Mama's Got a Plan:

Maternity Care, Health Insurance, and Reproductive Justice


A Third Amendment theory of abortion rights

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This cartoon grew out of the study of different constitutional theories of abortion rights, some better known than others. The First and Second Amendments of the Constitution have infiltrated the popular imagination, but the Third -? What is the Third Amendment, anyway?

Frame 1. The soldier in the title frame is General John Burgoyne, as shown in his portrait by Sir Joshua Reynolds, c. 1760.

Frame 2. Justice William O. Douglas first articulated the Privacy framework in the case of Griswold v. Connecticut (381 U.S. 479 (1965)), which concerned not abortion rights, but the right of married couples to use contraception. As Privacy is not a right specifically named in the constitution, Douglas introduced the concept of a penumbra, a cloud emanating from the Bill of Rights, chiefly the First Amendment. Privacy was defined as preventing the government from interfering with marital privacy. This protected area was later expanded to rights to contraception for unmarried people, and then to abortion rights (see Roe v. Wade, 410 U.S. 113 (1973).

Frame 3. Justice Ruth Bader Ginsburg believed that abortion rights were better protected by the Fourteenth Amendment’s Equal Protection Clause:

“… legal challenges to undue restrictions on abortion procedures do not seek to vindicate some gen­eralized notion of privacy; rather, they center on a woman’s autonomy to determine her life’s course, and thus to enjoy equal citizenship stature.”
Gonzales v. Carthart, 550 U.S. 124 (2007), dissent

Ginsburg’s critique of Roe‘s constitutional basis is described in greater detail in this article. Neil S. Siegel and Reva B. Siegel, in their 2013 journal article, “Equality Arguments for Abortion Rights,” further explore the Equal Protection argument by quoting Justice Blackmun’s dissent in Planned Parenthood  v. CaseyBlackmun asserts that the Court’s assumption that women “can simply be forced to accept the ‘natural’ status and incidents of motherhood—appears to rest upon a conception of women’s role that has triggered the pro­tection of the Equal Protection Clause.”

Frame 4. According to the History Channel, the photo of African-Americans in the cotton fields represents a “slave family standing next to baskets of recently-picked cotton near Savannah, Georgia in the 1860s.” The realities of slavery with respect to women’s reproduction has been ably addressed by Dorothy Roberts and Rickie Solinger, who discuss both the coercive nature of these women’s pregnancies as well as their subjugation to the role of producers of future slaves.

The connection to abortion rights is the Thirteenth Amendment, which forbids slavery and involuntary servitude. Legal scholar Andrew Koppelman, in his 2012 article, “Originalism, Abortion, and the Thirteenth Amendment,” draws an analogy between the forced labor of slaves, including their forced reproduction, and the forced labor of women compelled by abortion bans to carry their pregnancy to term. Of course, Koppelman is not claiming that absence of abortion access is equivalent in severity to the past system of slavery in this country, only that both issues can be seen as a violation of the Thirteenth Amendment.

Frame 5. The crowd at the 2004 March for Women’s Lives seems puzzled by the Third Amendment. The photo of the march by Bubamara, shared under a Creative Commons license, is augmented by an airplane towing a “Keep Abortion Legal” sign.

Frame 6.  At last! All is explained! The Third Amendment forbids the forcible housing of military personnel in a citizens’ homes. Its incorporation in the Bill of Rights was a reaction by the Founders to that very practice carried out by the British during the Revolutionary War. The home pictured here is the Brewster House of Setauket, New York, built in 1665. The photo is by Iracaz, shared under a Creative Commons license. The reluctant B&B host is taken from a work housed in the New York Public Library. She is Elizabeth Zane, whose exploits are detailed here; apparently, she was the inspiration for Zane Grey’s Betty Zane (1903), the first volume of his Ohio River Trilogy.

Frame 7. The Guttmacher Institute, one of the prime sources of U.S. abortion data, lists state abortion restrictions enacted during the last several years. The old woman in the shoe, it is surmised here, has so many children that she doesn’t know what to do because of these abortion restrictions. She accuses the state of forcibly housing a fetus in her uterus.

Frame 8. Prepare for a romp through property law, Dear Reader! (Remember, don’t go to law school.) We apply this question: when can someone else be in your home? In this frame, the fetus is compared to a guest who has been invited, but is now being asked to leave – as is acceptable at common law, under which guests of property owners or tenants possess relatively few rights. The scene shown, for those who came of age after reruns of The Jeffersons ceased, is of Mr. Jefferson ejecting Mr. Bentley. The dialog, however, is taken not from The Jeffersons, but from The Spellbinders Collection. Our thanks to Ed G. for suggesting this source.

