Mama's Got a Plan:

Maternity Care, Health Insurance, and Reproductive Justice

Inciting mommy wars

An article of dubious quality quotes President Obama’s remarks on improving daycare:

And sometimes, someone, usually mom, leaves the workplace to stay home with the kids, which then leaves her earning a lower wage for the rest of her life as a result.  And that’s not a choice we want Americans to make.

Then it misinterprets these remarks with this title: Obama on Moms Who Stay Home to Raise Kids: ‘That’s Not a Choice We Want Americans to Make.’

It troubles me that readers take the article at face value and allow discussion of it to devolve into an argument about whether it is “better” for mothers to stay at home with small children or to remain in the paid workforce. These arguments serve only to divide us and to keep us from uniting in support of policies that safeguard all families.

On the whole I believe that making sure families have access to quality daycare is a positive move. I do, however, find some things troubling in the President’s speech.

Choosing to stay home – whose choice?

We love that word “choice,” don’t we? Our lives are just one big candy store and we get to pick whatever we want.


(L) Oliver Tarbell Eddy  (R) Dorothea Lange

The truth is that some people do get to pick, which is not to say that all their choices are necessarily desirable. And some people do not. For example, most people receiving government assistance are required to work outside the home. So if we do believe that it is “best” for children to have their mothers at home, clearly we have decided that some children do not deserve the best.

Equal pay for equal work – but what is work?

rosie the riveterPresident Obama supports equal pay for equal work, and I’m glad of it. But that is hardly a new proposition.

When parents leave the workforce in order to spend more time caring for their children, they are hardly leaving work behind – just paid work. We as a nation are reaping the benefit of these parents’ – mostly women’s – unpaid work. Just this week, the UN Special Rapporteur on extreme poverty called on countries “to recognize unpaid care work as a major human rights issue.”

If we really valued the work that is required to raise our children, we would fairly compensate anyone who took on this task: mothers, fathers, and traditional paid caregivers. These last are often parents themselves, struggling to afford care for their own children.

Many young parents do not consider that when forgoing wages in order to take care of children, they are also forfeiting future Social Security payments. Having children is the number one reason women in the U.S. fall into poverty – it’s easy to see why that is the case, but not why it should be.


Earning a lower wage for the rest of our lives – why?

Do we really believe that motherhood robs us of the ability to be competent workers? At the same time that we laud motherhood as being a difficult yet supremely worthwhile task?

People’s experience of parenthood differs, but it is hard to accept that everyone who makes cabinets or medicines or burgers or nuclear reactors somehow irrevocably loses the ability to do so after spending time with children. We can look to other countries that manage to not penalize women for taking time off work to raise children.

There is no reason we cannot adjust our national policy to support all parents – those who would like to be home with their children, those who would not, and those who want a little of both – regardless of whether they can finance these choices themselves or require government assistance to do so. In the end, parents know what is best for their families and should be able to make these decisions, free from mandates imposed on the basis of economics or skin color or profession. This is the third arm of Reproductive Justice: the freedom to raise our children in safe conditions and with dignity.

Are you listening, President Obama? I’ve just written your next speech for you. obama speaking


Midwife licensure in Delaware

crockett delaware licensureEmily Crockett of RH Reality Check wrote an excellent article on the state of direct entry midwifery in Delaware. She correctly identified the chief obstacle to practice: while the law requires these midwives to maintain collaborative agreements with physicians, physicians aren’t obligated to collaborate. The predictable result: no collaborative agreements and very few midwives who can legally practice.

How it works

A little additional context might be helpful to those wishing to understand how the law works and how it might be improved. First of all, let’s start by clearing up two terms that are often used interchangably, to everyone’s confusion:

  • Certification indicates that a certifying organization has confirmed an individual’s skills, training and education.
  • Licensure means that a state governments has granted a license to practice. Increasingly, state governments base licensure requirements on a specific certification.

For example: A direct entry midwife (i.e. a midwife who is not a nurse) successfully undergoes the education, training, and testing requirements to be certified by the North American Registry of Midwives as a Certified Professional Midwife (CPM). The certification alone does not permit her to practice legally in any state, any more than graduating from medical school allows a physician to practice legally. The midwife is lucky enough to live in Wisconsin, one of the twenty-six states in which CPMs can obtain a license. She applies for a license, pays her fee, and is able to practice under Wisconsin law. She must abide by the licensure requirements in statute as well as any rules that the governing state department or agency has promulgated regarding midwifery practice.

