Policy Issue Analysis
Policy Issue Analysis
The right to superior maternal care is vital for the health of mothers and their babies in the United States of America. Sadly, expectant women often face an inadequacy of competent maternal care providers, especially those living in underserved regions of the country. The situation may compromise both prenatal and postnatal care provided to women, thus resulting in unsatisfactory outcomes for those involved. In some cases, women have to cover long distances, some taking several hours, in order to access these services, which may deter them from booking appointments with providers as often as they are supposed to (Anderson, 2013). The situation becomes worse during labor when the distance may even be fatal to either the mother or the child. This paper details an analysis of the Improving Access to Maternity Care Act, which was brought to Congress on the 3rd of March, 2015 by Representative Lois Capps, Representative Michael Burgess, Senator Tammy Baldwin and Senator Mark Kirk. This paper analyzes the bill, aiming at port rating a clear picture of the policy problem, the various factors relevant to the bill, including social, economic, ethical, political and legal factors, stakeholders, as well as its significance and relevance in solving the issues it was meant to address.
Problem Identification/Policy Problem Description
There is a considerable shortage in the number of doctors who provide prenatal and postnatal care services. According to the American College of Obstetricians and Gynecologists (ACOG) (2015), there will a deficit of roughly nine thousand to fourteen thousand obstetrician-gynecologists by 2035. Currently, one in seven practitioners has quit active practice, creating a serious crisis in over twenty states in the US. Scholars have provided diverse hypotheses for this trend. Kennedy & Kodate (2015) argue that, as it has been proven throughout history, the practice of obstetricians ages as they grow older. Therefore, it becomes difficult to maintain a steady call schedule for a small number of expectant mothers. Moreover, the increasing cost of malpractice insurance is unsustainable for a practitioner who has few deliveries to perform. In fact, obstetrician-gynecologists can halve their insurance premiums by doing away with their obstetrical responsibilities. This shortage in qualified obstetricians makes it difficult for some women to find the care they need during pregnancy and birth.
The recent economic times have widened the gap between the poor and the rich, creating notable class differences. Inequalities in income in the United States have continued to increase since the 1970s, a trend that is manifested in both income before tax and after tax. Income inequality in the US is among the worst compared to other developed nations, implying that a relatively less proportion of income is shifted from high income households to low income households. Consequently, this has led to lack of quality education in some areas and only a fewer people specializing in fields that are relevant to the provision of prenatal and postnatal care (Dalen et al., 2015).
Another significant reason that students and practitioners alike cite for avoiding the gynecology and obstetrics fields is the apprehension of malpractice charges. Theoretically, an insurance cover is supposed to shield them from the financial burdens associated with lawsuits, but it cannot eliminate the anxiety and stress as a result of the fear of being indicted. Surprisingly, such fear is not unfounded, since the average obstetrician or gynecologist will be sued about three times in his or her career. Over 90 percent of all obstetricians and gynecologists face lawsuits at some point before they retire (Anderson, 2013). These figures are better for most other professions.
The cost of education on its own is a significant disincentive. On average, a medical student accrues a debt of about $175,000, while the mean salary is only $220,000 for obstetricians and gynecologists, and only $150,000 for general practitioners. Although these figures may not sound small, factoring in the financial and time investment in medical school and residency and the probability of getting a lawsuit, other opportunities that require significantly less schooling seem more attractive to bright and ambitious people (Anderson, 2013).
The Medicaid and CHIP Payment and Access Commission (MACPAC), in a report dated June, 2013, highlighted that procuring coverage for maternity services is not a guarantee of accessing the required care. The persistent changes in the demographics of maternal care providers, regionalization, restructuring and closure of multiple maternity care centers, and the variation among practice environments have resulted in difficulties in accessing maternity care providers.
In 2013, for instance, the US population was comprised of 160.5 million women and girls. Approximately 74 million of them had acquired a child-bearing age. In the same year, there were 3.9 million recorded births, 11,392 certified midwives and nurse-midwives and 40,921 members of the American College of Obstetricians and Gynecologists. From these figures, the ratio of maternal care givers to women and girls was 3.3:10,000, which may be lower if the number of obstetrician-gynecologists who had quit active patient care is factored in.
