the country--they are among the
bestselling books in the country on any topic This week What To Expect
When You're Expecting is #3 on the New York Times bestseller list.
But I'm sorry to say, as many parents as the What To Expect books
have helped, they've missed many more. As you know, our nation's infant
mortality rate is higher than 28 other countries; we're right behind
Cuba. And even if a mother could afford to buy a prenatal guide she
might not be able to read it. The literacy rate in the United States is
a continuing problem. Today 21% to 23% of adults--or some 40 to 44
million people across the country read at less than a fifth grade
level.
Thus the birth of The What To Expect Foundation a non-profit
organization dedicated to helping mothers in-need receive prenatal
health and literacy education so they too can expect healthy
pregnancies, safe deliveries and--can read to their babies.
The BABY BASICS program provides prenatal education that takes into
account the special health, economic, social and cultural needs of low-
income women and gives prenatal providers culturally appropriate health
literacy tools and support.
By 2003 we will have provided over 200,000 women with the BABY
BASICS program in English and Spanish we are now building model BABY
BASICS health literacy sites at clinics across the country.
While researching the BABY BASICS book and program I had the
opportunity to speak to hundreds of pregnant, low-income women, and the
doctors, midwives, nurses, outreach workers, educators and social
workers that care for them.
From across the country I heard the pregnancy stories of our
country's poorest women some were stories about swollen feet,
indigestion, back pain. Others were about hopes and fears that cut
across income and education--will I be a good mother, will I know how
to hold a child? Will I be able to provide for my baby?
But too many of these stories broke my heart. Teens who were
pregnant because they wanted someone to love and to love them, women,
pregnant with no health insurance, who work long days for little
income, and had to take off unpaid time to sit in a hard chair for
hours waiting for an unscheduled 5 minute free appointment at a crowded
clinic. Women who saw a doctor for the first time the day their water
broke- because they could not afford care.
Secretary Thompson did an important thing and is to be
congratulated when he realized that many pregnant women could not
afford prenatal care. One look at the infant mortality rate, and he
looked for ways to fix it. He also realized that SCHP a dramatically
successful program for families had the funds and the ability to reach
out to help in our constant battle against infant and maternal
mortality. And I applaud him for finding a stop-gap measure that was
within his domain to help states provide pre-natal care quickly and
efficiently by extending the care to the fetus with an implicit
understanding that this was a quick-fix, one that would be remedied by
legislation.
Now, frankly, I'm confused. In his recent letters to you, Senators,
he seems to have changed his mind, saying such legislation is no longer
needed. His quick fix is enough.
But the quick fix put forward by the administration is not really a
fix at all. Because now we've created even more problems after we're
spent so much time and money promoting pre-natal care we've gone and
created an entirely new funded medical program--called ``fetal care''.
Because ``fetal care'' and ``prenatal care'' are not the same
thing. Please, let me tell you why.
Pre-natal care is about dignity. Fetal care is about shame.
This September, Secretary Thompson, Senator Kennedy, and Senator
Hatch, along with our Foundation's president, Heidi Murkoff, spoke at
Robert Wood Johnson's Covering Kids celebration, that honored SCHP's
5th anniversary. Mothers and fathers explained how Child Health Plus
helped their family. These were working families, with two jobs,
working double-shifts to keep their families afloat.
One family, suddenly unemployed, had no idea how they were going to
pay for their daughter's continuing diabetes care until they found
SCHP. Another hard working mother spoke about SCHP paying for surgery
that saved her boy's life.
These parents were heroes to their children, and to the audience.
With the help of SCHP they had provided for their families. Because
SCHP has been carefully crafted, marketed and promoted as help for
working families and children these parents were able to retain their
dignity, and were proud of their ability, as parents, to provide the
health care their child needed, when they needed it.
Just as offering pre-natal care to a woman can help her afford to
do the best for her unborn child. Its friendly help, that is offered
with dignity and can be accepted with pride.