Frame 9. On the other hand, perhaps the fetus is more like a tenant delinquent in rent payments and now facing eviction, as shown in this 1892 painting, Evicted, by Danish artist Erik Henningsen. This image is in the public domain. This comparison highlights the uncompensated nature of women’s labor: the fetus, after all, gives no consideration in exchange for housing – and neither does the state that imposes abortion restrictions.

Frame 10. We move on to trespassing. Harrison Ford, as President James Marshall, spends most of Air Force One (1997) playing hide-and-seek with a deadly group of planenappers. When Gary Holdham (“Ivan”) is finally in the president’s clutches, he is violently pushed off the plane. We show the classic line in a still from another scene (in which the president growls, “Leave my family alone!”). The true scene of Ivan’s end is here. It is worth mentioning that property owners are discouraged from using self-help to eject trespassers; since the president had no sheriff accessible, he can probably be forgiven for taking matters into his own hands.

Whether the fetus is trespassing on the pregnant person is an interesting philosophical question. However, given that almost half of all U.S. pregnancies are unplanned, it is fair to say that in many cases, the fetus is present against the pregnant person’s wishes.

Frame 11. Even a person who comes on the land without the owner’s permission may gain some property rights. A prescriptive easement is granted when a person takes adverse possession of the land: their use of the land is open, notorious, and hostile. That is, they use the land openly and against the owner’s wishes, continuously over the course of a statutory period defined by the state. At the end of this period, they are granted an easement to be on the land.

In Michigan, the statutory period is fifteen years. Therefore, we show a fifteen-year-old fetus establishing a Disco in Utero. Even if she is there without her mother’s permission, may she invoke the law in continuing to occupy the space, operate strobe lights and loud music, and dance all night?

Confirmation of the Michigan fifteen-year statutory period led to immediate thoughts of a prenatal quinceañeras celebration. Alas, there is not room here to explore this idea; the concept will have to be set aside for another cartoon. Forewarned!

Please note that this image is the only instance in this cartoon of a visibly pregnant person. That is because 65% of abortions in the U.S. are carried out by eight weeks’ gestation, before most pregnancies have begun to show at all. In fact, 91% of all abortions are carried out by thirteen weeks, still very early in a typical 40-week pregnancy. We felt that a fifteen-year gestation, on the other hand, really demanded a visibly pregnant person.

Frame 12. The final frame shows a 1787 painting of the Hartley family, by Henry Benbridge. We discovered this painting on the blog 18C American Women, maintained by art historian Barbara Wells Sarudy; we later tracked it down to the collection of the Princeton University Art Museum.

The ladies of Family Hartley are declaring their autonomy and personhood as an explanation of why an analogy of the fetus to an occupier of maternal land must ultimately fail. To separate pregnant person and fetus as conflicting entities – occupier and occupied – is tempting but unsound. As explained by the authors of Laboring On: Birth in Transition in the United States, mother and fetus constitute a bonded dyad.

A fetus is neither property nor a legal person, but a potential person. Women are not houses, airplanes, or discos. The fetus is not their possession, but part of them. The reason that pregnant people are the best decision-makers about abortion – or childbirth, for that matter – is that they are the experts. They hold close to their hearts the interests of their families, present and future, their own lives, and their many other responsibilities. They are vast. They contain multitudes.


Your cartoonist expresses gratitude to SMV for inspiring this cartoon through his persistent complaints of the sad neglect of the Third Amendment in both U.S. jurisprudence and high school government classes.

[Updated Oct. 22, 2016, for some minor grammar and punctuation fixes. Updated Oct. 23, 2016, to fix factual error about Griswold.]


The midwife national convention

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It’s time for the
Midwife National Convention!

Publicity for the upcoming annual conference of the Midwives Alliance of North America, combined with this summer’s Republican and Democratic national conventions, were the twin inspirations for this cartoon.  It seems unlikely that we will elect a midwife-in-chief anytime soon, but cherishing midwives’ skills and experience under the cover of political maneuvering seems like an end in itself.

References and Explanations

Frame 1. The background photo is from one of this summer’s conventions. Does it matter which? The MNC logo is based on a graphic by Sam Taeguk, shared under a Creative Commons license.

