Tagged Women’s Health

States Extend Medicaid For Birth Control, Cutting Costs — And Future Enrollment

The Trump administration is weighing whether to allow Texas to receive millions of federal Medicaid dollars for its family planning program, which bars abortion providers.

The Lone Star State eliminated its Medicaid-funded family planning program five years ago when state officials said they wanted to specifically exclude Planned Parenthood because the group provides abortions. Dozens of women’s health clinics closed as Texas established a wholly state-funded program that officials say today serves 220,000 women.

Medicaid’s family planning program is optional for states and used by half of them to provide contraception services for low-income women who earn too much to qualify for traditional Medicaid.

Texas, Iowa and Missouri gave up that federal money to avoid supporting groups that offer abortion. Planned Parenthood says it does not use any government money for abortions.

Texas is the first state to appeal to a more conservative White House to restore the funds. The federal government has historically declined to provide Medicaid dollars to states that don’t allow patients to choose between “any willing provider.” Texas is asking for a change in that position.

As part of its “Medicaid Nation” series, Kaiser Health News is examining the far-reaching impact of Medicaid — which has expanded its services in the past decade — and how millions of American households routinely access health care through its programs.

The provision that covers only family planning is a tiny part of Medicaid, which now serves about 74 million Americans. But it is seen by advocates as a vital way to avoid unwanted pregnancies and for states to save money by reducing Medicaid-covered births and coverage for infants and children.

Nationally, about 2.8 million people were enrolled in the coverage last year, according to a Kaiser Health News survey of state Medicaid officials. California alone had 1.8 million people in the program.

“This is expanding Medicaid to cut Medicaid,” said Elizabeth Momany, associate research scientist at the University of Iowa. “If you avert one childbirth, you save quite a bit,” she said, noting that children on full Medicaid remain in the program for at least five years after birth, on average.

Medicaid began in 1965 as a way to provide for poor children, their mothers and people with disabilities. Maternal benefits are a key part of traditional Medicaid. It pays for half of all U.S. births and covers 45 percent of children under the age of 6.

The federal government encourages the benefit limited to family planning— which does not include physician visits or hospital care — by covering 90 percent of the cost. In contrast, Medicaid covers births and related costs at 50 to 74 percent, with states picking up the rest of the tab.

The cost savings help explain why the family planning program is popular among states. Even some of those most opposed to the expansion of Medicaid under the Affordable Care Act — including the entire Southeast — largely take part in the Medicaid family planning program. North Carolina, South Carolina, Alabama and Florida rank in the top five by enrollment, behind California, the Kaiser survey found.

“For two decades, states across the country, red, blue and purple, have expanded Medicaid eligibility for family planning services because doing so helps people to avoid unintended pregnancies and to plan and space wanted pregnancies,” said Adam Sonfield, senior policy manager at the Guttmacher Institute, a reproductive health research organization that supports abortion rights. “In the process, that has also been proven to save the state and federal governments many millions of dollars.”

While eligibility and benefits vary by state, the family planning programs generally provide free coverage for a wide array of contraceptives, including birth control pills and long-acting implants. Some also provide checkups, assistance in kicking tobacco, cancer screenings and testing for sexually transmitted infections.

In family planning programs around the country, services are generally provided by Planned Parenthood clinics, county health departments, federally funded community health centers and private physician offices. Critics say prohibiting Planned Parenthood from family planning programs would hurt patients’ access to services.

Eligibility in some states starts as early as age 12, while others automatically enroll women in the programs after their maternity benefit expires, typically 60 days after giving birth.

In California and some other states, both men and women are eligible, but women make up the vast majority of the enrollees.

North Carolina Medicaid officials estimate the program saves the state about $15 million a year, according to spokesman Cobey Culton. 

Alabama has also seen savings. Kari White, a health policy professor at the University of Alabama at Birmingham, said the program covers about 120,000 women in the state with income levels below 141 percent of the federal poverty level, or about $17,000 for an individual.

An evaluation she conducted for the state last year found the birth rate for women enrolled in the program was one-third of what would have been estimated without the coverage.