Offering ``fetal care'' is a slap in the face. This new regulation
makes clear that fetal care is about the fetus first. ``Extras'' like
epidurals and pain medication will only be available if a case can be
made that they are for the health of the fetus. Fetal care offers the
mother no dignity, devaluing her life which she risks by sharing her
body with the unborn child.
Pre-natal care acknowledges that there are two things that grow
when a woman becomes pregnant. First, of course, there's the fetus,
growing to become a healthy baby. And second, and no less importantly,
there's the woman who also must grow she must grow to think of herself
as a mother a parent, a provider. Inextricably linked in a dance as old
as creation mother and child grow together--both nurtured with love and
care.
``Fetal care'' unbinds those ties--breaks those bonds. It's about
the government choosing fetuses over women, providing the fetus will
all of its health care needs while saying to the woman we can't help
you.
Pre-natal care provides a woman with the comprehensive health
coverage she needs to have a baby. It cares for her body and her
health. It helps her stay strong so she can be strong as a mother. It
provides for her needs before and after the delivery, and gives her the
chance to recover so she has the strength and the health to nurse her
precious new bundle.
``Fetal care'' tells mothers that once they've had the baby they're
on their own. Like Cinderella after the ball, once the baby is
delivered, no more fairy godmother. Suddenly her health care is gone.
No glass slipper. Even her 48 hours guaranteed hospital stay is out of
the picture.
Pre-natal care is about family values. It helps create parents. It
does what Early Head Start, Head Start, Healthy Start and Even Start do
so well it gives parents the strong shoulders they need to make sure no
child is left behind. It fosters optimism.
``Fetal care'' throws the parent out with the bathwater. It fosters
pessimism, and an early pervading sense of failure. From the start it
fails to acknowledge that a parent is a child's first and best teacher.
To me, ``fetal care'' fosters foster-care.
Pre-natal care fills hospital wards with healthy babies.
Fetal care fills hospitals with wards of the state.
Senators, so many good things can happen when a women gets proper,
comprehensive pre-natal care. As you've heard, The What To Expect
Foundation links prenatal care to literacy training. So women learn how
to read, and learn how to read to their babies. Healthy Start and other
programs across the country are linking prenatal care to all kinds of
positive, self-esteem building social programs. Parenting skills, job
training, long-term housing planning, financial planning.
We have trouble getting women into pre-natal care why would we ever
want to put up any barriers to pre-natal care? Secretary Thompson has
done an honorable thing by opening the door to pre-natal care for
thousands of women each year. But imaginary barriers, liberal barriers,
conservative barriers, unintended barriers? No matter what we want to
call these barriers regardless of their politics or their intent, they
are unnecessary barriers to care. I'm here to tell you that hundreds of
providers, practically every doctor, midwife and nurse across the
country agrees that this fetal care quick-fix must not stand as a
barrier. And every mother including this mother and the mothers who
have told millions of mothers across the country What To Expect agree--
Our job is to knock down the barriers. Passing S724 will remove those
barriers.
And then we can roll up our sleeves and get back to work. Because
only a healthy parent can provide a healthy future for a healthy child.
Prepared Statement of Kate Michelman
NARAL applauds the Committee for holding this hearing to highlight
the current lack of adequate health-care coverage for pregnant women
and children, and explore potential solutions.
NARAL's mission is to guarantee every woman the right to make
personal decisions regarding the full range of reproductive choices,
including preventing unintended pregnancy, bearing healthy children,
and choosing legal abortion. NARAL has 26 affiliates nationwide and
nearly 300,000 members and supporters. On behalf of our membership and
pro-choice Americans, NARAL submits this testimony to: (1) illuminate
what is at stake for reproductive rights by making embryos, not women,
beneficiaries of governmental health care programs and provide context
illustrating the dangers inherent in the Administration's chosen
course; and (2) advocate for greater coverage of pregnant women under
SCHIP's existing framework or new legislation such as that sponsored by
Senator Bingaman.
The Stakes and The Context. A woman's right to choose is in peril,
jeopardized by a fragile consensus on the part of the Supreme Court in
favor of legal abortion and an Administration determined to make use of
every power at its disposal to roll back women's reproductive freedom.