Frame 2. Every gathering needs a quilt exhibit! This quilt is intended to convey – by the variety of fabrics in the baby blocks – the diversity of North American midwifery. Every midwife has been caught out at least once wearing good clothes when the urgent summons to a birth arrives. What to do with those stubborn stains? When Spray N Wash fails, cut up that fabric for a quilt! Many thanks to Kathy Peters for her quilt design skills. The person gazing at the quilt is taken from a photo by Phil Roeder, shared under a Creative Commons license.

Frame 3. The photo by Pete Souza shows a 2009 meeting of President Obama’s cabinet, shared under a Creative Commons license. We’ve taken the liberty of cropping out the President, but perceptive readers will recognize individual cabinet members.

Frame 4. This frame shows the White House Situation Room, as portrayed in The West Wing.

Frame 5. This song, published in 1980 by Molly Scott of Sumitra, is sung here in the U.S. House of Representatives.

Frame 6.  Anyone with knowledge of the midwifery model of care will recognize the original context for the words MANA president Marinah Farrell is speaking to Vladimir Putin against the background of the Oval Office:

Laboring person: I can't do it!!!
Midwife: You're doing it!

The Midwifey Face is an invention of your cartoonist, who theorizes that midwives are endowed with special facial features or expressions that allow them to persuade anyone to do anything, no matter how difficult.

 


The right to refuse medical care

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The Law Giveth and Taketh Away:
Religion, Science, and the Right to Refuse Care

This cartoon grew out of our astonishment that, particularly in the context of childbirth, U.S. law seemed to most strongly approve the right to refuse care when the refusal was based on irrational grounds. Evidence-based refusals both in law and in fact seemed to meet with much stronger resistance.

Legal Basis for the Right to Refuse Care

The right to refuse care is itself based on the overarching ethical principle of informed consent. While common understanding of informed consent is that a patient has signed a consent form that allows a provider to continue with a suggested treatment or procedure, in reality informed consent is – or should be – a repeated process, in which the following actions take place:

  • The provider explains the suggested treatment or procedure. The explanation sets forth the risks and benefits of the treatment as well as the risks and benefits of any alternatives, including doing nothing. The provider must ensure the patient understands what they have been told.
  • The patient makes a decision based on the information received, as well as on their own values and circumstances.

Case Law

Although informed consent requirements are now incorporated into patients’ rights acts in some states, informed consent doctrine has traditionally evolved as interpreted through a line of court cases, as shown in this cartoon in dark red text.

  • Schloendorff v. Soc’y of NY Hosp., 105 N.E. 92 (N.Y. 1914). Patients who do not consent to treatment that is carried out on their bodies can sue the provider for battery, with exceptions for emergencies and unconscious patients.
  • Canterbury v. Spence, 464 F.2d 772 (D.C. Cir. 1972). Physicians bear a responsibility to explain the risks of a procedure to the patient before proceeding with treatment.
  • In re Quinlan, 70 N.J. 10, 355 A.2d 647 (NJ 1976). Patients may refuse care, even if not receiving the care might result in their death.
  • Stamford Hosp. v. Vega, 236 Conn. 646 (1996). The court ruled that the hospital had violated the rights of the plaintiff, a Jehovah’s Witness who refused a blood transfusion. The hospital had obtained a court order that allowed it to administer transfusions or blood products to the plaintiff for a postpartum hemorrhage. This case supports the right of a mother to refuse care, notwithstanding the contention that the loss of the mother would cause harm to the child.
  • McFall v. Shrimp, 10 Pa. D. & C. 3d 90 (July 26, 1978). A person cannot be forced to donate body tissue (here, bone marrow), even if not to do so would cause death in the person needing the donation, and even if the potential donor is a close relative (here, a first cousin).
  • Tamesha Means v. United State Conference of Catholic Bishops (appeal in progress). Tamesha Means, a Michigan woman experiencing a miscarriage at 18 weeks, was denied care at a Catholic hospital because her fetus still had a heartbeat. The hospital’s actions were a result of a directive of the U.S. Conference of Catholic Bishops that prohibits abortion under all circumstances. Rather than intervening when Means developed an infection, the hospital turned her away without disclosing that the refusal to treat her was based in religious belief rather than in the standard of care. The case was dismissed at the trial court, but Means appealed to the Sixth Circuit Court of Appeals, where it now awaits a decision.

Statute

Some provisions in state statute allow providers to refuse to offer care and require that parents accept care for their minor children.