“It helps to save Medicaid dollars overall to have these programs,” White said. 

Even the Trump administration, which is seeking to reduce the number of adults on Medicaid rolls, signaled its support of the family planning program in late December when it approved a 10-year extension of Mississippi’s program.

California’s program — called Family Pact (Planning, Access, Care and Treatment) — covers people with incomes up to 200 percent of the federal poverty level (about $24,000) who don’t have other sources of family planning coverage.

“It provides a very essential public health benefit to all Californians who otherwise wouldn’t get these services,” said Claire Brindis, director of the Philip R. Lee Institute for Health Policy Studies at the University of California-San Francisco, who evaluated California’s program.

A big reason California’s enrollment is so much higher than other states, in addition to its much larger population, is that undocumented immigrants can also receive the services, although their care is paid for only with state funds. 

Marta Mateo of Los Angeles is using the family planning program for a tubal ligation to prevent another pregnancy.

“I’m ready to have my tubes tied,” she said in the lobby at Eisner Pediatric & Family Medical Center as the youngest of her four children slept in her arms. “I don’t want any more babies.”

Mateo said she’s grateful for the coverage because her factory job doesn’t offer it, and she can’t afford to buy it on her own.

“I just don’t have the money for that,” she said. “This is a good opportunity for us to get care.”

Nationwide, the number of women covered by the Medicaid family planning program dropped from 3.8 million in 2013 to last year’s 2.8 million, as many people gained other coverage through the Affordable Care Act, according to the KHN survey and interviews with state officials. The enrollment decline was also due to several states discontinuing the program.

Three states that expanded Medicaid under the ACA dropped the program — Michigan, Illinois and Ohio. But the Medicaid expansion covers women up to 138 percent of the federal poverty level, which is an annual income of about $16,700 for an individual, while the family planning programs had an average eligibility level of 185 percent of federal poverty level, or $22,400.

Clash Over Abortion Hobbles A Health Bill. Again. Here’s How.

The Affordable Care Act very nearly failed to become law due to an intraparty dispute among Democrats over how to handle the abortion issue. Now a similar argument between Democrats and Republicans is slowing progress on a bill that could help cut soaring premiums and shore up the ACA.

At issue is the extent to which the Hyde Amendment — language commonly used by Congress to prohibit most federal abortion funding — should be incorporated into any new legislation affecting the health law.

Republicans generally want more restrictions on abortion funding. Democrats generally want fewer. Here’s a guide to the history of the current impasse:

What Is The Hyde Amendment?

The Hyde Amendment, named for Rep. Henry Hyde (R-Ill.), an anti-abortion crusader who died in 2007, prohibits federal funding of abortion in Medicaid and several other health programs run by the Department of Health and Human Services. Current exceptions allow for funding in cases of rape, incest or “where a physical condition endangers a woman’s life unless an abortion is performed.”

But the Hyde Amendment is not permanent law. Rather, it has been included every year since 1977 as a “rider” to federal spending bills. Hence, its exact language changes from time to time. The rape and incest exceptions, for example, were not included in the annual HHS spending bill from 1981 to 1993. During that time, the only exception was for abortions required to save a pregnant woman’s life.

Hyde-like language has been added to other annual spending bills over the years, so federal abortion funding is also now forbidden in private health insurance plans for federal employees, women in federal prisons, those in the Peace Corps and women in the military, among others.

Over the years, Democrats have worked, unsuccessfully, to eliminate the Hyde Amendment, charging that it unfairly harms low-income women who cannot afford to pay for abortions. Proposed elimination of the language was included in the Democratic Party’s 2016 platform.

Republicans have tried, also so far unsuccessfully, to write the Hyde funding prohibitions into permanent law. “A ban on taxpayer funding of abortion is the will of the people and ought to be the law of the la

nd,” said then-House Speaker John Boehner (R-Ohio) in 2011.

How Did The Affordable Care Act Deal With Federal Abortion Funding?

Republicans in both the House and Senate unanimously refused to support the Affordable Care Act when it passed Congress in 2010. Even without their backing, abortion remained a huge hurdle.