As long as we’re defining terms, let’s talk about different kinds of law:

  • Statutes are what ultimately result when your elected representatives pass legislation. Legislation is hard to pass and hard to amend, so anything that goes into statute should be something that is not expected to change too much over time.
  • Rules (or regulations) are exactly what they suggest: the practical directions for carrying out the legislature’s wishes as expressed in statute. Rules are typically written by whatever board or government department the executive branch of state government appoints or hires to oversee the practice authorized by the statute. Rules are often open to a public comment period or public hearing before they are finalized. Rules are much easier to change than statutes as they don’t need to be voted on in the legislature.

How it works in Delaware

Delaware is one of two states in which CPMs cannot obtain a license but are nevertheless legally authorized to practice. The extent of the authorization in statute is that the Delaware Department of Health and Social Services may issue regulations that:

Control the practice of non-nurse midwives including the issuance of permits and protect and promote the health of all mothers and children[.]  – Del. Code Ann. tit. 16, §122 (3)(h), emphasis added

In other words, the legislature left everything up to the Department of Health and Social Services, so most of the law that controls Delaware CPMs lives in the rules. And those rules, as outlined in Crockett’s article, require a collaborative practice agreement before a midwife can obtain a permit (note: not a license). As an aside, the rules require startlingly little else – the exact fee an applicant must pay, the kinds of births midwives may attend, the medications they may carry. None of these are specified, although there is a suggestion that some of these items fall under the collaborative agreement. It is possible, therefore, that the Department envisioned physicians as setting midwife standards of practice.

What’s the solution?

Current Delaware law may lead concerned parties to oppose regulating midwives. This is unfortunate, in my opinion, because the problem is not that midwives are regulated, but that they are regulated badly. Rather than being licensed as an independent profession, midwives are currently permitted to practice based on subordination to physicians. The remedy is full licensure – and that is exactly what advocates support in a bill currently active in the Delaware legislature.

The devil still remains in the details. Should the bill pass and become law, advocates must remain engaged throughout the process of rule promulgation in order to ensure that the rules are not restrictive to the extent that midwives are unable to practice.

Readers familiar with this issue may have noticed that I have failed to mention the safety of midwife-attended births. That may or may not be a subject for another post. However, in a sense it’s a moot point: the Delaware legislature obviously believes midwife-attended births are safe, because it passed legislation to permit midwives to practice under its constitutional and statutory duty is to protect the public’s health. Families will continue to have midwife-attended births; it is now the legislature’s duty to create an environment where midwives can practice under the protection and discipline of state law. At the end of the day, although licensure does not guarantee quality – just think of other health professions! or lawyers! – it does provide a structure where midwives’ qualifications are knowable and where midwives are subject to rules designed to keep parents and babies safe.


C-section rate a little high? You think?

Social networks are abuzz this week following the publication of the article, “Safe Prevention of the Primary Cesarean Delivery,” developed by ACOG (the American College of Obstetricians and Gynecologists) and the Society for Maternal-Fetal Medicine. ImageThe gist of the article is that the U.S. c-section rate, hovering somewhere around 25% of first-time births (and 33% of all births), is too high and measures should be taken to lower it. I couldn’t agree more.

However, before I fall all over myself congratulating ACOG for its perspicacity, I’d like to call attention to a few truths it has omitted. Commence strategic changes of headgear now!

Image Late to the party

Members of the overlapping midwifery, physiologic birth, and maternity care reform communities have been warning of the dangers of the rising c-section rate for decades. Because of c-sections’ greater risk of injury to both mother and baby as well as the consequent restrictions on mothers’ fertility, many advocates have emphatically sounded this warning for a long time. I think it’s fair to say that gladness reigns in these communities that ACOG has finally gotten the memo, but many of us would have been happier to see ACOG acknowledge its long delay in coming to these conclusions.

