Commentary Maternity and Birthing

Why on Earth Do U.S. Families Pay More for Maternity Care Than Anywhere Else?

Martha Kempner

Maternity care in the United States is far more expensive than anywhere else in the developed world, and it’s not because we’re getting more services than women elsewhere.

Hanging over my grandparents’ kitchen table was a framed, hand-written receipt from a Brooklyn hospital. It was made out to my great-grandmother and namesake, Martha Ravich, and dated October 1920. It told me two important things: She was in the hospital for almost two weeks after having my grandfather, and the entire stay cost her $2.

Needless to say, my experiences with maternity care some 85 years later were much shorter and much more expensive. According to recently released research, my experience was not outside the norm; the cost of vaginal delivery in the United States rose 49 percent and the price of a c-section 41 percent between 2004 and 2010 alone. Indeed, maternity care in the United States is far more expensive than anywhere else in the developed world, and it’s not because we’re getting more services than women elsewhere. As New York Times writer Elisabeth Rosenthal details in a feature published this weekend, which discusses the research conducted by conducted by Truven Health Analytics for the Times, it’s all about what we expect and how we pay for it.

In most developed countries, maternity care comes as a package that costs somewhere around $4,000 all in;  women pay very little, if any, of that. Here, we are charged (sometimes twice) for each service we get, and much of it comes out of women’s pockets.

Rosenthal’s article follows one uninsured woman’s prenatal journey and points out how she was billed $935 by the hospital for an ultrasound that she had already paid a radiologist $256 to read. Another couple mentioned in the article was quoted $265 for a fetal heart scan but then charged $2,775. (Both were able to negotiate their ultimate payments down.) Experts believe that this fee-per-service pricing system encourages health-care providers to offer more, whether it’s additional ultrasounds or more blood tests, and over the years pregnant women have come to expect the reassurance that can come with the extra poking and prodding.

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Adding it all up, hospitals charge about $30,000 for a vaginal delivery and newborn care and about $50,000 for a c-section. Insurance companies usually negotiate down and pay between $18,000 and $28,000. Medicaid pays a lot less—about $9,000 for a vaginal delivery and $13,500 for a c-section. Women are then charged separately by their obstetricians (OBs), whom they pay either by the visit/service or on a flat-fee basis. According to the American College of Obstetricians and Gynecologists (ACOG), this fee ranges from $4,000 in Denver to $8,000 in Manhattan.

Though much of this is paid by insurance, even women with coverage tend to have to pay a few thousand dollars out of pocket (on average, $3,400) to cover co-pays, out-of-network service, or tests for which the insurer refuses to pay. Many women, however, don’t have insurance, and some who do don’t have maternity coverage. In fact, 62 percent of women who have private (not employer-provided) insurance are not covered for pregnancy and birth. This will change in 2014 under the Affordable Care Act, which requires all policies to cover maternity care, but what is included in that maternity package—or, more importantly, what isn’t—is not yet clear.

Women are left wondering not just if an amniocentesis is necessary but worrying about how much it will cost. Renee Martin, one of the women followed in the Times article, pointed to her three-hour glucose test (the worst part of both of my pregnancies). When she threw up all over the floor of the testing facility, her first thought was not just that she would have to come back another day and attempt to choke down the extra-sugary drink but that she’d have to pay twice. Martin is a graduate student, and her husband works for a small music licensing business that does not offer health insurance. They purchased insurance, but not the $800 per month pregnancy rider, which they could not afford. When she first got pregnant, Martin called the hospital and asked for an estimate for prenatal care and delivery. She was told it would vary between $4,500 and $45,000. Following the delivery of a healthy baby, they are now facing approximately $33,800 in bills. The hospital has promised a 30 percent discount on all fees.

To get a handle on the increasing costs and make their services more appealing than their competitors, some hospitals are trying out a flat-fee system. Dr. Dean Coonrod, the chief of obstetrics and gynecology at Maricopa Hospital in Phoenix, told the New York Times that they went to this system two years ago for a few reasons. First, he pointed out that it seemed cruel or at least wrong to ask a woman in labor if she wanted a $1,000 epidural. Second, though, he wanted to engender good will with patients who have a choice both in where they have babies and where they go for health care in the future. As a public hospital whose doctors are all on salary, Maricopa was able to set a price of $3,850 for a vaginal delivery and $5,600 for a c-section, which was based on the average payout from insurance companies. The hospital breaks even on maternity care. Setting a price would be more difficult for other hospitals, especially when private doctors are involved.