In order to pass the bill over GOP objections, Democrats needed near unanimity among their ranks. But the Democratic caucus at the time had a significant number of abortion opponents, particularly those representing more conservative districts and states. In order to facilitate the bill’s movement, House and Senate leaders agreed that the health bill should be “abortion-neutral,” meaning it would neither add to nor subtract from existing abortion restrictions.

That proved difficult. So difficult that to this day there is disagreement about whether the law expands or contracts abortion rights.

Democratic sponsors of the bill were buffeted by appeals from women’s groups, who wanted to make sure the bill did not change existing coverage of abortion in private health insurance; and from abortion opponents, led by the United States Conference of Catholic Bishops , who called the bill a major expansion of abortion rights.

The bill passed the House in 2009 only after inclusion of an amendment by Rep. Bart Stupak (D-Mich.), a longtime opponent of abortion. That bill included a government-sponsored health plan and Stupak’s provision would have made the Hyde Amendment a permanent part of that plan. The amendment also banned federal premium subsidies for private health insurance plans that offered abortion as a covered service, although it allowed for plan customers to purchase a rider with non-federal money to cover abortion services.

The Senate bill jettisoned the government-sponsored plan, so no restrictions were necessary on the abortion issue. And it was the Senate plan that went forward to become law. Still, differences remained over how to ensure that subsidies provided by taxpayers did not go to private plans that covered abortions.

In the upper chamber, a compromise was eventually reached by abortion-rights supporter Sen. Barbara Boxer (D-Calif.) and Sen. Ben Nelson (D-Neb.), who opposed abortion. Nelson was the final holdout on the bill, which needed all 60 Democrats then in the Senate to overcome unanimous GOP opposition. The Boxer-Nelson language was a softening of the Stupak amendment, but still allowed states to prohibit plans in the ACA’s insurance marketplaces from covering abortion.

In addition, President Barack Obama agreed to issue an “executive order” intended to ensure no federal funds were used for abortions.

In the end, both sides remained unhappy. Abortion opponents wanted the Hyde Amendment guarantees in the actual legislation rather than the executive order. Abortion-rights backers said the effort constricted abortion coverage in private health plans.

And both sides are still unhappy. According to the Guttmacher Institute, a reproductive health research group, 26 states have passed legislation restricting abortion coverage in any plan sold through the ACA’s insurance exchanges.

Another 11 states have passed laws restricting abortion coverage in all private insurance sold in the state. Nine of those states allow separate abortion “riders” to be sold, but no carriers offer such coverage in those marketplaces, according to a 2018 analysis by the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

Three states — California, New York and Oregon — require nearly all insurance plans to provide abortion coverage, according to the National Women’s Law Center.

What Abortion Provisions Do Republicans Want To Add To The Latest Health Bill?

The issue for 2018 is a bipartisan bill that seeks to “stabilize” the individual insurance market and the ACA’s health insurance exchanges by providing additional federal funding to offset some recent premium increases. Some options include restoring federal subsidies for insurers who cover out-of-pocket costs for very low-income customers and setting up a federal reinsurance pool to help insurers pay for very expensive patients.

But once again, the abortion debate threatens to block a consensus.

Many Republicans are dubious about efforts to shore up the health law. They still hope its failure could lead to a repeal they were unable to accomplish in 2017.

Even some who say they are sympathetic to a legislative remedy want to add the permanent Hyde Amendment language that was left out of the final ACA, although included in Obama’s executive order.

That is “not negotiable for House Republicans,” a spokeswoman for House Speaker Paul Ryan (R-Wis.) told The Hill newspaper. The White House has also endorsed a permanent Hyde Amendment.

But Sen. Patty Murray (D-Wash.), who has been negotiating the insurance bill for the Democrats, calls any additional abortion restrictions “a complete nonstarter” for Democrats.

Women In Medicine Shout #MeToo About Sexual Harassment At Work

Annette Katz didn’t expect to be part of a major social movement. She didn’t set out to take on a major health organization. But that all began to change when a co-worker saw her fighting back tears and joined Katz to report to her union what amounted to a criminal sexual offense at a Cleveland Veterans Affairs Medical Center in 2012 and 2013.