A study by Eugene DeClercq, a professor at the School of Public Health in Boston University, in 2011, revealed that about 56 percent of counties in the US had no certified nurse midwives or certified midwives, 46 percent had no obstetricians or gynecologists, and 40 percent had neither certified nurse midwives, certified midwives, obstetricians or gynecologists (ACNM, 2015). Sadly, millions of women and girls live in these regions. Scarcity of maternal care givers often results in long and cumbersome waiting queues for appointments, or long journeys to prenatal or birth centers. Additionally, care givers in this field have become increasingly prone to work-related challenges as a result of issues such as unpredictable working hours, professional liability, decline in the number of residency programs, reduction in interest in medical studies by students, and escalating sub-specialization by graduating students (Carroll, 2010). All these factors have colluded to cause a shortage in maternal and reproductive care providers, particularly in underserved areas.
In 2014, the preterm birth rate was 11.4 percent. The number of children born with a low birth weight has been rising progressively over a quarter century, with the US rate being 8 percent in 2013. 44 percent of all maternal hospital stays related to childbirth in 2013 were paid for through the Medicaid program, while 52 percent were charged to private insurers. In 2012, private insurers were the primary payers for pregnancy and childbirth (14 percent) and newborns (13 percent), comprising of 27 percent of the total hospital discharges in that year. From these figures, it is evident that the bill is cost neutral (ACNM, 2015).
The acute shortage of qualified care providers in maternal care has a detrimental effect on mothers and children, leading to birth complication, high rate of still and premature births, as well death of mothers during labor and childbirth (Georgia Department of Public Health, 2015). According to recent studies, the rate of maternal deaths in the US is on an upward scale, increasing to more than double the rate 25 years ago. Professionals agree that the rate of maternal deaths is not decreasing, is underrated, fundamentally avertable and inexplicably affects selected groups of people (Alden et al., 2014). The recent rate is estimated to be 15 cases in every 100,000 live births. Approximately 700 mothers lose their lives to complications related to pregnancy and childbirth, while over 52,000 experience emergencies, including shock, renal failure, respiratory distress and heart surgery (CDC, 2010). Although several factors are responsible for this worrying trend, the shortage of obstetricians and gynecologists in the US, especially in underserved areas, is cited as one of the key causes.
The crisis in the public health sector is a serious one. A deficiency of qualified specialists to provide prenatal care and delivery alternatives is associated with an increase in children born with low birth weights, maternal deaths and infant mortality. According to a study by the March of Dimes Foundation, the standard cost of providing medical care to a low birth weight or premature baby during its first year is approximately $49,000. On the contrary, it only costs $4, 551 to care for a child born without any complications. This report highlights the significance of quality maternity care (Landau, 2011).
Every woman has a right to quality medical care. Health care services should be equally accessible to all, regardless of one’s place of residence, race, gender or ethnicity. This right to quality care during pregnancy and childbirth has been severely violated as a result of the shortage of qualified practitioners in the US. Women in underserved regions cannot access maternal services as and when needed. Additionally, the right to life is also violated as a result of the crisis. Every person, irrespective of age, has a right to live. The deficiency of professionals to attend to women during birth has increased the rate of death of both mothers and children (Dalen et al., 2015).
Political and legal Factors
The shortage of maternity care practitioners presents a political nightmare for representatives of the shortage areas. The people living in these areas may view the crisis as a case of neglect from their elected leaders. Additionally, there may be legal cases when people consider the shortage as a contravention of their constitutional rights to life and quality health care.
The issues surrounding maternity health care in the US represent a significant shortcoming of the current legislation on public health, which can only be solved through appropriate amendments of the existing laws.
There are numerous interest groups in this bill. Medical practitioners such as doctors and nurses, insurance firms, professional associations, human rights associations and politicians all have a stake in the outcome of the Improving Access to Maternity Care Act. This bill may receive limited resistance from any of the involved parties since most of them stand to gain if the bill is passed. Existing practitioners will have less burden to carry and less lawsuits. Professional associations, human rights groups and politicians all stand to gain from this bill. However, insurance firms may see the bill as a potential threat to their income stream since permitting National Health Service Corps to serve in underserved areas will mean less obstetricians and gynecologists will sign up for medical liability cover.
S.628/H.R 1209 – Improving Access to Maternity Care Act of 2015 was introduced to Congress on the 3rd of March, 2015. It proposes amendments to the Public Health Service Act and requires the Health Resources and Service Administration to specify areas with shortages in qualified maternity health care providers and to conduct an annual review of these designations. Under the amendments, National Health Service Corps (NHSC) providers will be able to provide services in medical centers situated in designated shortage areas, thus availing requisite care to expectant women and facilitating them to get the mush needed maternity care (ACOG, 2015).
