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As policymakers across the country look to balance their budgets, some are turning to Medicaid, recycling the same harmful policies they've used year-after-year: eliminating coverage for vulnerable Americans, restricting critical benefits like prescription drug coverage, imposing premiums on those who can't afford them, and slashing already-low provider reimbursement rates.

Community Catalyst and Georgetown University Health Policy Institute Center for Children and Families created the States of Innovation blog series to shine a spotlight on states that are trying to find a better way.  Our blog series highlights states that are pioneering new approaches to making Medicaid more sustainable without harming - and often by improving - care for the millions of vulnerable seniors, people with disabilities, children and low-income parents that rely on Medicaid.         ________________________________________________________________

Camden, New Jersey is one of the nation's poorest cities and has one of the highest crime rates in the nation. Homelessness, drug trafficking, high unemployment, and sky rocketing health care costs are a fact of life in this city of just 79,000. Between 2002 and 2008, 978 patients made 3,882 visits to emergency departments in the city - a majority of the visits were for preventable conditions that could be treated by a primary care doctor.

In this dire situation a family practice physician, Dr. Jeffrey Brenner, pioneered a successful approach to reducing hospital readmissions and health care costs of the sickest and most vulnerable populations. A recent episode of PBS's Frontline highlighted Dr. Brenner and his innovative work and praised his initiative as a new model of care. The work of the Camden Coalition of Healthcare Providers, the practice that Dr. Brenner set up, laid the groundwork for the "Garden State" to adopt this model, the Medicaid Accountable Care Organization (ACO) Demonstration Project, which was signed into law by Governor Christie last week.

Where it all began

An article by Atul Gwande in The New Yorker features a story about Frank Hendricks, who had multiple health issues, weighed 560 pounds, had a substance abuse problem and lived on welfare. Hendricks spent a majority of his time in the hospital because no one in the health care system was able to effectively manage his care. Dr. Brenner visited him regularly, arranged for a social worker and a nurse practitioner to coordinate his care, and advised him on how to best take care of his health -taking medication on time, healthy eating habits, etc. This team approach to care resulted in a significant improvement in Hendricks's health.

Hendricks is an example of a "super utilizer" in Camden's health care system. Through the collection of hospital data, Dr. Brenner found that a core area in the city, where a nursing home and a low-income housing tower are located, accounted for a majority of the hospital visits and millions of dollars in health care costs. Mr. Hendricks's case and the other super utilizers identified by Dr. Brenner's work showed that primary and preventive care with a team approach, which takes the whole person into consideration, significantly improves the overall health of the patient. According to Dr. Brenner this team approach has resulted in a 40-50 percent reduction in Camden's health care costs since he started this work in 2007. The cost saving strategies that Dr. Brenner and his team have used include:

* Nurse practitioner-led clinics in high cost buildings

* More super utilizer outreach teams

* Medical home-based nurse care coordination

* More same day appointments (open access scheduling)

What is New Jersey doing?

Despite the great success of Dr. Brenner's work to improve patient care and bring down overall health care costs, there are a few barriers to replicating this model elsewhere. Many state Medicaid programs do not have a payment system that provides incentives for providers to work together to improve care for patients, and hospitals in many states often lose money if the rate of preventable hospitalizations decreases.

New Jersey passed the Medicaid ACO Demonstration Project to try to remedy those misaligned incentives and help other communities replicate Dr. Brenner's success. This legislation enables community-based, non-profit coalitions of hospitals and primary care providers to apply for recognition by the state of New Jersey as Medicaid ACOs. Once approved as ACOs, these coalitions would qualify for "shared savings" if they reduce Medicaid costs by providing increased access to primary care and working together to better coordinate patients' care.

Under the legislation, the state is required to share any savings it accrues as a result of improved care coordination with the participating providers in the ACOs. To protect patients from any adverse incentives that might give ACOs a reason to skimp on care, ACOs must demonstrate improved care for their patients in order to qualify for these "shared savings".  The state will therefore be measuring - and requiring - quality improvement based on benchmarks which include: patient experience, access to primary and behavioral care, and reduction of unnecessary and inefficient medical costs.  