Four years later, Katz, a licensed practical nurse at the hospital, testified in a court deposition that a male nursing assistant had shoved her into a linen closet and groped her and subjected her to an onslaught of lewd comments.

In speaking out and taking legal action, Katz joined a growing group of women who are combating sexual harassment in the medical field at every level, from patients’ bedsides to the executive boardroom.

Much as the #MeToo moment has raised awareness of sexual harassment in business, politics, media and Hollywood, it is prompting women in medicine to take on a health system where workers have traditionally been discouraged from making waves and where hierarchies are ever-present and all-commanding. While the health care field overall has far more women than men, in many stations of power the top of the pyramid is overwhelmingly male, with women occupying the vast base.

In a recent survey, 30 percent of women on medical faculties reported experiencing sexual harassment at work within the past two years, said Dr. Reshma Jagsi, who conducted the poll. That share is comparable to results in other sectors and, as elsewhere, in medicine it had been mostly taboo to discuss before last year.

Dr. Reshma Jagsi, director of the Center for Bioethics and Social Sciences in Medicine at the University of Michigan, conducted a survey that found 30 percent of medical faculty women reported experiencing sexual harassment at work within the past two years. (Courtesy of Reshma Jagsi)

“We know harassment is more common in fields where there are strong power differentials,” said Jagsi, who is director of the Center for Bioethics and Social Sciences in Medicine at the University of Michigan. “And we know medicine is very hierarchical.”

Workers in the health care and social assistance field reported 4,738 cases of sexual harassment from fiscal 2005 through 2015, eclipsed only by fields such as hospitality and manufacturing, where men make up a greater proportion of the workforce, according to data gathered by the Equal Employment Opportunity Commission.

A Kaiser Health News review of dozens of legal cases across the U.S. shows similar patterns in the waves of harassment cases that have cropped up in other fields, from entertainment to sports to journalism: The harassers are typically male. The alleged harasser supervises or outranks the alleged victim. There are slaps on the butt, lewd comments and requests for sex. When superiors are confronted with reports of bad behavior, the victims, mostly women, are disbelieved, demoted or fired.

But recently, physicians have taken to Twitter using the #MeTooMedicine tag, sharing anecdotes and linking to blogs that chronicle powerful doctors harassing them or disrobing at professional conferences.

Women who work in cardiology recently told the cardiology trade publication TCDMD that they felt the problem was particularly widespread in their specialty, where females account for 14 percent of the physicians. A Los Angeles anesthesiologist made waves in a blog post urging “prettier” women to adopt a “professional-looking, even severe, hair style” to be taken seriously and to consider self-defense classes.

Among those speaking out is Dr. Jennifer Gunter, a San Francisco obstetrician-gynecologist, who recently wrote a blog post about being groped in 2014 by a prominent colleague at a medical conference — even naming him.

“I think nothing will change unless people are able to name people and institutions are held accountable,” she said in an interview. “I don’t think without massive public discourse and exposure that things will change.”

Dr. Jennifer Gunter, a San Francisco OB-GYN, recently wrote a blog post about being groped in 2014 by a prominent colleague at a medical conference. (Courtesy of Jennifer Gunter)

Lawsuits, many settled or still making their way through the courts, describe encounters.

A Florida nurse claimed that in 2014, a surgeon made lewd comments about her breasts, asking her in a room full of people if he should “refer to her as ‘JJ’ or ‘Jugs,’” the nurse’s lawsuit says. The nurse said she “responded that she wished to be called by her name.”

In other cases: A phlebotomist in New York alleged in a lawsuit that a doctor in her medical practice gave her a box of Valentine’s Day candy and moved in for an unwanted kiss on the mouth. A Florida medical resident alleged that a supervising doctor told her she looked like a “slutty whore.” A Nebraska nurse claimed that a doctor she traveled with to a professional conference offered to buy her a bikini, if he could see her in it, and an extra night in a hotel, if they could share the room. She declined.

