Mama's Got a Plan:

Maternity Care, Health Insurance, and Reproductive Justice


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Michigan Senate Bill “Legalizes Breastfeeding in Public”? No, Even Better!

The recently passed Michigan Senate Bill 464 received a warm but somewhat confused reception from local media. The voices of the internet – not surprisingly – jumped at this new opportunity to sermonize on public breastfeeding. But what is the bill really about? What is it not about? What is its public policy basis?

What it is

The bill amends Michigan’s Elliott-Larsen Civil Rights Act to include breastfeeding as a right whose exercise may not be prohibited by discriminatory practices. Such rights currently consist of religion, race, color, national origin, age, sex, and marital status. The Elliott-Larsen Act, like the federal Civil Rights Act of 1964, prohibits discrimination by private actors in the context of public accommodation. These federal and state laws were originally enacted to address race-based discrimination in public accommodation.

Michigan S.B. 464 and its companion House Bill 4733 do the same for breastfeeding. The act of breastfeeding in public is already protected by statutes that prevent breastfeeding women from being charged under indecent exposure laws. However, this constrains the behavior only of law enforcement and fails to forbid privately-owned establishments from refusing to accommodate breastfeeding women. The new legislation, if enacted, would permit breastfeeding in all places the mother herself has the right to be.

What it is NOT

Nursing mothers vs. formula-feeding mothers

This is not an opportunity for media flame wars on whether mothers should breastfeed or formula-feed. Although science has established breastfeeding to be largely beneficial to mothers and children, there are women who should not or cannot breastfeed. Before we start throwing stones, it would be prudent to review the minimal accommodations for women who want to, but cannot, breastfeed. We have no national policy on parental leave, save the very limited, unpaid leave available under the Family Medical Leave Act. It was  only under the Affordable Care Act that the federal government granted women working outside the home the right to take unpaid time to pump breast milk in a private place that is not a bathroom – but as breastfeeding legal expert Jake Marcus points out, these provisions may be less effective than they appear. In any case, the ACA provision covers only the right to pump milk, not to the right to actually breastfeed.

Breastfeeding also comes with real costs. While the milk itself bears no price tag, that very fact obscures the considerable costs in time and labor to the mother. Until we can support and subsidize these costs, we must affirm the decision of the mother who weans a child in order to take care of other responsibilities, not least of which may be getting an education, caring for other children, or making a living.

Every mother’s experience of breastfeeding is unique; indeed, one mother’s experiences can vary from pregnancy to pregnancy. We can continue to improve circumstances for mothers who wish to breastfeed and make sure that unbiased information about risks and benefits is available to them, but we must trust mothers to make the right decision for themselves and their children.

The sexy breast vs. the nursing breast

Likewise, this should not be our cue to reopen the quarrel about whether breasts are for sexual partners’ gaze or for nursing our children. This line of argument makes it sound as if breasts were pets kept on leashes rather than being actual attached body parts. Our breasts are “for” whatever we say they are for –  and they are far from having only two functions.

The fact that sexualized breasts are frequently visible in public is often used to suggest that these sexy breasts somehow contaminate nursing breasts with sexiness, thus making nursing breasts in public unacceptably sexual. However, following the thinking of sociologist Linda M. Blum, I believe it is the other way around: In our society, the chief acceptable public use of breasts or other female body parts is for sexual display. Nursing breasts in public are transgressive, because they are used for the non-sexual purpose of nourishing children. Urging nursing women to be “discreet” by covering up their nursing breasts aims to banish the offensively non-sexy breast from public view.

Again, each woman must make her own decision about the manner in which she wishes to nurse in public, if at all. Some women follow religious guidelines about display of the body in public; others may suspect that such a display may put their personal safety at risk; still others may be embedded in our country’s racist history in which some women’s bodies and reproductive capacities were used by others against their will. We must respect every woman’s capacity to decide what is best for her.

Policy basis

Public health policy and law, at least according to some authorities, seek not to badger people into behaviors that some privileged segment of the population thinks everyone should adopt, regardless of other priorities. Rather, their role is to move obstacles out of the way for the benefit of those people who wish to adopt practices that are widely held to be beneficial to the public health.

Breastfeeding is one of those practices. In order to make a path for people who wish to breastfeed their children in public, the bill gives a right and a remedy. The right is the liberty to breastfeed children in public any place the breastfeeding woman herself is entitled to be. Remedies (as already outlined in the Elliott-Larsen Act), should this right be denied, are the ability to seek a judicial injunction against the offending party, to pursue legal action through the state Civil Rights Commission, or to bring suit against the offending party in a civil suit.