Key lessons for other states

Dr. Brenner's work shows that by providing more primary care and better coordinated care, we can drive down costs and create better outcomes for patients. The key is offering the right incentives to providers so they can work as team to coordinate care for the patient.

While New Jersey offers us one model to accomplish that, the Affordable Care Act (ACA) encourages many innovative approaches to improving care while reducing costs. For example, the ACA established the Center for Medicare and Medicaid Innovation (Innovation Center). The Innovation Center has the resources and flexibility to rapidly test innovative care and payment models and encourage widespread adoption of practices that promote better health and deliver better health care at lower cost.

The ACA also created an option for states to quality for enhanced federal funding to set up health homes to better coordinate the care of Medicaid beneficiaries with chronic physical or mental illness. If we can make this approach work for the sickest and most vulnerable population - then the health care system can work for everyone.

Editor's Note: This is the second blog in our series.  You may view the previous blog here.

"It was once said that the moral test of government is how that government treats those who are in the dawn of life, the children; those who are in the twilight of life, the elderly; and those who are in the shadows of life, the sick, the needy and the handicapped."

                                                                     --- Hubert H. Humphrey

Our nation's leaders are facing a watershed moment as they try to build a consensus on how to best address the long-term deficit.  The path our government takes at this pivotal point in history will define our society.  Probably no other group has more at stake in this debate than children and youth with special health care needs.  In the words of the late Hubert Humphrey, they are both in the dawn of life and the shadows of life.  How these children are treated in the budget debate is a moral test of government.

Children and youth with special health care needs are more likely to be covered by Medicaid than other children. Families raising children with serious conditions such as autism, cancer, cerebral palsy, complex genetic disorders, and epilepsy rely on Medicaid's comprehensive benefit and cost-sharing protections because of their relatively extensive health care needs. Overall, Medicaid is the largest single payer of health care services for these children and many of their families would face financial ruin without its help.  Many of these families have private health insurance but need Medicaid to help them meet the costs of caring for their child in their home rather than placing them in more costly institutional care.  Others need help paying for expensive life-saving medicine or medical bills that are not covered by their private health insurance plans.  Even with Medicaid's help, many of these families make great personal and financial sacrifices in order to care for their children.

Georgetown University Health Policy Institute's Center for Children and Families partnered with Family Voices to collect case studies of families raising children with special health care needs to help inform policymakers about what is at stake in the debate over the future of Medicaid.  The families included in our report were from all across America and working hard to meet the needs of children with a wide variety of medical needs but they were remarkably similar in one respect - they all cherished Medicaid and didn't know what they would do without it.  Not only does Medicaid provide their children with the health coverage their lives depend on, but it many instances, it is the backbone of the family's economic security.

The mother of a child born with spina bifida said:

"I cannot imagine going one single moment through Emma's life without Medicaid as her secondary insurance. At times her medical and pharmaceutical bills could easily put our family of six on the street. It's hard enough to raise a family in this day and age, but imagine what it's like to live with children affected by life-long special healthcare needs."

The mother of two children with a mitochondrial disorder said her family would be bankrupt without the help of Medicaid.  She shared the following story:

"When I was pregnant with Matthew, my husband and I felt well-prepared to meet the financial responsibilities of parenthood:  we had college educations, owned a home, were blissfully without consumer debt and, via my husband's job as a high school history teacher, had great private insurance.  Six months later, as Matthew spent his first Christmas in our local children's hospital, our world was very different. Our son's complex medical needs were not entirely covered by our health insurance, we had a staggering amount of medical debt, and even when our medical cost swallowed a huge portion of our income we did not qualify for the majority of safety net programs.  For several years, our young family struggled to meet our children's needs, often making painful choices about how long we could safely wait for doctors visits, test and procedures. We worried about our ability to maintain our housing and often struggled to have enough money for food. For many families like mine Medicaid is a key partner in meeting those needs. We are happy to be a family like so many others, spending money in the economy and paying taxes back into the system, as well as volunteering, but none of that could happen without Medicaid. I share my story because it is the story of families all over America, who never expected to need Medicaid and likely didn't understand its role in supporting children with special health care needs until it affected them directly."