Rosenthal explains that the reliance on OBs is actually one of the reasons that maternity care in the United States is so expensive. In most other developed countries, maternity care is left primarily to midwives who charge must less; OBs are only brought in when there are complications. In the United State, where the average vaginal delivery cost $9,775 in 2012, only 8 percent of births are attended by midwives, compared to 68 percent in Britain (where the average vaginal delivery cost $2,641) and 45 percent in the Netherlands (where the average vaginal delivery cost $2,669).

One of the reasons OBs charge so much, however, is because they pay hundreds of thousands of dollars in malpractice insurance each year. In fact, we seem to be stuck in a “more is more” kind of cycle. OBs provide more tests during pregnancy and more intervention during delivery because of threat of malpractice. Women expect more tests and intervention. And each of these adds a line to the bill.

I never expected to pay only $2 like Nana Martha had, but I do remember finding maternity services to be an odd combination of health care and commerce. I first dipped my toe into it a year or so before I even became pregnant when my OB suggested I have genetic testing. As the descendants of Eastern European Jews, there are a slew of genetic diseases/disorders that I could be carrying (two of my aunts carry the Tay Sach’s gene, for example) so I wanted to test for all of them. I agreed with the genetic counselor that I should even have the ones that were not covered by insurance, and I never asked her how much they might cost.

When I started going to my OB, again years before I was pregnant, she was on my insurance plan and visits cost a mere $10 co-pay. By the time I got pregnant, however, she had stopped taking all insurance because the reimbursement rates were not keeping up with the increasing rates of her practice—especially her insurance. She charged a flat fee of $7,500 for the entire pregnancy and delivery with a $500 surcharge if I had a c-section. Luckily, because I was a loyal patient, her staff billed my insurance company first (it covered 80 percent), and then I paid them the rest (about $1,500). Otherwise I would have had to pay thousands first and wait for reimbursement.

About a month before I was due to give birth, I got a bill from Mt. Sinai in which the hospital anticipated my delivery would cost $11,000 and said my insurance company would pay none of it. I was surprised to be getting billed before I even walked in the door and panicked at the idea that none of it would be covered by insurance. The first person I got on the phone explained quite clearly that since I had chosen a doctor who was out of network, everything associated with my pregnancy would be out of network. I argued with her—the doctor was out of network, but the hospital was not. If I showed up there for anything else it would be covered. She agreed that it didn’t make sense, but she didn’t back down. I asked to speak to her supervisor. She said someone would call me back. No one did. I called a few days later and started from scratch. He took one look at the bill and agreed that it must be an error. A few days later a new bill arrived in the mail, which put my estimated out-of-pocket expenses at $0.

That wasn’t exactly the case once I gave birth, however. Mt. Sinai only had a small number of private rooms; they were given out on a first-come, first-serve basis, were ridiculously expensive, and were not covered by insurance. We ended up paying $475 for a room (it was an extra $45 for a park view).

My second time around, I was in the suburbs and I noticed that there was a real competition here between the two hospitals in the area which were both vying for maternity patients. One was considered swankier and was rumored not just to have all private rooms but to offer a lobster and champagne dinner the night after you gave birth. I admit I wanted to go there, but I ended up at the other, because that’s where the OB I chose delivered.

All of these choices that I made were available to me because I had employer-provided health insurance and because I have resources. I was able to cover the extra genetic tests and the room that looked out over Central Park without having to worry that I wouldn’t then have enough money to feed the babies that I was about to take home. I am well aware that this is not the case for many women and that we have to change the system—event the parts of it that I liked, such as ultrasounds at nearly every appointment.

The Affordable Care Act should help in some ways, because it will mean that people like Renee Martin will have some maternity coverage and won’t have to pay the equivalent of college tuition before the baby is even three-months old. This, however, is not enough.

Rosenthal’s article is a stark portrayal of a system that is in desperate need of a major overhaul. Women need to rethink what they expect, hospitals and doctors need to rethink how they bill, insurance companies and Medicaid need to rethink how and when they reimburse, and the legal system needs to rethink malpractice cases. Until we do that, the United States will continue to have the unique distinction of having the most expensive maternity care and one of the highest maternal and infant death rates in the developed world.