Up to now, the Bush Administration has been pursuing an incremental
campaign to denigrate and restrict a woman's right to choose. We have
seen the nomination of anti-choice judges for the federal district and
appellate courts, support for anti-choice legislation such as the Child
Custody Protection Act and the Unborn Victims of Violence Act,
Executive Orders attacking the reproductive rights of women around the
world, appointment of anti-choice officials to key cabinet and sub-
cabinet positions, statements of support for groups seeking the
overturn of Roe v. Wade, and the filing of a legal brief supporting
restrictions on a woman's freedom to choose. Dr. W. David Hager,
strongly credentialed in anti-choice activism, is the rumored favorite
to head the Food and Drug Administration's Reproductive Health Drugs
Advisory Committee. Health agencies from the Centers for Disease
Control and Prevention to the National Institutes of Health have begun
censoring their websites for material offensive to the ideology of the
hard right that is, material disproving anti-choice propaganda about
abortion, sex education, sexually transmitted diseases, and HIV
prevention.
Against this backdrop, this month the Administration took a
significant step towards its ultimate goal of making abortion illegal.
On October 3, 2002, the Bush Administration published a final rule that
would actually designate embryos and fetuses as ``children'' eligible
for medical benefits independent of the pregnant woman under the State
Children's Health Insurance Program (SCHIP) (42 C.F.R. 457 (2002)).
Under the joint federal/state SCHIP program, states provide health care
to low-income children who are not covered by the Medicaid program. The
Administration took this unorthodox course, notwithstanding the fact
that both SCHIP and Medicaid law allow states to cover more pregnant
women than would otherwise be eligible under the state's income limits
to ensure quality prenatal care.
Although the rule on its face does not change the status of legal
abortion, any challenge to Roe v. Wade that reaches the Supreme Court
will surely contend that an evolving legal trend recognizes fetuses as
persons. In support of this contention, opponents of Roe will point to
state legislation recognizing embryos and fetuses as persons in a
variety of circumstances, and this new SCHIP rule will be an essential
piece of evidence for their argument. The Administration's interim
strategy to prepare the way for a challenge to Roe is underway. To
protect the foundation of Roe v. Wade, NARAL thus opposes this rule
that distinguishes the embryo's or fetus' interests from those of the
pregnant woman.
In a more immediate sense, the new rule could actually do harm to
women by pitting them against the program's ``patients'' the embryos.
Under this regulation, would a pregnant woman with cancer be able to
access potentially life-saving radiation treatment or chemotherapy,
since such treatment could harm the embryo? The effects of many
prescription drugs on pregnancies have not been studied; under this
rule, a woman's treatment for any variety of medical conditions might
be denied, in favor of the embryo or fetus. If a woman were carrying an
embryo or fetus covered under this new proposal and she had a
miscarriage, there would no longer be a ``beneficiary'' for the SCHIP
program. Would the government then refuse to pay for her follow-up
care?
It is commonly understood as a matter of public health that healthy
women tend to have healthier babies, and as a legal matter that the
woman should make all decisions relating to her pregnancy. The rule
imposes a new paradigm separating the woman from her pregnancy, and
allowing a government health care program to work on behalf of the
fetus, without any reference to the woman herself. That is, the new
rule would not provide care for the woman only care for the fetus. A
woman's pre-existing conditions, such as diabetes or asthma, could
apparently only be treated if and to the extent that such treatment
would benefit the fetus. Doctors might well face confusion about basic
preventive or maintenance care for the woman would her medical
conditions only be covered when they worsened so as to jeopardize the
pregnancy? As a practical matter, then, this rule is either unworkable
or unethical, in setting up potential conflicts between the woman's
interests and fetal interests.
In an unexpected move, the Administration's rule also allows the
embryos and fetuses of immigrant pregnant women to be covered under
SCHIP. This creates a strange dichotomy because under current law,
legal immigrants cannot receive Medicaid or SCHIP benefits until they
have been in the country for five years. (Illegal immigrants do not
qualify at all.) As a legal matter, the regulation treats immigrant
pregnant women as if their embryos and fetuses were already born here
as citizens and were thus entitled to the full benefits of citizenry.