  • Provider “Conscience Clause” statutes. Many states have enacted legislation to permit various health care providers to file a professional, ethical, moral, or religious objection to any procedure without any consequences for the individual provider or institution. Michigan’s law, Mich. Comp. Laws §§ 20182-4 concern abortion, but other states have enacted broader provisions for refusing to provide other services, such as filling contraceptive prescriptions.
  • Required newborn procedures. State public health code usually specifies mandated procedures to be performed on newborns. As a rule, the parents have the right to opt out of most or all procedures. In Michigan, for example, only newborn screening and prophylactic eyedrops are mandated by statute. The legal duty to perform the procedures tends to attach to the provider, which is perhaps why parents are discouraged from opting out, often to the extent of simply being told, “it’s the law” that their child receive these procedures. Other procedures, such as Vitamin K and Hepatitis B vaccine administration, are also often characterized by providers as being legally required. Enforcement varies by state; New York is usually held out as the strictest state in requiring parents to accept the procedures for their child. Regardless, parents are increasingly sharing anecdotes of being threatened with reporting to Child Protective Services if they refuse this care.

References and Explanations

Frame 1. The building in the background is, of course, the U.S. Supreme Court building.

Frame 2. Count Dracula is refusing a transfusion because he is a practicing Jehovah’s Witness, as signified by the copy of The Watchtower tucked under his arm.

Frame 3. Parents do have to put their foot down on serious matters like broken legs and Sunday School attendance. Parents are empowered by law to make medical decisions for their minor children. Children cannot give informed consent, although they are – ideally – consulted to see whether they assent to care. Little Jimmy apparently does not.

Frame 4. Thanksgiving dinner, when the family is all present and dismantling a large bird, seems the ideal time to talk about donating body parts. It’s either that or politics, right?

Frame 5. The nurse in this illustration is invoking a conscience clause right to refuse to assist with an abortion. If the refusal seems sudden, that is because state law does not require providers to register their refusal at any given time – or indeed, forbid them from changing their stance at any time.

Frame 6. Tamesha Means’s less than forthright provider (see Tamesha Means v. United State Conference of Catholic Bishops, above) did not inform her that she was suffering from an infection that could ultimately prove life-threatening. Means was fortunate not to be permanently injured, unlike a case in Ireland that ended tragically. See the story of Savita Halappanavar.

Frame 7. Many providers believe that a signed informed consent form of the kind that is often required when a patient is admitted to a maternity care unit constitutes a contract that cannot be changed. Nothing could be farther from the truth. Consent can be revoked vocally at any time.

Frame 8. The topic of who decides for the fetus is a rich one – and much too complex to include in this cartoon. Move along now!

Frame 9. Medical malpractice liability is often held up as an excuse for ignoring informed consent requirements – or as an opportunity to blame lawyers. (Health care providers tend to forget that lawyers defend them too!) This frame seeks to make the point that there is no corresponding liability avoidance right for the provider that would trump the patient’s right to refuse care.

Frame 10. Continuous electronic fetal monitoring (EFM) for all pregnancies is the standard of care in the United States, even though it has not been shown to improve outcomes in low-risk pregnancies. (It does reduce the number of seizures suffered by newborns, but not to the extent that final outcomes are affected.) Furthermore, EFM has been shown to lead to an increase in cesarean sections. Maternity care patients in particular have been heard to remark with surprise that they seem to be responsible for upholding their right to consented-to care that is also evidence-based. One would think that it would be the provider’s responsibility to offer this care, but … blame the lawyers! In truth, the provider’s hands often are tied – usually by their own institution’s policies or their malpractice liability insurer’s rates.

Frame 11. See Required newborn procedures, above. The mother in this frame is musing on the likelihood of her one-day-old baby being exposed to Hep B by sharing needles with a cribmate.

pastafarian-800Frame 12. If you have not yet become acquainted with the Church of the Flying Spaghetti Monster, you can remedy that omission here. Perhaps the strategy suggested in this frame is inadvisable, since a Nebraska Federal District Court declined to recognize FSM as a religion. You can find a lovely stained glass panel representing the FSM here. The story behind an adherent of FSM (a “Pastafarian”) and her successful struggle to be permitted to wear her religious head covering in a state ID photo is documented here.

 

[Updated July 16, 2016, to add copyright designation.]