The mother of a boy with autism explained that her family has had a hard time saving for her other son's college education because they have spent the equivalent of college tuition on uncovered medical bills for the past several years.  She expressed deep concern about the current budget debate saying: 

"Proposals to cut Medicaid represent survival of the fittest at its worst. By cutting Medicaid, you're telling our children, the disabled and elderly that you are not valued in our society." 

Many of the families included in our report pointed out that they have made great personal and financial sacrifices in order to care for their children with special health care needs.  Most were so financially stretched that they would have nowhere else to turn if Medicaid were unavailable. 

Leaders from both sides of the aisle have publicly voiced support for protecting health care coverage for children.  Senator Orrin Hatch (R-UT) has said: "Parents should not have to decide whether to buy health insurance for their children or put food on the table."  President Obama has said:  "In a decent society, there are certain obligations that are not subject to tradeoffs or negotiation - health care for our children is one of those obligations." Families of children with special health care needs see Medicaid as a "lifeline" and are counting on lawmakers to back up those words with action by preserving that lifeline for those who need it the most.

As communities across the nation celebrate the one-year anniversary of the Affordable Care Act, CCF marked the event in its traditional style - by issuing an issue brief.  It has the facts about how the Affordable Care Act will affect children, but also stories from families whose children have personally been touched by the new law or stand to benefit from it when the law is fully implemented in 2014. 

We would like to introduce you to a couple of the moms that we talked to when putting together this new brief:

First, we head to Oregon to meet Cynthia Johnson who we met through our friends at Moms Rising  Her story underscores the important role that Medicaid and CHIP play in covering children - especially during turbulent economic times. Cynthia's husband was laid off from his IT job when she was seven months pregnant, but she was able to enroll her newborn son in CHIP. When her husband secured a job a few years later, the minimal employer plan capped the amount of expenses it would cover at $600 per patient and did not cover her son's speech therapy, occupational therapy, and other services essential to his development. When her son was seven years old, Cynthia heard that Oregon's CHIP program had expanded so she re-applied and her son was enrolled. Now he has high-quality, affordable health care coverage that allows him to resume the speech therapy and OT he needs. "We are grateful that the CHIP reauthorization and the Affordable Care Act were passed so that our son can once again resume his necessary therapies which we were unable to obtain for him for the last couple of years while he was on our inadequate private health insurance plan." said Cynthia.

Next, we head to Illinois to meet a member of the Family Voices network, Angela Chicoine, who lost her husband a couple of years ago. While helping her three children cope with the loss, Angela also had to figure out how to make ends meet and how to continue to meet their health care needs. When her twins were born, one of them, Emily, stopped breathing and is now a quadriplegic and has been diagnosed with a seizure condition, cerebral palsy, and other disorders. Emily is only ten years old has already come close to hitting a lifetime cap on one health insurance policy. The family is currently paying for COBRA coverage which will expire in August. While Angela is searching for affordable health insurance for her family, she can now rest easier knowing that in the future, Emily's care will no longer be subject to a lifetime cap.

As some Members of Congress celebrate and others try to re-debate the Affordable Care Act, it's moms like Angela and Cynthia that keep me working hard to make sure we do right by our kids and don't turn back the clock on the progress we've made. 

Please read the full report on our website and more stories from our friends at Family Voices, California's 100% Campaign and Mom's Rising.  Special thanks to Donna Norton at Mom's Rising, Kristen Thompson, Suzie Shupe and Michael Odeh with the 100% Campaign and Brooke Lehmann at Family Voices for putting us in touch with the families whose stories are told in the report.