Culture & Conversation Maternity and Birthing

On ‘Commonsense Childbirth’: A Q&A With Midwife Jennie Joseph

Elizabeth Dawes Gay

Joseph founded a nonprofit, Commonsense Childbirth, in 1998 to inspire change in maternity care to better serve people of color. As a licensed midwife, Joseph seeks to transform how care is provided in a clinical setting.

This piece is published in collaboration with Echoing Ida, a Forward Together project.

Jennie Joseph’s philosophy is simple: Treat patients like the people they are. The British native has found this goes a long way when it comes to her midwifery practice and the health of Black mothers and babies.

In the United States, Black women are disproportionately affected by poor maternal and infant health outcomes. Black women are more likely to experience maternal and infant death, pregnancy-related illness, premature birth, low birth weight, and stillbirth. Beyond the data, personal accounts of Black women’s birthing experiences detail discrimination, mistreatment, and violation of basic human rights. Media like the new film, The American Dream, share the maternity experiences of Black women in their own voices.

A new generation of activists, advocates, and concerned medical professionals have mobilized across the country to improve Black maternal and infant health, including through the birth justice and reproductive justice movements.

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Joseph founded a nonprofit, Commonsense Childbirth, in 1998 to inspire change in maternity care to better serve people of color. As a licensed midwife, Joseph seeks to transform how care is provided in a clinical setting.

At her clinics, which are located in central Florida, a welcoming smile and a conversation mark the start of each patient visit. Having a dialogue with patients about their unique needs, desires, and circumstances is a practice Joseph said has contributed to her patients having “chunky,” healthy, full-term babies. Dialogue and care that centers the patient costs nothing, Joseph told Rewire in an interview earlier this summer.

Joseph also offers training to midwives, doulas, community health workers, and other professionals in culturally competent, patient-centered care through her Commonsense Childbirth School of Midwifery, which launched in 2009. And in 2015, Joseph launched the National Perinatal Task Force, a network of perinatal health-care and service providers who are committed to working in underserved communities in order to transform maternal health outcomes in the United States.

Rewire spoke with Joseph about her tireless work to improve maternal and perinatal health in the Black community.

Rewire: What motivates and drives you each day?

Jennie Joseph: I moved to the United States in 1989 [from the United Kingdom], and each year it becomes more and more apparent that to address the issues I care deeply about, I have to put action behind all the talk.

I’m particularly concerned about maternal and infant morbidity and mortality that plague communities of color and specifically African Americans. Most people don’t know that three to four times as many Black women die during pregnancy and childbirth in the United States than their white counterparts.

When I arrived in the United States, I had to start a home birth practice to be able to practice at all, and it was during that time that I realized very few people of color were accessing care that way. I learned about the disparities in maternal health around the same time, and I felt compelled to do something about it.

My motivation is based on the fact that what we do [at my clinic] works so well it’s almost unconscionable not to continue doing it. I feel driven and personally responsible because I’ve figured out that there are some very simple things that anyone can do to make an impact. It’s such a win-win. Everybody wins: patients, staff, communities, health-care agencies.

There are only a few of us attacking this aggressively, with few resources and without support. I’ve experienced so much frustration, anger, and resignation about the situation because I feel like this is not something that people in the field don’t know about. I know there have been some efforts, but with little results. There are simple and cost-effective things that can be done. Even small interventions can make such a tremendous a difference, and I don’t understand why we can’t have more support and more interest in moving the needle in a more effective way.

I give up sometimes. I get so frustrated. Emotions vie for time and energy, but those very same emotions force me to keep going. I feel a constant drive to be in action and to be practical in achieving and getting results.

Rewire: In your opinion, what are some barriers to progress on maternal health and how can they be overcome?

JJ: The solutions that have been generated are the same, year in and year out, but are not really solutions. [Health-care professionals and the industry] keep pushing money into a broken system, without recognizing where there are gaps and barriers, and we keep doing the same thing.

One solution that has not worked is the approach of hiring practitioners without a thought to whether the practitioner is really a match for the community that they are looking to serve. Additionally, there is the fact that the practitioner alone is not going to be able make much difference. There has to be a concerted effort to have the entire health-care team be willing to support the work. If the front desk and access points are not in tune with why we need to address this issue in a specific way, what happens typically is that people do not necessarily feel welcomed or supported or respected.

The world’s best practitioner could be sitting down the hall, but never actually see the patient because the patient leaves before they get assistance or before they even get to make an appointment. People get tired of being looked down upon, shamed, ignored, or perhaps not treated well. And people know which hospitals and practitioners provide competent care and which practices are culturally safe.

