SD15 - Financing Maternal and Child Health Care

  • Published: 1988
  • Author: General Assembly. Joint Subcommittee
  • Enabling Authority: Senate Joint Resolution 172 (Regular Session, 1987)

Executive Summary:
AUTHORITY FOR STUDY

During the 1987 Session of the General Assembly, Senator Clarence A. Holland was the chief patron of Senate Joint Resolution No. 172 (Appendix A). The resolution created an eight-member joint subcommittee to assess the extent of the problem of uncompensated prenatal care and delivery services and to develop statewide solutions. The joint subcommittee was requested to complete its work prior to the 1988 General Assembly.

The membership of the joint subcommittee was appointed as follows: The Senate Privileges and Elections Committee appointed Senators Clive L. DuVal and William A. Truban from the Senate Finance Committee and Senator Clarence A. Holland from the Senate at large; and, the Speaker of the House appointed Delegates Robert S. Bloxum, Frederick H. Creekmore, George H. Heilig, Jr., and A. Victor Thomas from the House Appropriations Committee and Delegate Joan H. Munford from the House of Delegates at large.

ACTIVITIES OF THE JOINT SUBCOMMITTEE

The joint subcommittee was created to determine what steps could be taken to improve the financing of maternal and child health care services in Virginia. In particular, the joint subcommittee was directed to review certain new options available under Medicaid to expand coverage for services to lower income, pregnant women and their children.

The joint subcommittee held its organizational meeting in Richmond on June 29, 1987. Senator Clarence A. Holland was elected Chairman and Delegate Joan H. Munford was elected Vice Chairman. Dick Hickman and Jane Kusiak presented a background report on the problem of uncompensated prenatal and delivery care. This report is included as Appendix B.

The joint subcommittee held its second meeting in Virginia Beach on July 27. Presentations were made at that meeting by the Commissioner of Health, Dr. C.M.G. Buttery, local health department directors from Eastern Virginia, the Medical College of Hampton Roads, and the Virginia Medical Society. Mary Devine of the Division of Legislative Services summarized the activities of the joint subcommittee on tort reform.

The third meeting was held in Lynchburg on September 21. At that time Maston T. Jacks, Deputy Secretary of Human Resources, presented the results of a secretarial task force which analyzed the costs of expanding Medicaid for prenatal and delivery care. This report, as amended, is included as Appendix C. Stephen Pace, a consultant to the Virginia Hospital Association, also presented his report on the extent of uncompensated deliveries in selected hospitals. The text of this report is included as Appendix D.

Other speakers included representatives of local health departments in Western Virginia, the Medical College of Virginia Hospital, the University of Virginia Hospital, local area hospitals in Lynchburg and Roanoke, the Perinatal Services Advisory Board, and the Virginia Primary Care Association.

The final meeting of the joint subcommittee was held in Richmond on November 9. At that time staff presented a draft report which was amended and adopted, as follows:

FINDINGS AND RECOMMENDATIONS

The joint subcommittee recommends that the Commonwealth expand Medicaid coverage for lower income pregnant women and their children. Evidence has been presented to suggest such coverage would, in the long run, reduce medical expenses related to low birth weight deliveries. In particular, expanded coverage for prenatal and delivery services could reduce expenses for specialized neonatal intensive care, special education and other life long support services for low birth weight infants.

Virginia has the option of expanding Medicaid eligibility to cover pregnant women and children with family income up to the federal poverty level. This option was approved as part of the 1986 Omnibus Budget Reconciliation Act, in October, 1986. A report to the joint subcommittee by the Virginia Hospital Association suggests that such coverage might offset as much as 20 percent of the current burden of uncompensated delivery care now placed on hospitals by women who have neither public nor private insurance coverage.

At the same time, the joint subcommittee recognizes that simply expanding Medicaid coverage for prenatal and delivery services will not by itself reduce the number of low birth weight infants and the infant mortality rate.

In order to improve pregnancy outcomes we must recognize that our greatest problem is the persistence of a high-risk target group of young women who are not as likely to use available services in the absence of outreach and support.

In order to help this target group we must encourage improved prenatal health through a comprehensive effort to identify barriers to services, develop outreach programs to overcome these barriers, and evaluate their effectiveness in improving access to prenatal care. Such a comprehensive effort should include expanded case management and support services. Evidence from various local health departments indicates that such efforts can have a substantial impact on reducing infant mortality and morbidity.