The Wall Street Journal is reporting that the nation's incoming Republican governors (and four of those who are on their way out) are releasing a letter today asking Congress to dismantle the protections in the Affordable Care Act for low-income Americans aimed at holding Medicaid and CHIP coverage steady until health reform can be implemented in 2014.  The protection, known as the "maintenance-of-effort" or "MOE" requirement, was one of the most important early wins in the Affordable Care Act for low-income families and individuals. It requires states to maintain their Medicaid and CHIP eligibility rules and enrollment procedures that were in effect on March 23, 2010 - until 2014 for adults and 2019 for children.  (One exception is that states with coverage of adults above 133% of the federal poverty level can eliminate their coverage if they are facing a budget deficit.)

The MOE requirement already has been extraordinarily effective in holding coverage steady for families losing their jobs and job-related insurance (particularly the children in these families); seniors in need of health and long-term care services; and people with disabilities.  Without the MOE requirement, for example, Arizona would have entirely eliminated its Children's Health Insurance Program in June of 2010, and some 47,000 children would have instantly become uninsured.

The Republican governors strike a strident tone in the letter calling the maintenance-of-effort requirements "unconscionable" because they "force governors to cut other critical state programs, such as education, in order to fund a 'one-size-fits-all' approach to Medicaid." Frankly, if I had to use the word "unconscionable," it wouldn't be to describe the plight of the nation's governors, but rather to describe the potentially life-threatening implications of cutting back on coverage for low-income people when they need it now more than ever. 

If anyone needs a vivid example, check out the story of Tiffany Tate in Arizona, a young woman who has battled cystic fibrosis for 26-years, largely successfully.  She has managed to become a high school basketball player and to become an assistant coach at Setton Catholic High School.  In September, Tiffany was taken off the transplant waiting list due to Arizona's decision to deny organ transplants to Medicaid beneficiaries (an optional service which is not protected by the Affordable Care Act's maintenance-of-effort requirements).  Without a transplant, Tiffany would die.  Her family started raising the $277,000 needed to privately fund the transplant.  It is unfortunate that her family had to resort to fundraising to save her life but, fortunately for Tiffany, publicity about her case helped them raise $200,000 and she is now back on the waiting list.  Other Arizona Medicaid patients in need of transplants haven't been able to raise the funds in time and have lost their lives.  Charity can't take the place of a strong, stable Medicaid program.  Tiffany's story underscores the need for stronger maintenance-of-effort protections, not weaker ones.

While there is no disputing that the country's weak economic recovery will continue to pose major challenges to state budgets for at least a while longer, it will be even tougher on families as they continue to face dauntingly high unemployment rates. It may take determined, effective leadership, but states need to find a balanced way to get through the remaining budget downturn that doesn't involve cutting off coverage for low-income families, seniors, and people with disabilities.  

By Sabrina Corlette, Georgetown Health Policy Institute

One of the great new patient protections in the ACA is the ban on lifetime and annual limits.  The law, as readers of this blog know, prohibits all plans from imposing lifetime dollar limits on essential benefits and, in 2014, prohibits annual limits on the dollar value of essential benefits.  Before 2014, the law phases in the ban on annual limits over three years. 

For families like the Wustarbarths of Wake Forest, North Carolina, whose toddler daughter hit their plans' lifetime limit within 3 weeks of a heart transplant, this critical component of the ACA's patient protections gives them new hope that their children can get needed treatment and reduces their fears of medical bankruptcy.

Today, thanks to early portions of the Affordable Care Act that have already gone into effect, consumers have far more protections in dealing with insurance companies than they have had before.  But, until the Affordable Care Act is fully implemented and all the consumer protection provisions are in place, there are some loopholes that insurance companies can take advantage of, so families should be aware of the following:

