With Senate Republicans threatening to push their version of the American Health Care Act (AHCA) to a vote before Independence Day, the future of U.S. health care is uncertain. Although the Senate is being secretive about its version of the bill, the extensive proposed changes in the House’s version could roll back many gains from the last eight years of health-care policy, particularly when it comes to protecting the welfare of babies.
Today, private insurers and Medicaid alike are required to provide coverage to pregnant people and infants. The nature of that coverage may be about to shift, however, making it more difficult for individuals to obtain prenatal care, and for premature and low birth weight babies to access the hospital care and early childhood resources they need. The party of “pro-life” values, it seems, is unwilling to safeguard the health of some of the most vulnerable children.
Nicole Garro, director of public policy research at the March of Dimes, told Rewire that access to prenatal care increases the probability of positive birth outcomes—including being born at or near term, with a typical birth weight—and the earlier, the better. Pregnant patients with access to smoking cessation programs, nutrition advice, prenatal screening to identify pregnancy risks, and a variety of other services are more likely to have healthy babies. And, in turn, babies born healthy are more likely to succeed later in life, as long as that healthy birth outcome is supported with continuing access to high-quality care.
Adverse birth events such as being born prematurely, by contrast, can increase the risk of cognitive disabilities like ADHD, as well as behavioral health problems. Premature infants can also be subject to neurological risks, vision problems, hearing loss, dental problems, infections, gastrointestinal complications, respiratory distress, and a host of other costly medical issues that also interfere with quality of life. Without early screening and care, these kids can fall behind.
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And as Garro said, worrisome trends among maternal and infant health are already displaying inequity among pregnant people, especially those of color. For example, she said, preterm birth rates are nearly 50 percent higher for Black women than white women. Garro noted that this works in conjunction with other heightened risks for people of color. These include higher maternal mortality and infant morbidity rates, reduced access to health care services, and medical racism.
The first issue of concern to advocates is the radical changes proposed to Medicaid in the House version of the AHCA as well as under the Trump budget proposal. Medicaid, a national program that provides health coverage to 70 million low-income U.S. residents across the country, is a lifeline. Under its current structure, the program provides disbursements to states, which are required to meet or exceed some basic federal standards—such as income eligibility. Beyond that, states can set their own terms. Medicaid extends additional coverage to pregnant women, while children receive benefits under both Medicaid and the Children’s Health Insurance Program (CHIP).
Through the ACA, 32 states adopted the Medicaid expansion, which made them eligible for more Medicaid funding in exchange for raising the income eligibility standard to 138 percent of the federal poverty level. That move radically increased access to coverage for those who had been making too much for Medicaid, but not enough to pay for their own insurance.
Should the Medicaid expansion be repealed through the AHCA, the March of Dimes believes up to 6.5 million women of childbearing age could lose insurance.
“What’s problematic in terms of pregnant women and kids in the AHCA is that it not only would phase out the expansion, it significantly cuts Medicaid beyond that, forcing states to potentially roll back some of the coverage they’ve had in place for decades,” Elisabeth Wright Burak, the senior program director at Georgetown University’s McCourt School of Public Policy’s Center for Children and Families, told Rewire.
“Medicaid for kids and pregnant women was really already largely in place before the Affordable Care Act. The Medicaid expansion was geared towards uninsured parents and other adults that didn’t otherwise have health coverage,” she continued.
Children may stay covered under Medicaid and CHIP, but their parents might lose insurance, which would affect their quality of life. Meanwhile, uninsured people who get pregnant could still apply for Medicaid coverage if they meet the slightly expanded income standards used for means testing in pregnancy—but, said Cynthia Pellegrini, senior vice president for public policy at the March of Dimes, “The importance for us has been the ability to get them into care before they get pregnant, so they can get healthy and address whatever health issues or medical problems they may have. That increases the likelihood of having a healthy pregnancy.”
And even keeping some degree of Medicaid coverage for kids doesn’t mean maintaining the current quality of that coverage. States may be offered the option to convert to a block grant option, in which they are provided with lump sum grants to spend how they see fit. Block grants are sold as an option that increases flexibility and empowerment by allowing states to set their own priorities, but in the long term, they’ll almost certainly create funding limitations that lead to eligibility and benefits cuts, including increasing premiums and co-pays and reducing provider rates. This effectively limits access to health-care services, as states may cut things like home health care, a variety of prescription drugs, surgical procedures, physical therapy, and a range of other needs. As Burak dryly commented, “States already have a lot of flexibility. This is flexibility on what to leave out.”
In addition, the House AHCA provides measures for per-capita funding caps: limitations on expenditures for Medicaid funding beneficiaries. States could receive funding capped per enrollee or could classify enrollees into different categories subject to different kinds of caps. Once the funding’s gone, it’s gone. Pellegrini told Rewire it’s possible that care for a premature baby could blow through a cap before even leaving the neonatal intensive care unit (NICU); for infants born prior to 32 weeks gestation, care can cost nearly $300,000. The baby would continue to remain eligible for Medicaid funding, but perhaps at the expense of other children in the future.
Something else is at risk too. Pellegrini brings up Early Periodic Screening, Diagnosis, and Treatment (EPSDT), a federal standard that requires states to provide coverage to child Medicaid beneficiaries for testing and treatment for medical necessities. This includes things like hearing tests, new wheelchairs as kids outgrow them, and glasses—all services that children born prematurely are more likely to need due to their increased risk of health complications. The program has been in place almost as long as Medicaid has, and provides unique coverage to child beneficiaries that isn’t included for adults. Republican language around health care and the AHCA indicates they want to erode EPSDT by allowing states to apply for waivers that could allow them to scrap all or some of these benefits.
If that sounds familiar, it should: They’re using the same strategy for private insurance with the offer to allow states to waive the ten essential benefits covered under the ACA, which highlights the fact that GOP health care reform hurts those getting coverage through private insurance plans as well. As Sen. Ron Wyden (D-OR) noted on Twitter, eliminating the essential benefits would mean “insurance could be worth less than the paper it’s printed on.” If pregnancy and newborn care are no longer obligatory, insurance plans may be quick to strike this coverage—or to charge differentially for plans that include it, something they would also be able to do under the AHCA in states that apply for waivers to the ACA’s community rating requirement.
Pellegrini pointed out that though the ACA eliminated the individual annual and lifetime benefits caps, that only applied to “those services that fall under essential health benefits.” Eliminating those benefits would allow insurers to return to being selective about what they cover, and also means they can cap how much they will cover. Even if that baby needing NICU care had private insurance, she could go through her entire lifetime limit before even leaving the hospital—her insurer would refuse to spend any more money on her. She might have difficulty obtaining new insurance as well if burdened with one or more complex medical needs as a result of her NICU stay.
This looming threat for children and families could have a profound effect on the future of the United States, with extremely far-reaching implications. Children born at a disadvantage aren’t just less likely to thrive, but also more likely to need educational and social supports to succeed. With cuts at every level of the safety net, those children may be left without the resources they need.
“None of these are hypotheticals,” says Pellegrini, speaking of the consequences of provisions in the House plan. “These are all the way the insurance market worked prior to 2010. We have many years of experience showing what a disservice it was to many families. These are not things that we’re sort of making up as something that might happen. This is just a matter of returning to the status quo of less than a decade ago.”
CORRECTION: This piece has been updated to correct the spelling of Nicole Garro’s name and to clarify a statistic cited in an interview.