The joint subcommittee recognizes the need for increased reimbursement for obstetricians who deliver infants of Medicaid patients. Recognition must also be given to the need to strengthen the capacity of our local health departments to prevent unwanted pregnancies and to provide necessary outreach and prenatal care services for the indigent.

Action Steps to Improve the Medicaid Program

The joint subcommittee therefore urges the Governor, in preparing his budget recommendations for the 1988-90 biennium, to set aside General Funds for the following purposes:

1. Expand Medicaid eligibility to cover pregnant women and children up to age one whose family income falls below the federal poverty level ($11.1 million GF).

2. Expand Medicaid services to include prenatal care for pregnant women whose family income falls below the federal poverty level ($1.7 million GF);

3. Expand Medicaid services to include targeted case management ($3.7 million GF);

4. Expand outreach efforts through the Departments of Health and Medical Assistance Services to increase the likelihood that increased public expenditures will have the desired outcome ($494,000 GF); and,

5. Increase Medicaid reimbursement rates for obstetricians from the 25th to the 35th percentile to assure access to care by increasing the number of obstetricians participating in the Medicaid program ($3.4 million GF).

The total cost to the General Fund of this series of options is estimated at $20.3 million for the 1988-90 biennium. This takes into account all of the available offsets of current General Fund expenditures which could be transferred to Medicaid to take full advantage of federal matching funds. In particular, the two state teaching hospitals have provided estimates of indigent care funds which could be transferred to Medicaid. A detailed analysis of the cost of each option is included as Appendix C.

Action Steps to Prevent Illegitimate Pregnancies

The joint subcommittee recognizes that Virginia's number of low birth weight infants does not occur in a vacuum, apart from other social and economic factors. While the physical health of young Virginians is very good overall, there is increasing concern for a "new morbidity" of health concerns which were not so prominent just a generation ago.

These new concerns are interrelated. They include teenage and out-of-wedlock pregnancies, drug and alcohol abuse, dropping out of school, violence, suicide, depression and other mental health problems. Each of these concerns can be identified with a similar high risk, lower income group. While these concerns are not limited to non-whites, the incidence and severity of these concerns are of particular concern to the black community.

The likelihood of creating stable, self-sufficient, two-parent families under these circumstances is very low. Young, lower-income women are at particular risk today of becoming pregnant out-of-wedlock, experiencing a poor outcome of their pregnancy, dropping out of school and becoming dependent upon public assistance. Young men from similar backgrounds are also less likely to succeed in school and obtain regular, steady employment. They are more likely to become involved in drug and alcohol trafficking and abuse as well as violent crime.

All of these factors underscore the very high correlation between teenage and out-of-wedlock pregnancies and infant mortality and morbidity. Virginia pays a high price for the poor outcomes of pregnancies -- a price which is all the more unacceptable because it is avoidable.

The joint subcommittee hesitates to set forth a single broad recommendation to address the problems of teenage and out-of-wedlock pregnancies, because there is certainly no single, easy solution. Even the action steps we recommend to improve pregnancy outcomes among the high risk group will be insufficient if they do not encourage responsible behavior.

The joint subcommittee does, however, wish to set forth the point of view that the present and future health and well-being of Virginia's children depend upon the ability and the willingness of the Commonwealth and its public and private institutions to encourage responsible behavior with respect to the fundamental roles of creating and supporting families.

The joint subcommittee recognizes that this is a longer term problem that will require increased emphasis on prevention. For the next biennium, however, the joint subcommittee believes that certain program enhancements in the area of prevention can have a beneficial impact. For this reason, the joint subcommittee affirms its support for the following- budget addendum requests submitted by the Department of Health:

6. Increase support for voluntary sterilization services to adults through local health departments.

7. Increase support for family planning services through local health departments, as authorized under existing Virginia law.

8. Increase support for conversion of part-time to full-time positions in local health departments, in order to reduce staff turnover and reduce waiting times for prenatal care and family planning services.

The joint subcommittee does not attach a General Fund cost to each of these last three items because the actual figures may be adjusted prior to submission of the Governor's budget recommendations for 1988-90.

CONCLUSION

The joint subcommittee believes these action steps will have the intended effect of reducing Virginia's rate of infant mortality and other problems associated with poor pregnancy outcomes. These actions will also help to reduce the number of teenage and out-of-wedlock pregnancies. The expenditure of public funds to accomplish these objectives is a sound investment in Virginia's future.

The joint subcommittee wishes to express its sincere appreciation to all of the officials and representatives of various agencies, institutions and associations who generously contributed their time and effort to this study.