I would like to convince people to try something different, for real. One of those things is an open-door triage at all OB-GYN facilities, similar to an emergency room, so that all patients seeking maternity care are seen for a first visit no matter what.

Another thing would be for practitioners to provide patient-centered care for all patients regardless of their ability to pay.  You don’t have to have cultural competency training, you just have to listen and believe what the patients are telling you—period.

Practitioners also have a role in dismantling the institutionalized racism that is causing such harm. You don’t have to speak a specific language to be kind. You just have to think a little bit and put yourself in that person’s shoes. You have to understand she might be in fear for her baby’s health or her own health. You can smile. You can touch respectfully. You can make eye contact. You can find a real translator. You can do things if you choose to. Or you can stay in place in a system you know is broken, doing business as usual, and continue to feel bad doing the work you once loved.

Rewire: You emphasize patient-centered care. Why aren’t other providers doing the same, and how can they be convinced to provide this type of care?

JJ: I think that is the crux of the matter: the convincing part. One, it’s a shame that I have to go around convincing anyone about the benefits of patient-centered care. And two, the typical response from medical staff is “Yeah, but the cost. It’s expensive. The bureaucracy, the system …” There is no disagreement that this should be the gold standard of care but providers say their setup doesn’t allow for it or that it really wouldn’t work. Keep in mind that patient-centered care also means equitable care—the kind of care we all want for ourselves and our families.

One of the things we do at my practice (and that providers have the most resistance to) is that we see everyone for that initial visit. We’ve created a triage entry point to medical care but also to social support, financial triage, actual emotional support, and recognition and understanding for the patient that yes, you have a problem, but we are here to work with you to solve it.

All of those things get to happen because we offer the first visit, regardless of their ability to pay. In the absence of that opportunity, the barrier to quality care itself is so detrimental: It’s literally a matter of life and death.

Rewire: How do you cover the cost of the first visit if someone cannot pay?

JJ: If we have a grant, we use those funds to help us pay our overhead. If we don’t, we wait until we have the women on Medicaid and try to do back-billing on those visits. If the patient doesn’t have Medicaid, we use the funds we earn from delivering babies of mothers who do have insurance and can pay the full price.

Rewire: You’ve talked about ensuring that expecting mothers have accessible, patient-centered maternity care. How exactly are you working to achieve that?

JJ: I want to empower community-based perinatal health workers (such as nurse practitioners) who are interested in providing care to communities in need, and encourage them to become entrepreneurial. As long as people have the credentials or license to provide prenatal, post-partum, and women’s health care and are interested in independent practice, then my vision is that they build a private practice for themselves. Based on the concept that to get real change in maternal health outcomes in the United States, women need access to specific kinds of health care—not just any old health care, but the kind that is humane, patient-centered, woman-centered, family-centered, and culturally-safe, and where providers believe that the patients matter. That kind of care will transform outcomes instantly.

I coined the phrase “Easy Access Clinics” to describe retail women’s health clinics like a CVS MinuteClinic that serve as a first entry point to care in a community, rather than in a big health-care system. At the Orlando Easy Access Clinic, women receive their first appointment regardless of their ability to pay. People find out about us via word of mouth; they know what we do before they get here.

We are at the point where even the local government agencies send patients to us. They know that even while someone’s Medicaid application is in pending status, we will still see them and start their care, as well as help them access their Medicaid benefits as part of our commitment to their overall well-being.

Others are already replicating this model across the country and we are doing research as we go along. We have created a system that becomes sustainable because of the trust and loyalty of the patients and their willingness to support us in supporting them.

Photo Credit: Filmmaker Paolo Patruno

Joseph speaking with a family at her central Florida clinic. (Credit: Filmmaker Paolo Patruno)

RewireWhat are your thoughts on the decision in Florida not to expand Medicaid at this time?

JJ: I consider health care a human right. That’s what I know. That’s how I was trained. That’s what I lived all the years I was in Europe. And to be here and see this wanton disregard for health and humanity breaks my heart.

Not expanding Medicaid has such deep repercussions on patients and providers. We hold on by a very thin thread. We can’t get our claims paid. We have all kinds of hoops and confusion. There is a lack of interest and accountability from insurance payers, and we are struggling so badly. I also have a Change.org petition right now to ask for Medicaid coverage for pregnant women.

Health care is a human right: It can’t be anything else.