A Pennsylvania nurse described the unsatisfying response she got after reporting that a colleague had pressed his pelvis against her and flipped through her phone for “naked pictures.” A supervisor to whom she reported the conduct expressed exasperation, saying “I can’t deal with this” and “What do you want?”

Dr. Kayla Behbahani, chief psychiatry resident at University of Massachusetts Memorial Medical Center, did not file a lawsuit but recently wrote about sexual harassment by a subordinate. In an interview, she said her instincts were to pity the man, and also to follow a dictate that’s drilled into medical students: Don’t make waves. So, she disclosed the harassment only after another woman’s complaint launched an investigation.

“As a professional, I come from a culture where you go with the flow,” Behbahani said. “You deal with what you’re dealt. In that regard, it was a dilemma for me.”

Annette Katz (pictured with her husband, Steve), a licensed practical nurse at the Cleveland Veterans Affairs Medical Center, testified in a court deposition that a male nursing assistant had shoved her into a linen closet and groped her and subjected her to an onslaught of lewd comments. (Courtesy of Annette Katz)

Annette Katz, the Veterans Affairs nurse, initially didn’t complain about the harassment. A single mother with two children, she needed her job. Her attacker, MD Garrett, was also a nursing assistant but had more seniority, was a veteran and was friends with her boss.

“I really did feel that I would lose my job,” Katz said in an interview. “I would be that troublemaker.”

But as the abuse escalated, she went to the VA inspector general and the Cleveland police.

She estimated that five times Garrett pushed her into a closet where he would ask for sex. She would “tell him ‘no’ and fight my way out of [his] grip,” her statement said. He shoved her into an unconscious patient’s bathroom and would “try to restrain me, but I eventually could break free.”

After one such assault, a colleague noticed tears in Katz’s eyes. The co-worker shared with Katz that she, too, had been a target of Garrett’s lewd behavior.

Katz and the colleague filed complaints in March 2013 with their union, the police and with their managers. That July, Garrett was indicted by a grand jury and later pleaded guilty to three counts of sexual imposition and one count of unlawful restraint. He was also dismissed from his job.

Reached by phone, Garrett said he agreed to the plea because he was facing multiple felonies and didn’t know what a jury would do. He said that even though he pleaded guilty to four misdemeanors, he did not commit the crimes of which he was accused. “There was no harassment; she and I were friends,” he said.

Speaking quietly, going to HR — if that worked, we wouldn’t be here.

Dr. Jennifer Gunter

In 2013, Katz sued the VA, alleging that it failed to protect her from harassment and retaliated against her by refusing to give her a job-site transfer before firing her for not showing up to work.

The VA attorneys argued that the department had no direct knowledge of harassing behavior before Katz reported it, and that once it was informed, immediate action was taken. Veterans Affairs deputy press secretary Lydia Blaha said in an email that anyone engaged in sexual harassment is swiftly held accountable.

The U.S. Department of Veterans Affairs agreed in February to pay $161,500 to settle Katz’s lawsuit.

Katz said it was costly and emotional to press on with her legal case but hopes it helps other women see that seeking justice is worthwhile. “I do think there are a lot of women who just suffer in silence,” she said.

Gunter, the San Francisco physician-blogger, said that needed change will come only when people who are more established across all professions stand up for those who are more junior. “Speaking quietly, going to HR — if that worked, we wouldn’t be here,” she said.

It’s ironic, she said, that as a gynecologist she’s trained to believe patients’ claims about sexual assault. In the workplace, though, it’s well-known that raising such matters can backfire. She added: “Physicians should be setting a standard on this.”

Docs Worry There’s ‘Nowhere To Send’ New And Expectant Moms With Depression

Lawmakers in California will begin debate next month on a bill that would require doctors to screen new moms for mental health problems — once while they’re pregnant and again after they give birth.

But many obstetricians and pediatricians bristle at the idea, saying they are afraid to screen new moms for depression and anxiety.