As a practical effect of this expanded concept of citizenship, the
three year-old daughter of a recently immigrated pregnant woman cannot
receive publicly funded health care, but the woman's fetus can. This
illustrates that the true nature of this rule is not to deliver health
care to children who need it for the three year old surely needs care
but to grant fetuses special legal rights.
In sum, the Administration's failure to address the many practical
problems with implementing this rule problems NARAL identified in our
comments opposing the proposed rule indicates that its SCHIP regulation
is not serious health-care policy; instead, it is a political statement
and a legal stratagem.
An alternative vision. NARAL has long supported initiatives to
provide prenatal care for pregnant women; indeed, the millions of
uninsured deserve comprehensive health care. Women planning pregnancy
and the children they bear benefit immensely from high-quality care,
and conversely, the chronic lack of access to a continuum of services
for low-income women jeopardizes the promise of healthy pregnancies and
healthy childbearing.
For many months, the Administration tried to play expanded health
care coverage both ways: it said it supported legislation expanding
SCHIP eligibility, while at the same time issuing the proposed (now
final) rule making embryos and fetuses federal health care
beneficiaries. The other shoe has now dropped. The Administration's
recent reversal, announcing that it no longer supports legislation
expanding SCHIP to cover pregnant women, must be met with determined
Congressional opposition. The Administration's about-face reveals that
its real goal is a legal and political one endowing fetuses with legal
rights and shoring up its ideological base rather than a substantive
policy goal. Moreover, as a matter of separation of powers and the
proper allocation of governmental responsibilities, the regulation is a
significant policy change, one that should be overridden by Congress.
NARAL urges Congress to enact legislation allowing states to expand
their SCHIP programs to pregnant women, which would effectively nullify
the regulation. The best way to assure healthy pregnancies and healthy
childbearing is to provide dependable, quality care for pregnant women,
and NARAL commends Senator Bingaman and others for their efforts in
this connection and continues to urge Congress' passage of legislation
that does so.
Congress must set the legal and political record straight: pregnant
women deserve health care coverage. Governmental agencies entrusted to
protect the public health cannot be misused as vehicles for advancing
an anti-choice political agenda to the detriment of Americans' health.
Prepared Statement of Priscilla Smith
The Center for Reproductive Law and Policy (CRLP) commends the
Committee for underscoring the rights of pregnant women to safe
pregnancy through this hearing and through the ``Mothers and Newborns
Health Insurance Act'' (S. 724). CRLP is a non-profit legal advocacy
organization dedicated to protecting and defending women's reproductive
rights, including the rights of pregnant women to safe pregnancy. CRLP
submits this testimony to support efforts to expand access to
pregnancy-related care through legislation such as the ``Mothers and
Newborns Health Insurance Act.'' This bill not only addresses a
significant gap in our nation's healthcare system, but also mitigates
the negative effects of misguided amendments to the State Children's
Health Insurance Program (SCHIP) recently adopted by the Department of
Health and Human Services.
i. ``mothers and newborns health insurance act'' addresses a
significant healthcare gap
Currently, the United States ranks twenty-first in the world in
rates of maternal mortality and twenty-eighth in the world in rates of
infant mortality. It is estimated that every week, 8,500 children in
the United States are born to mothers who lack access to prenatal care.
Furthermore, it is likely that half of all maternal deaths in the
United States could be prevented through early diagnosis and
appropriate medical treatment of pregnancy complications. This is
shocking given the availability of unsurpassed medical care and
technology in the United States and widespread knowledge of the
importance of early and ongoing prenatal care to help ensure a healthy
pregnancy and optimal birth outcome.