Rewire: You launched the National Perinatal Task Force in 2015. What do you hope to accomplish through that effort?

JJ: The main goal of the National Perinatal Task Force is to connect perinatal service providers, lift each other up, and establish community recognition of sites committed to a certain standard of care.

The facilities of task force members are identified as Perinatal Safe Spots. A Perinatal Safe Spot could be an educational or social site, a moms’ group, a breastfeeding circle, a local doula practice, or a community center. It could be anywhere, but it has got to be in a community with what I call a “materno-toxic” area—an area where you know without any doubt that mothers are in jeopardy. It is an area where social determinants of health are affecting mom’s and baby’s chances of being strong and whole and hearty. Therein, we need to put a safe spot right in the heart of that materno-toxic area so she has a better chance for survival.

The task force is a group of maternity service providers and concerned community members willing to be a safe spot for that area. Members also recognize each other across the nation; we support each other and learn from each others’ best practices.

People who are working in their communities to improve maternal and infant health come forward all the time as they are feeling alone, quietly doing the best they can for their community, with little or nothing. Don’t be discouraged. You can get a lot done with pure willpower and determination.

RewireDo you have funding to run the National Perinatal Task Force?

JJ: Not yet. We have got the task force up and running as best we can under my nonprofit Commonsense Childbirth. I have not asked for funding or donations because I wanted to see if I could get the task force off the ground first.

There are 30 Perinatal Safe Spots across the United States that are listed on the website currently. The current goal is to house and support the supporters, recognize those people working on the ground, and share information with the public. The next step will be to strengthen the task force and bring funding for stability and growth.

RewireYou’re featured in the new film The American Dream. How did that happen and what are you planning to do next?

JJ: The Italian filmmaker Paolo Patruno got on a plane on his own dime and brought his cameras to Florida. We were planning to talk about Black midwifery. Once we started filming, women were sharing so authentically that we said this is about women’s voices being heard. I would love to tease that dialogue forward and I am planning to go to four or five cities where I can show the film and host a town hall, gathering to capture what the community has to say about maternal health. I want to hear their voices. So far, the film has been screened publicly in Oakland and Kansas City, and the full documentary is already available on YouTube.

RewireThe Black Mamas Matter Toolkit was published this past June by the Center for Reproductive Rights to support human-rights based policy advocacy on maternal health. What about the toolkit or other resources do you find helpful for thinking about solutions to poor maternal health in the Black community?

JJ: The toolkit is the most succinct and comprehensive thing I’ve seen since I’ve been doing this work. It felt like, “At last!”

One of the most exciting things for me is that the toolkit seems to have covered every angle of this problem. It tells the truth about what’s happening for Black women and actually all women everywhere as far as maternity care is concerned.

There is a need for us to recognize how the system has taken agency and power away from women and placed it in the hands of large health systems where institutionalized racism is causing much harm. The toolkit, for the first time in my opinion, really addresses all of these ills and posits some very clear thoughts and solutions around them. I think it is going to go a long way to begin the change we need to see in maternal and child health in the United States.

RewireWhat do you count as one of your success stories?

JJ: One of my earlier patients was a single mom who had a lot going on and became pregnant by accident. She was very connected to us when she came to clinic. She became so empowered and wanted a home birth. But she was anemic at the end of her pregnancy and we recommended a hospital birth. She was empowered through the birth, breastfed her baby, and started a journey toward nursing. She is now about to get her master’s degree in nursing, and she wants to come back to work with me. She’s determined to come back and serve and give back. She’s not the only one. It happens over and over again.

This interview has been edited for length and clarity.

Commentary Violence

Major League Baseball Has More Work to Do When It Comes to Domestic Violence Charges

Claire Tighe

Major League Baseball's response to charges of domestic violence against Jose Reyes is really just a step in the right direction. The league, its fans, and the media outlets covering it have work to do before there is additional cause to celebrate.

Two weeks ago, the Colorado Rockies Major League Baseball (MLB) team made headlines for designating their shortstop, Jose Reyes, for assignment. The designation for assignment (DFA) means he was removed from their roster, most likely so the Rockies could trade him or release him to the minors.

The decision came after an announcement from MLB in May concluding that Reyes had violated its new Joint Domestic Violence, Sexual Assault, and Child Abuse policy. Reyes was put on leave in February while the league investigated charges that he had allegedly assaulted his wife in a Hawaii hotel the previous October. Though the charges were ultimately dropped, MLB still concluded that he had violated its policy—which allows discipline no matter a case’s legal status—based on the available police reports. Ultimately, Reyes was suspended for 52 games.