“What are you going to do with those people who screen positive?” said Dr. Laura Sirott, an OB-GYN who practices in Pasadena. “Some providers have nowhere to send them.”

Nationally, depression affects up to 1 in 7 women during or after pregnancy, according to the American Psychological Association.

And of women who screen positive for the condition, 78 percent don’t get mental health treatment, according to a 2015 research review published in the journal Obstetrics & Gynecology.

Sirott said her patients give a range of reasons why they don’t take her up on a referral to a psychologist: “‘Oh, they don’t take my insurance.’ Or ‘my insurance pays for three visits.’ ‘I can’t take time off work to go to those visits.’ ‘It’s a three-month wait to get in to that person.’”

She said it’s also hard to find a psychiatrist who is trained in the complexities of prescribing medications to pregnant or breastfeeding women, and who is willing to treat them, especially in rural areas.

“So it’s very frustrating,” Sirott said, “to ask patients about a problem and then not have any way to solve that problem.”

Moms are frustrated, too. After the baby comes, no one asks about the baby’s mother anymore.

Wendy Root Askew struggled for years to get pregnant, and when she finally did, her anxiety got worse. She couldn’t stop worrying that something would go wrong.

“And then, after I had my son, I would have these dreams where someone would come to the door and they would say, ‘Well, you know, we’re just going to wait two weeks to see if you get to keep your baby or not,’” Root Askew said. “And it really impacted my ability to bond with him.”

Wendy and Dominick Root Askew with their son. When the little boy (now 6) was born, Wendy struggled with postpartum depression. (Courtesy of Wendy Root Askew)

She likes California’s bill, AB 2193, because it goes beyond mandated screening. It would require health insurance companies to set up case management programs to help moms find a therapist, and connect obstetricians or pediatricians to a psychiatric specialist.

“Just like we have case management programs for patients who have diabetes or sleep issues or back pain, a case management program requires the insurance company to take some ownership of making sure their patients are getting the treatment they need to be healthy,” said Root Askew, who is now advocating for the bill on behalf of the group 2020 Mom.

Health insurance companies haven’t taken a position on the legislation. It’s unclear how much it would cost them to comply, because some already have infrastructure in place for case management programs, and some do not. But there is consensus among insurers and health advocates that such programs save money in the long run.

“The sooner that you can get good treatment for a mom, the less expensive that condition will be to manage over the course of the woman’s life and over the course of that child’s life,” Root Askew said.

Some doctors still have their objections. Under the bill, they could be disciplined for not screening. Some have said they worry about how much time it would take.

The health care system, and the incentives, aren’t set up for this sort of screening, Sirott said.

“Currently, I get $6 for screening a patient,” she said. “By the time I put it on a piece of paper and print it, it’s not worth it.”

It’s not clear whether the direct and indirect costs of screening would be worth it to the patients, either. Four other states — Illinois, Massachusetts, New Jersey and West Virginia — have tried mandated screening, and it did not result in more women getting treatment, according to a study published in Psychiatric Services in 2015.

Even with California’s extra requirement that insurance companies facilitate care, women could still face high copays or limits on the number of therapy sessions. Or, the new mothers might be so overwhelmed with their care for a newborn, that it would be difficult to add anything to their busy schedules.

What does seem to work, according to the study of mandated screening in other states, is when nurses or mental health providers visit new moms at home.

“Despite abundant goodwill, there is no evidence that state policies are addressing this great need,” the study’s authors report.

Supporters of California’s proposed bill, however, say doctors need to start somewhere. Screening is the first step in recognizing the full scope of the problem, said Dr. Nirmaljit Dhami, a Mountain View, Calif., psychiatrist. Women should be screened on an ongoing basis throughout pregnancy and for a year after birth, Dhami said, not just once or twice as the bill requires.

“I often tell doctors that if you don’t know that somebody is suicidal it doesn’t mean that their suicidality will go away,” she said. “If you don’t ask, the risk is the same.”

This story is part of a partnership that includes KQED, NPR and Kaiser Health News.