In fact, it would have been reasonable for ACOG to concede that perhaps these communities might be correct in some other stances as well:

  • MIdwives are widely acknowledged to be experts in lowering c-section rates, but the word “midwife” appears nowhere in the article. Doulas are mentioned in the context of the benefits of “the presence of continuous one-on-one support during labor and delivery.” However, overlooked is the reason why doulas are necessary: hospitals fail to provide continuous one-on-one support for their pregnant patients. Everyone is familiar with the obstetrician who swoops in at the last moment to catch the baby, but many new parents are not aware that labor and delivery nurses will for the most part be monitoring multiple patients’ fetal monitoring traces from a computer in another room. If ACOG is serious about lowering the c-section rate, it needs to get behind a model of care that can accomplish this. Rather than making patients responsible for providing their own support personnel at added cost, hospitals should step up by establishing and increasing midwifery services and empowering midwives to practice autonomously. As a bonus, hospitals could incorporate doula services.
  • Out-of-hospital midwives, particularly when they are direct-entry midwives rather than nurse-midwives, have long faced hostility from ACOG. It’s time for ACOG to recognize that families plan out-of-hospital births for many reasons, and that no amount of censure by obstetricians will change that. If ACOG is serious about lowering the c-section rate and improving the U.S.’s abysmal maternity and infant mortality rate, it should be falling over itself to learn from these midwives who are experts in protecting physiologic birth. It would also be a show of good faith if ACOG recommended protocols for hospital for receiving appropriate home birth transfers, as home birth is made safer if smooth transfers are a given. Finally, ACOG might consider throwing its political might behind state legislative measures to license direct-entry midwives and to permit nurse-midwives to practice autonomously to their full scope of practice.
  • While the article addressed limits on interventions such as inductions that are known to increase the number of c-sections, it left out others of the other widely acknowledged healthy birth practices, including encouraging patients in labor to move around and to avoid giving birth on their backs, and to refuse unnecessary interventions shown to increase c-sections, such as continuous electronic fetal monitoring.

Overall, I would remind ACOG that its members are experts in performing c-sections – and thank goodness, because this surgery can be life-saving. But to reduce the number of c-sections, ACOG would do well to look elsewhere for guidance.

ImageCausation, correlation, and stigma

It’s not only Weight Watchers, the First Lady, supermarket tabloids, and everyone’s family members who shame people for their size; medicine jumped on this bandwagon a long time ago. It is rare for a research study examining some aspect of pregnancy or childbirth to avoid blaming fat women for increased risk. The ACOG article doesn’t disappoint:

A large proportion of women in the United States gain more weight during pregnancy than is recommended by the Institute of Medicine (IOM). Observational evidence suggests that women who gain more weight than recommended by the IOM guidelines have an increased risk of cesarean delivery and other adverse outcomes. In a recent Committee Opinion, the College recommends that it is “important to discuss appropriate weight gain, diet, and exercise at the initial visit and periodically throughout the pregnancy.”  Although pregnancy weight-management interventions continue to be developed and have yet to translate into reduced rates of cesarean delivery or morbidity, the available observational data support that women should be counseled about the IOM maternal weight guidelines in an attempt to avoid excessive weight gain. (Citations removed)

While to the uninitiated this paragraph might seem eminently sensible, I invite you to consider the following thoughts:

  • The correlational evidence between weight gain and increase in c-sections is somewhat less than solid, by ACOG’s own admission. Even if the correlation were solid, it doesn’t mean that managing weight gain would resolve the problem – after all, the weight gain and adverse outcomes might both be caused by some third factor. Finally, even if causation were shown, there are vast amounts of evidence to show that in general, trying to control weight through restrictive eating and increased exercise is a losing game. In pregnancy, restricting intake may well have harmful effects on the child. One of the best sources for information on these matters is Pamela Vireday’s website, The Well-Rounded Mama.
  • Vireday also points out that adverse pregnancy outcomes for fat women can at least partially be attributed to weight bias-influenced pregnancy management practices. In addition, the effects of stigma as physiological mechanisms are beginning to be known; these effects might also account for some outcome disparities. Rather than demanding that pregnant patients their weight, providers might instead refrain from practices rooted in bias that increase stigma.
  • Finally, because poor nutrition and too much or too little exercise can be bad for people of all shapes and sizes, it would be more reasonable – and easier! – for practitioners to recommend good nutrition and appropriate exercise to all their patients rather than to target fat patients with weight control advice. This approach is in fact a feature of midwifery-led care and of the Health at Every Size philosophy.

However inured we have become to messages positioning fat as the the next Great Terror, I suggests we think critically about fairness, practicality, and evidence when making recommendations about what size or shape pregnant people should be.