Many sports fans and media outlets are celebrating the Rockies’ decision to designate Reyes for assignment, framing it squarely as a moral response to his domestic violence suspension. As a result of the suspension, Reyes ultimately lost a total of $7.02 million for missing 30 percent of the season and is required to donate $100,000 to “charity focused on domestic violence.” Still, the team will owe Reyes $41 million despite the DFA—and that, spectators say, makes the Rockies’ actions worthy of praise. The Denver Post‘s Mark Kiszla, for example, wrote that the Rockies franchise owner, Dick Monfort, deserves a “standing ovation” for taking a “$40M stance against domestic violence” that was “not just financial.” According to Kiszla, “the franchise did right by battered women by showing zero tolerance for physical abuse.”

Yet instead of a purely moral response that deserves “a standing ovation,” the Reyes case is really more of a step in the right direction. If, as Bob Nightengale at USA Today suggested, MLB is setting a precedent by suspending Jose Reyes, the league and the media covering it have work to do before there is additional cause to celebrate.

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The league could have acted faster and given Reyes a longer, more consequential suspension to show its seriousness in responding to his violation of the policy. In fact, the New York Mets’ recent signing of Reyes, which the team explained as giving him a “second chance,” underscores just how much tolerance for reports of domestic violence truly exists in professional baseball as a whole.

The public excitement about the connection between Reyes’ domestic violence record and his sportsmanship is warranted, albeit overstated. As MLB Commissioner Rob Manfred put it, the league has taken “a firm national and international stance” on domestic violence. Reyes was only the second player to receive a suspension under the new policy, which was approved by the league in August 2015 as a result of the ongoing national conversation about intimate partner abuse in professional sports. His case was the first to be negotiated with the MLB Player’s Association; his was the harshest punishment a player had received at the time.

Even so, while the Rockies’ consideration of Reyes’ charges of domestic abuse in their decision should be appreciated, the DFA should be understood for what it really appears to be overall: based on the team’s response, it was a business decision, not an action on behalf of domestic violence survivors.

“Would we be sitting here talking about this if the domestic violence thing hadn’t happened in Hawaii? We wouldn’t. So it’s obviously part of the overall decision,” said Colorado general manager Jeff Bridich told the New York Times. After all, an incident causing a player to miss a third of the season is enough to make any team pause for consideration.But, as the Times pointed out, there are other reasons that the Rockies were ready to move on, including “never really wanting him in the first place,” the great performance of his replacement during the suspension, and the fact that the franchise had already sunk the costs of bringing Reyes onboard. By the terms of their contract, designating him for assignment was no more expensive than keeping him.

Furthermore, the handling of the Reyes case within the league and the franchise has been mostly professional, but there is still a lingering tone of undue apology toward Reyes—suggesting, again, that the treatment he has received may not be the unilateral condemnation of domestic violence that others have implied.

It begins with Reyes himself, who first apologized “to the Rockies organization, my teammates, all the fans, and most of all my family,” before retweeting Mike Cameron, a former MLB player who said that Reyes just had a “bad moment in life” and deserved forgiveness for committing physical violence against his wife.

Commissioner Manfred walked a thin line in a news conference in November just after the Hawaii incident, stating his interest in maintaining Reyes’ privacy despite the charges against him. “There’s a balance there,” he said. “On the one hand, I think our fans want to know that the case has been dealt with appropriately. On the other hand, whoever the player is, the fact that he’s a major league player doesn’t mean he has absolutely no right to privacy and or that everything in the context of a relationship or a marriage has to be public.”

While domestic violence can happen “behind closed doors,” that does not mean it is an issue of one’s personal privacy. As Bethany P. Withers has argued for the New York Times, there may not be public witnesses to abuse occurring between partners, but we should not ignore professional athletes who are charged with committing acts of domestic violence. Manfred’s comments, as well as Cameron’s, minimize Reyes’ Hawaii incident into “a lovers’ quarrel,” rather than a report of an abusive act of behavior that most likely exposes an ongoing pattern.

Rockies Franchise owner Dick Monfort’s comments were better, though not ideal. In April he told the Associated Press, “I’d like to know exactly what happened. It’s easy for us all to speculate on what happened. But really, until you really know, it’s hard. You’re dealing with a guy’s life, too.” Monfort, while expressing understandable concern for this player, sounds apologetic to Reyes, rather than the woman he was charged with abusing.