The bill seeks to find a solution to the adverse effects of the shortage in maternity care providers. By identifying and classifying shortage areas, the responsible authorities will be in a position to channel required assistance to such areas, as well monitor the outcomes of all policies implemented in these areas. Incorporating maternal health designations is a suitable and satisfactory approach to enhancing public health in the US. It will reduce the general cost of maternity care by ensuring that mothers can access requisite prenatal care and delivery alternatives. Enactment of the bill will also provide accurate data to the NHSC to efficiently allocate maternity care providers (Hay & Connors, 2010).
However, the issues proposed by the bill do not offer an absolute solution to the bill. A more lasting solution would be finding ways to increase the number of practicing obstetricians and gynecologists. Limiting the lawsuits against maternity care providers or subsidizing their educational loans and insurance premiums would attract more people to this field.
Evaluation of Bill – See Appendix I
Results of Analysis and Summary
The Improving Access to Maternity Care Act provides a basis for identifying areas in need of additional maternity care specialists and facilities. It mandates the HRSA to categorize such areas and review them annually. In addition, it allows the NHSC to provide incentives to obstetricians and gynecologists to provide their services in shortage areas. Such measures are only effective, efficient and equitable in the short run. A more permanent solution would be identifying the real causes of the shortage and finding measures to address them.
To ensure that the real causes of the shortage are addressed, some additions to the proposed bill are necessary. Advocating for the change may be dome in various ways. The first way is to approach members of the committee discussing the bill. Arranging a meeting with someone on the committee who is well versed with this issue may help in bringing the propose changes into perspective. The second way may be through the use of interest groups ad professional lobbyists. These organizations are usually stakeholders who are usually interested in the outcome of the bill (Hamric & Delgado, 2014).
It is important to gather data on shortage areas. Such data may be used to channel help to specific areas. The current shortage of maternity care experts has adverse social, economic, ethical, political and legal factors. The Improving Access to Maternity Care Act seeks to find a solution to these issues by amending the Public Health Service Act. The Health Resources and Service Administration (HRSA), is required to categorize those regions with a shortfall of qualified maternity care experts and labor and delivery centers. However, the bill does not provide a solution to the shortage. The real issues behind the shortage, including high premiums on medical liability insurance, high educational loans and the fear of lawsuits, have not been addressed. Additional measures to deal with the reasons responsible for the shortage are necessary to ensure that a future crisis is averted.
Talking Points – See Appendix II
Evaluation of Bill
S.628/H.R 1209 – Improving Access to Maternity Care Act
Evaluation Criteria Pro Con
Effective Categorizing and acquiring vital information about areas that are in dire need of maternity services and professionals, is the first and most important step towards addressing the shortage in obstetricians and gynecologists. This bill lays the groundwork for any other future measures that may be taken. Moreover, there is an already established system for classifying shortage areas in primary care, mental health and dental care which this new bill may utilize (Alden et al., 2014). This bill only addresses the designation of shortage areas and role of the HRSA in allocating specialists to these regions by providing various incentives. However, research shows that the number of students enrolling for obstetric or gynecology residences is declining (Carroll, 2010). The bill fails to address the real issues behind the decline in the number of maternity care specialists, such as the high costs of insurance. As such, it may fail to solve the public health concern.
Efficient The bill will reduce the general cost of maternity care by ensuring that mothers can access requisite prenatal care and delivery alternatives. Additionally, the bills imposes no extra costs on US citizens since it does not create new overheads, but focuses on the already existing ones (Hamric & Delgado, 2010). Although the bill does not impose any additional costs on the citizens, the money that will be spent incentivizing existing practitioners to work in shortage areas could be spent on more long-term solutions. The loan premium payable by practicing obstetricians and gynecologist and the educational loans for medical students may be subsidized by the government (Hamric & Delgado, 2014). This would attract more people to this field, thus ensuring a lasting solution to the problem.
