Mama's Got a Plan:

Maternity Care, Health Insurance, and Reproductive Justice

My children on MIChild … and meditations on the purpose of government

I did not need to apply for marketplace health insurance for my children, because they already receive coverage through the federal Children’s Health Insurance Program (CHIP), know in Michigan as MIChild.

Before MIChild, my children were covered for a short time under Medicaid, implemented in Michigan as the “Healthy Kids” program. What’s the difference? Medicaid is the public health insurance program for low-income people, run under a state-federal partnership. In Michigan, children are eligible to receive coverage under Medicaid if their family income is under 150% of the federal poverty line. New figures should be out soon for 2014, but under last year’s guidelines, the poverty line for a family of four in most states was $23,550. MIChild/CHIP, on the other hand, is a program funded entirely by the federal government, available to children whose family incomes fall between 150-200% of the poverty line.

Is it too embarrassing to talk about?

Considerable stigma attaches to receiving direct assistance from government programs, especially when it’s in the form of health insurance. This piece by an anonymous writer provides an excellent portrayal of the stigma, including its racial dimensions. Besides indignation surrounding “socialized medicine” – that don’t seem to apply to politicians, other government employees, armed services members, or senior citizens, by the way – many of our fellow citizens seem to feel that it’s shameful to be the recipient of this or other forms of assistance.

I disagree about the need for shame, based both on policy considerations and on our family’s experience. For us, having the children receive public health insurance was beneficial and sensible because it removed the need to worry whether the children were sick enough to warrant care. At that time, on our very minimal insurance plan, we paid out-of-pocket for all care aside from two doctors’ visits a year. So if, for example, a child ran a fever for five days (not unheard of for small children), we had to decide whether it could possibly be the sign of something much more serious that would warrant the $100 doctor’s visit – or wait and see. To pay $100 to be told the fever was the result of a common virus, and that the child should be given OTC painkillers and kept hydrated, was a disaster. But waiting to see whether something worse developed was equally dreadful. Once the children were on Medicaid and then later on MIChild, this scenario never arose. If we were worried about the children’s condition, they got evaluated. The shame, to my mind, attached to the earlier need to delay the care.

From a public policy perspective, public health insurance for children is a reasonable trade-off: the government pays money up front for children to receive care so their illnesses don’t become more serious. It’s bad policy to create incentives for parents to wait for illness to progress until their children get care – not least of all when we remember the traditional public health rationale of protecting society against the spread of contagious disease. Frankly, I think we should extend public health care to all inhabitants of our country, not just children, for that reason alone.

Health policy rationale and the means of delivery

That dream aside, I find that the real policy rationale for providing insurance – and consequently, one hopes, health care – to those who cannot afford it lies in the responsibility we have to each other. Noam Chomsky spoke eloquently on this topic when opposing the political push to dismantle Social Security through privatization, but his answer works just as well as a rebuttal to those questioning the need for public health insurance. This passage is taken from a transcript of a 2011 interview on Democracy Now!:

Social Security is based on a principle. It’s based on the principle that you care about other people. You care whether the widow across town, a disabled widow, is going to be able to have food to eat. And that’s a notion you have to drive out of people’s heads. The idea of solidarity, sympathy, mutual support, that’s doctrinally dangerous. The preferred doctrines are just care about yourself, don’t care about anyone else. That’s a very good way to trap and control people. And the very idea that we’re in it together, that we care about each other, that we have responsibility for one another, that’s sort of frightening to those who want a society which is dominated by power, authority, wealth, in which people are passive and obedient. (Emphasis added.)

I would like to think that it matters to others whether my children are healthy, and vice versa. In smaller civic organizations, we show this concern by bringing meals to parents of sick children, donating our time – if we’re health care professionals – to work at free clinics, holding fund drives through our houses of worship for children’s special medical needs, and much more. While these attempts are laudable, by their very nature they are limited to certain families, clinics, and congregations. We have a way to make these changes systematically and on a larger scale: that method is called government. We can embody the virtues of charity, kindness, generosity, fairness, and social justice through the use of our shared resources (yes, through taxation!) to make sure all children get the care they need.

Takeaways from my experience

Enough with the pronouncements! What useful tips can I supply regarding  MIChild/CHIP and Medicaid/Healthy Kids? These will be most helpful to Michigan parents, but parts may also be applicable to other states.

  1. Billing. My experience with Medicaid billing was delightful – there was none! MIChild was a little more complicated, but not much.
  2. Dental care. During our experience on Medicaid, dental care was effectively unavailable – no private dentist in the entire state accepted Medicaid, as far as I could make out. Since I have children with mercifully few medical needs, but who have inherited my fragile teeth (sorry, kids!), this was a hardship. Since then, Medicaid has improved its dental program for several counties. However, a look at this map shows that the counties containing and surrounding Detroit still lack coverage.
  3. Choice of providers. Another reason I wanted to get the children on MIChild was its broader choice of physicians. My children’s long-standing doctor does not take Medicaid patients – presumably because of its low reimbursement rate and high paperwork burden, particularly for a solo practitioner. I was thrilled to return to him on MIChild, but am now less thrilled; seven months in, MIChild has changed its plan and we must look for a new doctor.
  4. Surveillance. The sense of surveillance while on Medicaid was not overwhelming, but it was palpable. In the presence of health care providers and program administrators, I felt a presumption that because we qualified for Medicaid, our ability to parent could be called into question. I was able to combat this impression with my professional, class, and race privilege, but of course that’s not a satisfactory answer to the problem. For a scholarly examination of this kind of surveillance in the context of maternity care, I highly recommend The Reproduction of Race: An Ethnography of Pregnancy as a Site of Racialization, by Khiara M. Bridges. reproduction of race
  5. Funding. While this has little to do with our health care delivery experience, I must say I was happy to know that receiving MIChild coverage meant my children were pulling much-needed federal dollars into our state.
  6. Application tip! Finally, this one very useful hint: If you have determined you meet the income eligibility requirements for MIChild, do NOT fill out a paper application. These seem to get funneled automatically into Medicaid. Instead, fill out the online application. I wish I had known this before applying; our income seemed to fall in the MIChild range, but we were twice assigned to Medicaid.