A primary barrier to timely prenatal care, and thus to improving
the health of pregnant women and newborns in the United States, is a
lack of health insurance coverage. Despite the Medicaid expansions
implemented in the late 1980s and early 1990s, recently released
figures from the March of Dimes indicated that nearly one in five women
of childbearing age (ages 15-44 years) in the United States were still
uninsured in 1999. See Kenneth E. Thorpe et al., The Distribution of
Health Insurance Coverage Among Pregnant Women, 1999, prepared for the
March of Dimes (Apr. 2001), available at http://www.modimes.org/files/
2001FinalThorpeReport.pdf (last visited Apr. 16, 2002). Thus, further
expansions are necessary to reach the uninsured.
Moreover, as this Committee and the Administration have recognized,
there is a troubling disparity in access to prenatal care between white
women and minority women. Rates of maternal mortality and morbidity and
infant mortality which are highest among non-white populations reflect
this disparity. While research suggests that racial and ethnic
inequalities in medical treatment would persist in some measure even if
access to health insurance were equalized, see Key Facts: Race,
Ethnicity, and Medical Care, The Henry J. Kaiser Family Foundation
(October 1999), it also appears that increased access to health
insurance coverage would reduce these disparities based on race and
ethnicity. Id.
Therefore, increasing access to health insurance coverage for
pregnant women is vital for two reasons. First, insuring access to
early and ongoing pregnancy-related care for women in all ethnic and
racial groups must be the first step in any efforts to reduce overall
rates of maternal mortality and morbidity, and to erase the disparity
between the quality of care received by women of color and white women.
Second, increased access to prenatal care will improve the health of
newborns throughout the country and similarly work to erase disparities
in infant mortality rates between racial and ethnic groups.
The ``Mothers and Newborns Health Insurance Act'' serves these
goals by increasing access to insurance coverage. The legislation
provides insurance coverage for prenatal care, delivery and post-partum
care to targeted, low-income pregnant women. The legislation also
provides coverage for newborns for their first year of life. Through
these provisions, S. 724 ensures better birth outcomes and healthier
mothers and children.
ii. the ``mothers and newborns health insurance act'' is far superior
to the new schip regulation amendments.
Unlike S. 724, the recent amendments to the State Children's Health
Insurance Program (SCHIP), promulgated by the Department of Health and
Human Services (HHS), fail to adequately address the overwhelming need
for healthcare coverage for pregnant women. Instead of extending
benefits to pregnant women, the new regulation classifies the fetus as
an ``unborn child'' and expands coverage to ``an individual in the
period between conception and birth up to age 19.'' 67 FR 61956-01
(Oct. 2, 2002). It is greatly disturbing that HHS has promoted
amendments to the SCHIP regulations to extend the plan to cover
fetuses, while patently ignoring the health needs of pregnant women.
This new policy is fraught with legal and practical problems:
The regulation could place the health of pregnant women at risk and
threatens a woman's integral right to control her own healthcare.
By defining a fetus as a ``child'' from the moment of conception
for purposes of SCHIP, the regulation is in clear tension with
fundamental principles of constitutional law.
Low-income pregnant women deserve actual, not merely incidental,
health insurance coverage that covers all of their pregnancy-related
needs.
There are superior means of ensuring prenatal care for women whose
incomes fall within the SCHIP-eligibility criteria in their state, such
as the ``Mothers and Newborns Health Insurance Act.''
CRLP has significant concerns with the new amendments, as outlined
below. CRLP urges Congress to enact the ``Mothers and Newborns Health
Insurance Act'' to address and remedy the significant gaps left by the
SCHIP program.
A. By Covering the Zygote, Embryo or Fetus and Not the Woman Herself,
the Regulation Could Place the Health of Pregnant Women at
Risk.
Although the Administration claims that the goal of the new
regulation is to provide for comprehensive prenatal care in order to
improve the pregnant woman's health, the mechanism chosen could
actually place the woman herself at risk. The regulation does not
provide any insurance coverage for pregnant women in the post-partum
period, nor does it provide for comprehensive care for pregnant women
during either pregnancy, or labor and delivery.