What happens next and how to help

Now that S.B. 464 has passed the state Senate, its companion bill must also be given a committee hearing, receive a favorable vote, and be voted upon on the House floor. Should that happen, once the governor signs the bill, it will become law.

If you wish to support these bills and this cause, you can follow through with these actions:

  1. Thank Senator Rebekah Warren for sponsoring S.B. 464. I am very proud to be her constituent – thank you, Sen. Warren!
  2. Encourage the chair of the House Judiciary Committee, Rep. Kevin Cotter, to schedule a hearing on H.B. 4733.
  3. Especially if your representative is a member of the House Judiciary Committee, encourage him or her to support H.B. 4733. You can identify your representative here.

Finally, easiest of all, we can help mothers to breastfeed in public simply by speaking out on the spot. If someone asks a mother to cover up, or to leave, we can object. When I was a new mother nursing my first child in public, strangers would occasionally come up to me and murmur approvingly, “I nursed my child for three years, or “I nursed two children.” I can’t tell you how supported this made me feel! Now I try to carry on this tradition by telling women how nostalgic I feel when I see their beautiful little nurslings. But a simple smile and a nod also does the trick.

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Time served

Governments manage to build roads, regulate air quality, invade countries – however imperfectly and occasionally inappropriately. So I am moderately hopeful that my new health insurance plan, purchased through the marketplace set up by the Affordable Care Act, will be an improvement, even if only because of the generous tax credit that subsidizes my premiums.

That said, if time spent could be parlayed into dollars, I might be able to forgo the tax credit. Although my search for insurance for the adults in our family was neither quick nor easy, I can’t blame the ACA or even healthcare.gov. Much of the complexity was the result of my family’s economic circumstances and the structure of private health insurance.

Essential tool: crystal ball

I was surprised when healthcare.gov asked me for proof of income for 2014 – frankly, I would like proof of income for 2014 too. Neither healthcare.gov, the federal exchange, nor a local navigator were able to tell me what documentation I could reasonably provide for income not yet earned – or even conceptualized! [Time spent on phone calls and internet chats: approximately 2 hours.]

Out of necessity, I invented a solution: I will submit my final pay stub from this year, even though it is not a reflection of my income for next year, as evidenced by the fact that I will also submit a letter from my employer confirming that I am no longer receiving paychecks. My husband will submit a “self-employed ledger”; because no one is able to tell us exactly what that means, we will concoct a spreadsheet of business income and expenditures and hope that it suffices. I give healthcare.gov credit for not requiring that documentation be uploaded before selecting a plan. [Time spent gathering documentation so far: 1 hour.]

What’s my point? The ostensible purpose of the ACA is to provide affordable care by means of health insurance to people who would otherwise lack access. It’s not a long shot to say that a large number of people in this situation are those whose employment is sporadic, variably paid, or simply unpredictable. Demanding proof of future income defeats the purpose of providing easier access to care for this population.

Dental …

Our family is blessed with relatively good health, with the notable exception of My Teeth. Thanks to genetics and my tendency to send stress directly to my jaw – and believe me, I’m grateful it doesn’t go to some other body parts – I am very familiar with dental care. Health insurance, on the other hand, has always considered dental care to be a separate, alien entity. When I searched for plans within my price range that also included dental care, I found one, for which our out-of-pocket cost for the premium would be higher than we’re currently paying, even taking the tax credit into account. Naturally, I wanted to be sure this costly plan was worth it, so I carefully examined the dental benefits. While I was on hold with the insurer, I also hopefully text-chatted with healthcare.gov, to no avail. The insurer was finally able to clarify several of the “Benefit Explanations” regarding frequency of coverage of fillings. For anyone who’s wondering: “1x per 48 months for permanent teeth” means as many teeth as need to be filled in 48 months  (subject to plan maximums, of course), just not more than once in any given tooth during that time. Perhaps I was overly suspicious of that language; however, I have forked over plenty as a result of past misunderstandings of policy language. [Time spent on hold: 1 hour.]

After looking at the numbers again, I decided to investigate dental riders available directly through the insurer. I reasoned that if such a rider cost only about $50 a month, as it did in our pre-ACA individual plan, we could easily buy one of the more cost-effective health care plan without dental benefits. I had questions regarding:

  1. My dentist’s participation in a provider network, the meaning of which was far from clear on the insurer’s website;
  2. Whether as a result of my dentist’s possible participation, I would or would not be charged for the difference between the insurer’s approved amount and my dentist’s charges;
  3. Whether the deductible on the dental rider worked as a group or individual deductible.