Sympathizing with Reyes in this matter, while he may be sorry for reportedly committing actions that had visible consequences, centers the experience of an abuser in a culture that silences, blames, shames, and erases survivors of domestic violence and perpetuates abusive behavior.

Much of the media, meanwhile, has taken action either to diminish Reyes’ alleged crimes or dismiss them completely. The Post‘s Kiszla, for example, was plain encouraging of Reyes, for whom he “hoped nothing but the best, if his wife had forgiven him.” His uninformed commentary shows utter lack of understanding of domestic violence and what Katherine Reyes might be experiencing in deciding to “not cooperate with the prosecutors” on the case. Fox News was similarly insensitive. At the very least, the media can provide a short explanation as to what domestic violence is and why victims may be reluctant to work with police and the criminal justice system in the first place. The “inaction, hostility, and bias” they might face, as the American Civil Liberties Union put it, is real. And their personal fear of consequences are legitimate.

Nightengale of USA Today had a particularly awful response, explicitly sympathizing with Reyes, saying “that one ugly night in Hawaii cost Reyes his pride and his job.” Except that domestic violence, a cycle of power and control, is hardly ever just “one ugly night.”

Furthermore, incidents of reported domestic violence need to be named as such. In the coverage of Reyes’ charges in Hawaii, the media failed to do so. Though ESPN reported Reyes had been arrested on abuse charges, it still said Reyes had “an argument with his wife [that] turned physical.” The Chicago Tribune labeled it as “an altercation.” The Tribune was also inaccurate in reporting that Reyes ‘choked’ his wife, when the it was actually strangulation. Technically, choking by definition is when the airway is blocked internally. Strangulation, however, is the act of blocking the passage of air through the external use of force. While the difference is subtle—in fact, the police report itself logged the action as “choking”—the ramifications are large. Describing the act as an expression of dominance signals to the public that acts of violence have perpetrators. It also gives detailed meaning to “domestic violence,” an all-encompassing phrase whose intricacies are not widely understood.

While it may seem petty to be picking over semantics, accurate framing is the difference between two partners having a disagreement and one partner committing threatening acts of violence against another in a cyclical power dynamic. It’s the difference between public acceptance of horrific behavior and public recognition of unhealthy, unacceptable relationship dynamics.

The focus on costs to Reyes and the Rockies should also be reframed. If we really want to talk big money, we should consider the exorbitant shared cost of domestic violence on all of our systems, both public and private. Domestic violence is “a serious, preventable public health problem.” The epidemic is estimated to cost $8.3 billion annually to the economy due to its effect on survivors’ physical and emotional health, as well as their workplace productivity. Because domestic violence is so widely underreported, this estimate is even a conservative one. It also does not encompass the cost to child survivors and the trauma inherited by future generations. Understanding the ridiculously high costs of domestic violence centers the long-lasting effects of an epidemic on survivors and our society as a whole, rather than the cost to a singular MLB player or team.

Wholly shifting the narrative is vital in Reyes’ case and in the cases of other players disciplined under MLB’s new policy. It is up to the public to connect the dots between all of the players and teams to understand the wide scale and scope of MLB’s domestic violence problem. The Mets’ quick re-signing of Reyes as a “second chance” to the player is a reminder of many teams’ true priorities.

Though the new MLB policy appears to be comprehensive and informed by experts, the league, the teams, and the media haven’t quite perfected their responses. With regard to MLB’s process and ultimate decision, critics are saying the league should act faster and make longer, more consequential suspensions in the future. If Commissioner Manfred is really going to give weight to charges of domestic violence, a quicker, more punitive response to charges like Reyes’ is a good way to start. There is also significant work to be done in the public relations and media responses to domestic violence in the League overall.

Five years ago, there was very little talk about domestic violence in professional sports, let alone in Major League Baseball. Almost ten years ago, it was a big joke. Until 2016, MLB had never suspended a player for domestic violence. It’s becoming clearer and clearer to the public that domestic violence pervades every arena, from professional sports to entertainment. There has been an explosion of coverage on the topic in relation to the National Football League, college campusesHollywood, theater, and the music industry. Domestic violence in Major League Baseball, in professional sports, and in our culture is a much larger problem than one suspension can solve. It’s up to us to see that domestic violence is not just the concern of a singular player, team, sport, or profession. We all have a domestic violence problem. Together we can solve it.