Medicaid Is Rural America’s Financial Midwife

ZANESVILLE, Ohio — Brianna Foster, 23, lives minutes away from Genesis Hospital, the main source of health care and the only hospital with maternity services in southeastern Ohio’s rural Muskingum County.

Proximity proved potentially lifesaving last fall when Foster, pregnant with her second child, Holden, felt contractions at 31 weeks — about seven weeks too soon. Genesis was equipped to handle the situation — giving Foster medication and an injection to stave off delivery. After his birth four weeks later – still about a month early, at 5 pounds 12 ounces — Holden was sent to the hospital’s special care nursery for monitoring.

Mother and son went home after a few days. “He was pretty small — but he’s picking up weight fast,” said Foster of Holden, now almost 4 months old.

Medicaid, the federal-state health insurance program for low-income people — including Foster, who most recently worked as a preschool teacher’s aide — is responsible for much of her good fortune.

Started in 1965, the program today is part of the financial bedrock of rural hospitals like Genesis. As treatments have become increasingly sophisticated — and expensive — health care has become inextricably linked to Medicaid in rural areas, which are often home to lower-income and more medically needy people.

Kaiser Health News is examining how the U.S. has evolved into a “Medicaid Nation,” where millions of Americans rely on the program, directly and indirectly, often unknowingly.

Medicaid covers nearly 24 percent of rural, nonelderly residents and offers some financial stability to rural facilities by reducing uncompensated care costs at hospitals that would otherwise be in dire straits. In some cases, it enables them to provide costly but vital services, such as high-risk maternity care.

Medicaid pays the tab for close to 45 percent of all U.S. births annually, and about 51 percent of rural births, according to research. In Ohio, Medicaid pays for about 52 percent of births, according to 2016 state data, the most recent available.

But efforts to control Medicaid costs are consistently high on Republicans’ to-do list. The Trump administration has encouraged states to introduce work requirements and other changes to Medicaid — changes that would almost certainly reduce the number of people it covers and the money rural hospitals receive. Ohio lawmakers have recently signaled they intend to require that Medicaid enrollees also be employed.

Matthew Perry, Genesis’ CEO, who identifies as conservative and finds plenty of fault in Obamacare, is concerned about high government spending. But he acknowledges that cuts to Medicaid would be deeply problematic for his hospital, affecting what services it can afford to provide. Perry keeps a map in his office to track local options for medical care, and the next-closest OB ward is an hour away in Columbus. What happens, hypothetically, if you take Genesis Hospital off the map?

“That’s a huge problem,” he said.

Brianna Foster sits with sons Carson (left) and Holden at her Zanesville, Ohio, home on Jan. 29, 2018. Foster, a Medicaid recipient, gave birth to Holden at a hospital just minutes from her home. (Maddie McGarvey for KHN)

Squeezed Hospitals, Cutting Costs

Like many rural hospitals Genesis is this area’s health care hub, the access point for primary care as well as mental health care, routine surgeries and other medical needs.

It is also central to the local economy.

Here in Zanesville, population 25,000, it seems as if almost everybody knows someone employed by the hospital.

Main Street is quiet — a stretch of scattered restaurants and pubs, county buildings and churches. Ten minutes away, across the river, Genesis anchors a stretch that would otherwise claim little more than fast-food chains, used car dealerships and cellphone shops.

This hospital, the flagship of a larger Ohio health system, is the product of a 2015 merger of two older town hospitals: Bethesda and Good Samaritan. Its 300 beds are the main source of health care across six counties — a quarter million people — and it delivers 1,500 babies per year.

Genesis Hospital, an acute-care facility in Zanesville, Ohio, is the main source of health care and the only hospital with maternity services in rural Muskingum County. The next nearest option is 60 miles away. (Maddie McGarvey for KHN)

Ask a woman in town where she would plan to deliver, and the answer is practically a given: Genesis, of course. Locals say it’s hard to conceive of a reality in which the hospital didn’t deliver babies.

In recent years, it’s also doubled down on other services, like cancer care, neurosurgery and open-heart surgery — which experts say can cushion a rural hospital’s bottom line, even if need isn’t as great.