 

After another long wait, I was connected with a customer service representative who was apparently puzzled by my questions. His answers included the word “probably” and once directly contradicted a benefits summary document, which itself was careful to state that it was not a contract – the legal equivalent of crossing your fingers behind your back. I was far from reassured. [Time spent on hold: 1 hour.]

However, I was gratified to discover that I could purchase the dental rider through healthcare.gov. I am almost certainly overestimating the scope of government oversight on private plans, but I felt that going through the exchange would provide me a layer of protection against the excesses or obfuscations of the insurer. We’ll see how that plays out when I deal with my first claim.

What’s my point? I am thrilled that it is possible to purchase a separate dental care rider through the exchange, but knowing that from the start would have saved me a number of steps. Better-informed customer service representatives staffing insurer phone lines would also be helpful, but I am under no illusion that this falls under government dominion.

… and mental

Mental health care has traditionally been as alien to the average insurance plan as dental care. The Mental Health Parity Act of 1996 sought to address this problem, but in the end did little to require plans to offer routine mental health care.

My hope was that our new health care plan would pay the mental health care professional seen regularly by our family. I found, however, that our provider was out of network for all of the plans available to us. In order to receive any coverage at all for her services, we needed to buy a plan with premiums more expensive than our recently expired plan. When I did the math, the best of those plans would cost us $200 more a month than the less expensive plan we were considering, and due to deductibles, coinsurance, co-pays, and a maximum 50% reimbursement, would save us at most $400 a year. This was the final impetus for us to discard that plan. [Time spent examining provider networks and crunching numbers: 40 minutes.]

What’s my point? Plans continue to prioritize coverage for inpatient mental care over outpatient care, and reimburse providers accordingly, thus providing less incentive for providers to participate. While inpatient care is more expensive and thus especially deserving of coverage, it is a mistake to neglect coverage for outpatient care, for the simple reason that regular outpatient care can significantly reduce the possibility of needing inpatient care. When outpatient coverage requires substantial out-of-pocket expenditure, patients are less likely to continue that care.

Just the facts – but where are they?

I haven’t described the process of sorting through possible plans, seeing whether our providers participated in those plans, constructing a spreadsheet to compare the plans, running through various health care needs scenarios to test the numbers, or any of the other tasks required to make a decision of this importance.  [Time spent: 6 hours.]

What’s my point? I am struck again and again by how unlike other purchases it is to buy health insurance. Consumers must predict what they will need to spend, in a market where costs are for the most part indiscernible. Customers must predict what they can afford to spend. Customers must decide whose services they will need should some of their scenarios come to pass.

Time and again

I’m grateful for the ACA and the chance to buy health insurance that actually allows us to receive medical care. Under our old plan, the deductible was so high that it was hardly even worth getting an annual physical: had an exam unearthed issues that needed further study or treatment, it would have been too expensive to follow up. The only answer would have been to buy a lower deductible plan – one that charged unaffordable premiums. The ACA cut through that problem to some degree by aligning income eligibility with insurance costs through the tax credit.

But the problem it didn’t solve was the vast amount of time needed to organize insurance. I’m an educated, privileged person with a computer, a fast network, and enough free time to make endless phone calls and sift through the benefits – or lack thereof – of various plans. Even so, getting coverage has taken weeks and is not yet completely resolved.

What’s my point? If I were an economist assessing citizens’ productive labor capacity, it would concern me that so many of us are must use our time to get something that other developed nations take for granted: access to affordable health care. After watching several British TV medical dramas, I reported to my family that I couldn’t get over how every patient expected care – and got it! I hope the ACA will make a dent in our nation’s problems that are responsible for this sort of amazed perception on my part, for the obvious public health reason that populations are healthier when they can access quality health care. However, setting aside health outcomes, I can’t help imagining the things I might have accomplished in the time I spent identifying and purchasing a workable health insurance plan. Multiply that by everyone buying plans on the exchange, and we potentially have the 21st century equivalent of Sputnik – some giant leap we might have made as a nation, but didn’t.

Furthermore, I am under no illusion that my work is done; past experience tells me that each time I have contact with the health care system, six months of phone calls and paperwork with my insurer ensue. It is in the financial interest of insurers to avoid reimbursing care and they count on the inability of most of their customers to take the time to vigorously pursue claims. I do not relish the prospect of disproving their expectations, but I cannot afford not to. When I had employer-based health care, I could count on my H.R. department to wage some of these battles for me. Now it’s just me against the insurer.

All this time! In which, perhaps, I could have written another article, looked for a new doctor for my children (due to their change of health plan – more about that in another post), lobbied legislators, done more laundry – you name it. Let’s hope it will have been worth it.

With luck, my next post will mark the beginning of my new health insurance plan.