Equitable The current situation entails a shortage of maternity care specialists, particularly in remote areas. This bill ensures that all women have equal access to quality maternity care, regardless of their race, ethnicity or place of residency. Women in underserved areas will no longer have to wait for long for appointments, or to travel long distances to access prenatal care or birth centers (Congress.Gov, 2015). The bill is equitable in all aspects. It creates a way of ensuring that all women get equal treatment in the US (Congress.Gov, 2015).
S.628/H.R 1209 – Improving Access to Maternity Care Act
Definition of bill
A bill is a legislative procedure introduced in the Congress. A number is assigned to bills from each house according to the order in which they were introduced at the start of each Congress. Every bill has to be passed by both the Senate and House in identical manner before being signed by the President into law (Congress.Gov, 2015).
Importance of this bill
According to the 2013 census data, the US population comprised of 160.5 million females. About 73.7 million of these females had acquired a childbearing age of between 15 to 49 years (Census.gov, 2013). Data from the CDC Viral Stats indicates that there were 3.93 million births during the same year (CDC, 2010).
In 2013, the ratio of maternity care experts was 4 for every 10,000 women above the age of 15 (ACNM, 2015).
There has been no notable increase in the number of graduates from medical schools enrolling for OB/GYN residencies for over three decades (ACNM, 2015).
A report by Eugene DeClercq, a professor at Boston University, showed that, in 2011, 56% of the counties in the US lacked Certified Nurse Midwives (CNM), 46% lacked OB/GYNs while 40 did not have either a CNM or an OB/GYN (Anderson, 2013).
As a result, millions of women have to endure long waits for appointments, or travel long distances to access prenatal care and birth centers.
Prenatal care has a significant effect on the rate of premature births and children born with a low birth weight, which have enduring costs and ramifications (March of Dimes, 2015).
There has been no significant change in the number of maternity care professionals in these counties over the past decade.
Potential effects of this bill
According to the bill, the Health Resources and Service Administration (HRSA) is required to categorize those regions with a shortfall of qualified maternity care experts and labor and delivery centers (Congress.Gov, 2015).
Presently, HRSA classifies other forms of shortage areas, including mental health, primary care and dental care. This implies that there is a working system for establishing the area identifiers ACNM, 2015).
How the bill will affect the National Health Service Corps (NHSC)
Currently, it is the role of the HRSA to facilitate the assignment of health care experts in various selected shortage regions. It does so through the provision of scholarships and loan repayments via the NHSC to those professionals working in shortage areas for a specific amount of time (Kennedy & Kodate, 2015).
OB/GYNs and CMs/CNMs can also be included in these schemes, subject to being placed in an area that has been identified as a shortage area for mental health, dental or primary care professionals. However, these areas may, or may not overlie areas in dire need of maternity care professionals (ACNM, 2015).
By newly designating areas with a shortage of maternity care professionals, the HRSA, through the NHSC, will be able to support those whose proficiency preeminently aligns with the specific form of shortage (Carroll, 2010).
The bill creates no new expenditures, but instead, it better focuses on the current expenditures.
ACNM. (2015). Improving Access to Maternity Care Act of 2015. Retrieved July 3, 2015, from http://www.midwife.org/Improving-Access-to-Maternity-Care-Act-of-2015
ACOG (2015). Women’s Health Care Physicians. Retrieved July 3, 2015, from http://www.acog.org/About-ACOG/News-Room/Statements/2015/ACOG-Applauds-Introduction-of-the-Improving-Access-to-Maternity-Care-Act
Alden, K., Lowdermilk, D., Cashion, M. & Perry, S. (2014). Maternity and Women’s Health Care. London: Elsevier Health Sciences.
Anderson, R. E. (2013). Ob-Gyn shortage is going to get worse. Retrieved from http://www.livescience.com/37824-obgyn-shortage-looming.html
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Hay, D., & Connors, C. (2010). Midwives, ob-gyns support bill to address maternity care provider shortage to provide pregnant women with greater access to services where they live. Retrieved July 3, 2015, from http://www.midwife.org/ACOG-and-ACNM-Press-Release
Kennedy, P. & Kodate, N. (2015). Maternity services and policy in an international context : risk, citizenship and welfare regimes. Abingdon, Oxon New York, NY: Routledge.
Landau, E. (2011). Retrieved July 3, 2015, from http://www.cnn.com/2009/HEALTH/03/17/premature.babies/
March of Dimes. (2015). The impact of premature births on society. Retrieved from http://www.marchofdimes.org/mission/the-economic-and-societal-costs.aspx#
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