Still, hospitals like Genesis often struggle with tight budgets and regular debates about whether cash flow can continue to support certain types of services. Rural hospitals have seen a sharp decline in the past decade. Nationally, 80 have closed since 2010 and the trend is expected to continue.

“When rural hospitals are squeezed, they have to look at what fixed costs they can shed,” said Katy Kozhimannil, an associate professor at the University of Minnesota School of Public Health, who studies obstetrics access. “The fixed costs of providing obstetrics services are very clear, and very distinct.”

Obstetrics requires pricey specialists, expensive malpractice insurance and, in the 21st century, the capacity to deal with extreme preemies and high-risk deliveries. At the same time, Medicaid reimburses hospitals less for this service— often below the cost of the care — than any other insurance program, making it a balance-sheet loss.

Already, about 45 percent of rural communities do not have a hospital with dedicated maternity care. From 2004 to 2014, almost 1 in 10 rural counties lost their hospital-based obstetrics programs, suggests research published last fall.

In Ohio, nine rural hospitals have dropped obstetrics since 2007 — including one that closed. The state currently has 73 small and rural hospitals in operation.

“We’ve seen a slow erosion of obstetrics in rural areas,” said Michael Topchik, national leader of the Chartis Center for Rural Health, an analytics and consulting firm. “And I’m afraid that further [Medicaid] cuts would exacerbate that trend.”

That scenario is part of the reason why rural health advocates have fiercely criticized GOP efforts at the federal and state level to cut Medicaid or to eliminate the Affordable Care Act’s option for states to expand eligibility for the program.

Research suggests that states’ expansion of Medicaid eligibility led to greater financial stability for rural hospitals. Also, more generous Medicaid coverage increases the odds that rural areas have any kind of obstetrics program.

Potential cutbacks offer a complicated calculation in this conservative town, with practical considerations bumping into politics.

“Things like trauma and obstetrics and behavioral medicine … they’ve got to be subsidized by other, more profitable things,” said Perry, the hospital CEO. “You can’t repeal the laws of economics.”

Still, Muskingum County backed Donald Trump over Hillary Clinton by more than 2-to-1. Its most recent congressional representative, Republican Pat Tiberi, was a vocal Obamacare critic who, until an early retirement this past January, consistently voted to repeal the ACA and pushed efforts to reduce Medicaid’s size and scope.

It’s obvious that better prenatal care means better outcomes.
Bijan Goodarzi, an OB-GYN at Muskingum Valley Health Center, a Genesis affiliate

(Maddie McGarvey for KHN)

A Public Health Concern

When pregnant women are geographically farther from health care, they and their babies are more likely to have poor outcomes, like lower birth weights, research suggests.

Foster said that if she had to travel to Columbus, she likely would not have made as many prenatal appointments. Each visit means scrounging up gas money and finding someone to watch her older son for at least three hours.

“It’s obvious that better prenatal care means better outcomes,” said Bijan Goodarzi, an OB-GYN at Muskingum Valley Health Center, a Genesis affiliate about a five-minute drive from the hospital.

And without an operational delivery unit, hospitals are unlikely to keep on staff obstetricians who are experienced in complicated births, experts said.

Keeping rural maternity services open with Medicaid funding also engages new mothers with the local health system in regions with high rates of chronic illness, drug addiction and smoking. The national opioid epidemic is acute in this corner of Ohio.

“What we see is someone who comes in with no teeth, or all rotted teeth or can’t eat. And she’s not complaining about dental work. She’s here worried about her pregnancy,” Goodarzi said.

Even as Obamacare repeal appears on pause, Medicaid remains vulnerable. In Ohio, many state lawmakers are pushing a cap on the state’s expanded Medicaid program — a controversial move that would almost certainly squeeze hospital revenue. Nationally, Republican leaders are weighing cuts to Medicaid, Medicare and other safety-net programs.

“If you pull too many of those foundational blocks out of the system that support the safety net … it can crumble,” said Perry, who worries about the effect of such cuts. “People can assume something’s always going to be there, when in reality, that assumption is not always true.”