First, the standard of care for pregnant women requires continuity
of medical treatment from prenatal care through post-partum care. The
American College of Obstetricians and Gynecologists (ACOG) and the
American Academy of Pediatrics (AAP) recommend that the physical and
psychosocial status of the mother be assessed on an ongoing basis
following hospital discharge. They further recommend that four to six
weeks after delivery the mother should receive a post-partum review and
examination. American Academy of Pediatrics & American College of
Obstetricians and Gynecologists, Guidelines for Perinatal Care (4th ed.
1997).
Unfortunately, the regulation does not allow states to provide
SCHIP coverage to pregnant women for any post-partum care. This is
because under the regulation, SCHIP would cover only the ``child'' in
utero, not the pregnant woman. While the pregnant woman would
incidentally receive some covered care as a result of carrying the
``child'' within her uterus, that covered care would be available only
during ``the period from conception to birth.'' The moment after the
birth of her child, a woman who may have been covered for any
incidental care as a result of having an SCHIP-covered fetus in utero,
would appear to lose insurance coverage. The woman would therefore not
be eligible for any covered care during the post-partum period,
including for the post-delivery hospital stay, care for her incision
received during a Cesarean section delivery, for an episiotomy or any
other post-delivery complications. This result flies in the face of
sound medical and public health policy, not to mention the regulation's
stated goals.
In contrast, S. 724 provides coverage to pregnant women for post-
partum care, thus remedying this troubling omission.
Second, by insuring only the fetus, it is unclear whether the
regulation authorizes insurance coverage for pregnant women for medical
treatments that do not have a direct impact on the well-being of the
fetus. Thus, for example, if an epidural is needed during delivery,
would that be covered even though it would benefit only the woman, and
not the fetus? If the woman broke her leg during the pregnancy, would
treatment be covered? And, since eligibility for benefits only exists
in relation to a living fetus, it is unclear whether any benefits would
be available to the mother for complications following a miscarriage
technically, since the beneficiary is no longer alive, such benefits
would not be available. While we agree with the statement made by
Secretary Thompson regarding the importance of prenatal services as ``a
vital, life-long determinant of health'' for the fetus, HHS to Allow
States to Provide SCHIP Coverage for Prenatal Care, HHS News Release,
January 31, 2002, we believe that ensuring meaningful health benefits
for the pregnant woman is an equally important goal, and one that this
regulation fails to meet but that S. 724 directly addresses.
Third, targeting coverage to the fetus also appears to create
serious conflicts over health care decision making, all of which
threaten a woman's integral right to control her own healthcare. It is
unclear under the regulation how the interests of the fetus and the
pregnant woman should be balanced when their health care needs diverge,
or where treatments needed by the pregnant woman could actually be
harmful to the fetus. For example, a woman with mental illness may
require medications, such as lithium, that are contraindicated for the
fetus. See, e.g., Jennifer R. Niebyl, M.D., Drugs in Pregnancy and
Lactation, in Steven G. Gabbe, M.D., Jennifer R. Niebyl, M.D., Joe
Leigh Simpson, M.D., eds., Obstetrics: Normal and Problem Pregnancies
at 249, 255 (3d ed. 1996). Similarly, a woman diagnosed with breast
cancer may not be covered for radiation treatments needed to save her
life. Would the treatments in these cases be covered? Could the state
intervene on behalf of the fetus? What would happen if the life-saving
treatment was for the fetus, but it endangered the mother could the
mother be compelled to undergo the treatment? Who would decide these
types of coverage questions the state, the federal government, the
doctor, or the pregnant woman herself? Could the state or the other
parent's health care decisions trump the pregnant woman's, even where
her own health could be adversely affected? These are all troubling
questions that are raised by the regulation but that would not be
implicated by S. 724 since the legislation recognizes the pregnant
woman's right to healthcare.
B. This Regulation Seeks to Chip Away at Fundamental Principles of
Constitutional Law.