Image Let’s blame all the lawyers

Physician anxiety over potential medical malpractice liability is a frequent topic when practice reforms are under discussion, particularly in the high-stake field of obstetrics. The typical solution proposed is tort reform – specifically, legislature-imposed caps on damage awards to injured parties. ACOG falls right into step:

A necessary component of culture change will be tort reform because the practice environment is extremely vulnerable to external medico-legal pressures. Studies have demonstrated associations between cesarean delivery rates and malpractice premiums and state-level tort regulations, such as caps on damages.  A broad range of evidence-based approaches will be necessary––including changes in individual clinician practice patterns, development of clinical management guidelines from a broad range of organizations, implementation of systemic approaches at the organizational level and regional level, and tort reform––to ensure that unnecessary cesarean deliveries are reduced.  (Citations removed and emphasis added)

Caps on damages, currently in place in a majority of states, can certainly lower the costs negligent physicians pay in damage awards and thus lower anxiety about liability, which in turn may lead to fewer c-sections. However, this strategy is akin to alleviating a family’s anxiety about its grocery bills by having it cut out breakfast and dinner each day: it solves one problem while creating a much more serious one.

The civil justice (“tort”) system enables individuals to obtain redress for civil wrongs without deploying government to do so; once a state government has established the necessary courts and basic rules of the game, private entities move the action along. Accordingly, the civil justice system is one of the few arenas in which individuals have the power to challenge negligent behavior of large, influential entities. In the realm of medical malpractice litigation, this capacity is further facilitated by the contingency fee arrangement that allows litigants to engage an attorney without paying a retainer fee. Attorneys front the costs of cases and receive payment only if the case is successful.

To limit the amount of damages awarded by juries is to undercut the redress that injured individuals can receive. If medicine wishes to avoid malpractice liability, numerous solutions are available:

  • Refrain from committing malpractice!
  • Eliminate the need for compensation. If families with babies injured at birth could be sure that the care required for the rest of the children’s lives would be available and accessible to them, one economic motivation for bringing suit would be removed. The considerable power of the medical lobby should be brought to bear on strengthening and broadening collective systems that compensate victims of illness, injury, and disability, such as Medicare and Social Security.
  • An approach pioneered by the University of Michigan demonstrates that liability after adverse events can be reduced when medical institutions provide 1. open communication and record sharing with patients, 2. early offers to settle when the institution is at fault and corresponding refusal to settle when not at fault, and 3. (if the institution is at fault) systemic changes, so the error is not repeated.

The three points above have been made before, and by wiser heads than mine. Rarely discussed, however, is the relative powerlessness of mothers to use the tort system to discourage non-medically-indicated c-sections. As the c-section has grown to an ever-greater proportion of American births, its potential harms have been increasingly played down, particularly those harms that are not apparent until subsequent pregnancies. As a result, projected damage awards are insufficient to induce plaintiffs’ attorneys to mount such cases and tort law thus fails to fulfill one of its functions of a feedback system to deter unsafe medical practices.

In “Distorted and Diminished Tort Claims for Women,” Jamie Abrams contends that tort law has come to privilege the claims of injured babies over those of their mothers in a way that “diminish[es] the birthing woman as a patient and a putative plaintiff.” She connects this primacy of the fetus as patient and plaintiff with the decline of the mother’s role as decision-maker for herself and the fetus. Among her recommendations to reverse this trend, Abrams suggests that “more pursuits of maternal harms claims are necessary. Even if the ultimate damage verdicts are nominal, the pursuit of damages will push courts to consider more carefully the harms to mothers and perhaps influence the standard of care.” If such actions could normalize for attorneys, judges, and juries the idea that unwanted and non-medically-indicated c-sections constitute harm to pregnant patients, just as the ACOG article finally admits, this might re-establish a remedy for patients who have suffered these harms. Furthermore, the tort system’s feedback function would then re-emerge to provide a counterweight to physicians’ traditional concerns that not performing c-sections exposes them to liability.

* * * * *

ImageIn summary, I congratulate ACOG on joining the party, however late, and urge it to mingle with all the guests, giving credit where credit is due. If ACOG can acknowledge the knowledge and experience of pregnant people, midwives, and yes, even lawyers, we might all join together to reverse the mounting c-section trend and make a safer world for parents and babies – and a less anxious one for physicians as well.

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.

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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 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 asked me for proof of income for 2014 – frankly, I would like proof of income for 2014 too. Neither, 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 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, 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 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.