 


Breastfeeding article posted on MSU bioethics blog

In Murphy’s Breast: Lactation Law and Advocacy in 2014, I discuss four instances in which breastfeeding parents found themselves affected by law and advocacy efforts last year. Many thanks to Michigan State University’s Center for Ethics and Humanities in the Life Sciences for inviting me to write this piece.

Special bonus for Mama’s Got a Plan readers: A fifth section of the post that had to be cut to meet length requirements is included below.  More is more!


 Section 2.5. The Sleeping Breast: We Really Think You Shouldn’t!

Public health recommendations have unwittingly discouraged breastfeeding by insisting on separating parents and babies during sleep, based on incomplete and sometimes outright faulty evidence. While maintaining breastfeeding depends on mothers’ ability to feed babies at night, the practice of bedsharing, common throughout the world, is discouraged in the U.S. for fear that sleeping parents will accidentally suffocate their babies. Many public health initiatives focus on procuring safety-rated cribs for newborns.

Proponents of bedsharing – and breastfeeding – have long held that while babies should sleep apart under certain conditions, such as having an impaired parent or one who smokes, in most cases infant safety increases when infants sleep in close proximity to their breastfeeding mothers, on an appropriate surface. The supposedly higher rate of Sudden Infant Death Syndrome (SIDS) attributed to bedsharing has been discredited by the presence of co-founding variables. Breastfeeding is believed to be protective against SIDS and, of course, in many other ways beneficial to infant health.

Evidence now shows that recommendations for separate infant sleep have actually harmed infant health. Parents who try to heed warnings to avoid bedsharing are more likely to fall asleep on couches or padded chairs with their infants; those surfaces are dangerous to infants, because babies may become trapped between their parents and padded crevices of the furniture.

How curious then that policy makers continue to emphasize “Safe Sleep” policies that equate deterrence from bedsharing with increased infant safety. Michigan went so far as to enact legislation that compels hospitals to advise new parents on infant sleep practices. To be fair, the law itself does not include a warning against bedsharing. It delegates the power to issue recommendations to the Michigan Department of Community Health – that persists in its prescription that babies sleep by themselves, on their back, without any items in their cribs. The law, having created additional liability for hospitals that fail to distribute safe sleep materials to their patients, excuses hospitals from such liability if they retain a “signed parent acknowledgment statement” of having received such materials.


You can read the article in its entirety here.

 


“[U]nconsented-to medical treatment is only generally a battery. Consent to a particular procedure may be “inferred from the patient’s action of seeking treatment or some other act manifesting a willingness to submit to a particular course of treatment.” [internal cite omitted]. Here, Carol came to the hospital for the purpose of medical treatment: the birth of Mikayla. The complaint itself admits that Carol had used marijuana and methamphetamines the week before giving birth to Mikayla. […] Insofar as we can determine from the pleadings and the record, Carol did not at any time communicate to any personnel at the hospital that she wished not to be tested for drugs. Testing Carol for drugs without first obtaining her consent did not constitute a battery here, where Carol unambiguously consented to the course of treatment — the birth of Mikayla — pursuant to which the drug test was conducted, and where Carol in no way communicated a desire not to be tested.”

I ran across the text above when looking for something else entirely in Michigan case law. In the 2008 case of Jodis v. Brubaker, the Michigan Court of Appeals apparently felt that when you enter a hospital to give birth, you automatically consent to anything your providers think is necessary, unless you explicitly tell your providers you do not consent to that procedure they haven’t told you about.

I will leave it to your imagination as to how this might play out for people in labor and what would happen if this scenario were extended to any other class of people seeking medical care.

What we have here is neither informed nor consent.


Not my usual topic, but not as far removed as you might think

Abortion rights article is not just about abortion!

My most recent article, “Michigan’s New Abortion Insurance Rider Law: Challenges, Spin, and Justice,” is now available on the blog of Michigan State University’s Center for Ethics and Humanities in the Life Sciences.

Although abortion rights is not my usual focus, fans of Mama’s Got a Plan may wish to read the article to the end to see how I tie abortion rights into the larger context of Reproductive Justice and then – presto! chango! – discuss the relevancy to my favorite topic of rights in pregnancy and childbirth.

Other content at MSU

MSU allowed me a great deal of freedom in constructing the article, for which I’m very grateful. I’d also like to thank them for inviting me to speak last year on the topic of vaginal birth after cesarean. The talk, The Declining Provider: Refusal, Responsibility, and Reasonableness, is still available as a free webinar.

Coming soon

  • Fun pop culture post
  • Custom-drawn blog header

Stay tuned!


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.