By defining a fetus as a ``child'' from the moment of conception
for purposes of SCHIP, the regulation is in clear tension with
fundamental principles of constitutional law. The Supreme Court clearly
stated in Roe v. Wade that ``[T]he word `person,' as used in the
Fourteenth Amendment, does not include the unborn,'' 410 U.S. 113,158
(1973). The Administration's impractical attempt to force the
definition of a child to include a fetus results in bizarre outcomes
and administrative confusion, revealing the Administration's true goal
of chipping away at fundamental rights. For instance, under current
law, states track eligibility for public benefits using Social Security
numbers, which all Americans receive when they are born. Since fetuses
are not eligible for Social Security numbers, it is unclear how states
will track their eligibility for benefits until they are born. Will
they create a whole new individual identifier just for fetuses? There
will be further implications for tax rules as well. Generally, an
American citizen is only counted for taxation purposes after they are
born. Does the granting of legal personhood under the regulation mean
that fetuses could be taxed inside the womb? Alternatively, could they
be claimed as a deduction before they are born? These examples
demonstrate the irrationality of this policy and the confusing results
it would generate.
Other Supreme Court cases, such as Planned Parenthood of
Southeastern Pennsylvania v. Casey, 505 U.S. 833 (1992) and Stenberg v.
Carhart, 530 U.S. 914 (2000) have emphasized the importance of
protecting women's health in the face of laws restricting access to
abortion. Because the regulation elevates the fetus' health to the
potential detriment of the woman's health, this conflict places the
regulation in further tension with Supreme Court precedent by
potentially jeopardizing the woman's health.
The regulation indicates that the Administration cares more about
promoting the ``rights'' of a fertilized egg with an eye to building
the legal foundation to overturn the Supreme Court decision in Roe v.
Wade, than it does about women's health. The best way to improve
women's health is to recognize their right and ability to make private,
medical decisions about their own bodies.
C. The Regulation Denigrates Women Without Achieving Its Purported
Goal.
Low-income pregnant women deserve actual, not merely incidental,
health insurance coverage that covers all of their pregnancy-related
needs, including those that extend into the critical post-partum
period. By providing insurance for the fertilized egg or fetus, but not
for the woman herself, this regulation denigrates women treating them
as mere vessels for a fetus, undeserving of health care in their own
right. Given the superiority of these alternative means of achieving
improved birth outcomes (see below), the Administration's decision to
promulgate the regulation--and inexplicably withdraw support for other
measures--must be seen as a political gambit, unrelated to improved
pregnancy-related care. It can only be seen as an ideologically-based
attempt to redefine a fetus as a ``person,'' in conflict with the
Supreme Court's ruling in Roe v. Wade, 410 U.S. 113 (1973) without
regard to whether health care coverage is actually increased.
D. There Are Superior Means of Ensuring Prenatal Care for Women Whose
Incomes Fall Within the SCHIP-Eligibility Criteria in Their
State, Including the ``Mothers and Newborns Health Insurance
Act.''
The regulation is all the more unacceptable because it is not
necessary to ensure prenatal care for women whose incomes fall within
the SCHIP-eligibility criteria in their state. There are at least two
superior means of achieving this goal: 1) the ``Mothers and Newborns
Health Insurance Act,'' which has been proposed with bipartisan support
to expand SCHIP to include pregnant women; and, 2) until federal
legislation is in place, a streamlined process for obtaining Sec. 1115
waivers to add pregnant women to a state's SCHIP program (as New Jersey
and Rhode Island have done).
CRLP supports the regulation's stated goal of expanding access to
early and regular prenatal care in order to ensure the health of both
pregnant women and newborns, but questions SCHIPS' approach of allowing
health insurance coverage for a zygote, embryo and fetus in utero.
Because there are other less controversial and more effective ways of
achieving the stated goal, the Administration's choice of this strategy
is curious at best.
v. conclusion
It now falls to Congress to stand up for the healthcare needs of
pregnant women through the ``Mothers and Newborns Health Insurance
Act.'' CRLP urges the Senate to quickly enact this legislation to
expand healthcare coverage to uninsured pregnant women. Once enacted,
this legislation would allow states to go beyond the current framework
of the SCHIP program and provide insurance to pregnant women in
addition to their children.
Thank you.
[Whereupon, at 11:47 a.m., the subcommittee was adjourned.]