What’s new with the ACA?

With regard to MIChild and Medicaid – not much. Michigan residents use the federal marketplace to apply for insurance, since our state declined to establish its own exchange. The marketplace should currently advise applicants whether their children are eligible for Medicaid or MIChild, but according to federal Medicaid documentation, will continue to refer qualified applicants to the state application process.

Michigan’s Medicaid expansion, planned to take effect in April 2014, changes the eligibility requirements only for adults: those whose income is under 133% of federal poverty guidelines will be eligible. However, the federal government recently granted Michigan a waiver to include previously prohibited conditions for Medicaid coverage, including limited premiums and co-pays as well as “Healthy Behavior Incentives.” Until I can locate waiver details on the CMS website, you can read about them as described by this management and communications firm.



Success! I greet the new year with new health insurance ID cards in hand. Many of them, in fact. How did that happen?

Pre-Affordable Care Act

Until December 1, I was covered by an insurance plan purchased on the individual market. This fall, I received notice that the plan would be discontinued because it did not comply with the ACA. I did not mourn this plan. As mentioned in an earlier post, the only thing going for it was its merely moderately high premiums.

My insurance carrier repeatedly urged me to buy an alternate “Keep Fit” plan. However, I knew  that my federal tax credit would almost certainly make a plan purchased through the Marketplace a better bargain. The Keep Fit plan’s other disadvantage was its notice of “lower deductible and fitness reward if you meet certain health standards.” Translation: your fitness activities and health standards count for nothing if you’re fat. Much has been written about the discriminatory nature and lack of evidence basis of such a restriction, both by the Health at Every Size and Size Acceptance communities as well as those critical of the Workplace Wellness provisions included in the ACA. I hope to return to this topic in a future post; for now, let me simply say that I knew the “Keep Fit” plan was not for me.

Temporary Insurance

To cover the gap from December 1 to January 1, when I expected to obtain Marketplace coverage, I purchased temporary insurance. This is a tactic I’ve used in the past; I mention it here because it can be a useful stop-gap. I did not expect to need any medical care in December, and I made sure to take care of any existing dental problems beforehand. The temporary insurance, which I obtained from the agency that provides our car and property insurance, was simply a hedge against catastrophe. If, for example, I slipped down the stairs and needed brain surgery, the insurance would kick in after a certain amount to ensure that our family did not lose all assets in a medical emergency – a reasonable fear, given that a majority of U.S. personal bankruptcies are precipitated by a medical emergency. The temporary insurance doesn’t pay for any routine care, so it is not suitable for everyone. But it bought me peace of mind for a month.

Enrollment – check! Payment – uh…

As reported before, through the federal Marketplace I successfully enrolled in a new plan from my earlier insurer and was told to expect a bill within a week. But when I opened the bill that arrived several days later, I was surprised to see a premium 50% higher than the one I had been quoted. Some small portion of this was due to federal and state taxes, but the remainder still constituted quite a large difference. I immediately got in touch with by online chat, was referred to the special hotline – only to learn that once I purchased a plan from the Marketplace, I was essentially on my own. I tried to imagine what it would be like if I bought a plane ticket from Orbitz, for example, and then found that the airline had raised the price of my ticket 50%.

Next stop: the insurance company. After I waited a very long time on hold, the customer service representative easily explained the problem. I had missed the reference to “Keep Fit” on my bill. Remember Keep Fit? The plan I did not purchase? Apparently the insurer decided to enroll me without my permission and then billed me for it.

The problem was easily remedied: I was instructed to simply ignore the bill. Imagine, however, that I had dutifully paid it. Now multiply this error by however many former customers the insurer mistakenly enrolled in this plan. I’m sure reimbursement would have been possible after considerable time and effort, but the insurer would have had the use of money not its own for some time – and presumably reaped the benefit in interest.

My many cards

The problem is solved. I eventually received a bill for the plan I actually selected, and I set up monthly payments through my bank account. My premiums are considerably lower now than they were for my pre-December high-deductible plan. With the money I’m saving in premium payments, I plan to pay off debts to various health care providers, all of whom have been remarkably patient. I look forward to scheduling an appointment with my doctor – the first in over a year. For the moment, life is good.

The insurer sent me four different sets of ID cards, including ones for the mistakenly-assigned “Keep Fit” policy. The cards have now been dealt; I look forward to seeing how the game plays out.