• Your plan may not have to comply. The restrictions on annual limits apply to all group plans, but do not apply to grandfathered individual plans.  So if you've been buying insurance on your own, your plan can continue to set low annual limits on your benefits.  You could try to find a new plan, but until the full range of protections in the ACA go into effect in 2014, if you or a family member has a pre-existing condition, plans in most states can refuse to issue you a new policy.
• Your plan may get a waiver from HHS. The regulation on the annual limits restrictions allows certain plans to apply to HHS for a waiver if they can show that the restrictions will result in a "significant decrease in access to benefits or a significant increase in premiums."  Well, guess what - a number of plans are claiming just that.  And so far, HHS has granted 30 plans waivers from the new requirements, including plans offered by big name companies like Jack in the Box, Denny's, and McDonald's.  And they're likely to grant many more.  HHS hasn't revealed the criteria they're using to determine whether the annual limit restrictions truly will reduce access to benefits or increase premiums, so it's hard to know whether these waivers are merited or not.  But the bottom line is: if you're in one of these plans, you won't get the benefits of higher annual limits promised under the law.
• The law says "dollar" limits, not service limits! The law restricts annual limits on the dollar value of benefits.  But it does not explicitly restrict plans' ability to impose limits on, say, the number of doctor visits, days in the hospital, or number of prescriptions filled.  For kids with high-cost chronic conditions, these kinds of limits are no different than a dollar value limit.
• The restrictions depend on plans' "good faith" compliance with the statute.  The restrictions on lifetime and annual limits apply only to benefits covered in the "essential benefits package."  But, you say, we don't know what's in the essential benefits package - it hasn't been defined yet!  Well, this is where things could get Kafka-esque. The regulation on annual and lifetime limits depends on plans and employers making "good faith" efforts to define essential benefits.  But who gets to decide what "good faith" means when no one knows what the essential benefits are?  Unfortunately, as we heard yesterday from one family in North Dakota, employers, insurance companies, state regulators, and HHS may be dropping the ball - leaving families without access to needed care and financially vulnerable.  In this case, the family's employer plan announced that they would be imposing new limits on physical, speech, and occupational therapy benefits.  The company's HR department refused to take action, and when the family complained to the state insurance department, the department declined to act, claiming that HHS had not yet defined "rehabilitative and habilitative services" as essential benefits (never mind that it's clearly a covered category of benefits under the ACA!) Meanwhile, HHS is saying it will be late 2011 before they produce any kind of definition of the essential benefit package.  For families who have been promised relief under the new law, this is cold comfort.

So...what are families, and those who advocate on their behalf to do? 

First - states can and should strengthen the law.  States could enact laws requiring grandfathered plans to comply with the annual limit restrictions.  State regulators could and should set robust standards for what constitutes a "good faith" effort to define essential benefits, and vigorously monitor plans' compliance with the law.

Second - while it's probably too much to hope that the Administration can speed up its rulemaking on the essential benefit package, HHS can and should be working closely with state insurance departments to hold plans accountable if and when they attempt to subvert the "good faith" requirement by claiming certain benefits are not in the "essential" package.

Third - the Administration should issue further guidance on the permissibility of item and service limits.  The Administration should clearly say that if a plan places limits on the number of visits, days in the hospital, or number of prescriptions, it constitutes a "constructive" dollar limit and would thus violate the annual limit requirements of the ACA.  There is precedent for this in the Mental Health Parity law which has a similar restriction on plans' ability to limit the number of visits without falling afoul of the prohibition on lifetime and annual limits.

Fourth - HHS needs to be more transparent about what plans are applying for waivers, what justifications they're giving, and what criteria the agency is using to grant waivers.  In addition, any plan that gets a waiver should be required to disclose that information to its policyholders.

As advocates, it's difficult for us to accept any shortfalls in the law that allow families to fall through the cracks.  And we're eager to get to 2014, when the full range of insurance reforms go into effect and the law delivers on its promise of more affordable, quality care for all Americans.  But, as a New York Times article noted today, "The hardest part of health reform is always going to be the transition."  We'll get there - we just need to recognize there will be bumps in the road and work together to fix them.

The views expressed by Guest Bloggers do not necessarily reflect the views of the Center for Children and Families.

In honor of the six-month anniversary of the Affordable Care Act, our friends at MomsRising invited moms, dads, grandparents, bloggers, community leaders, government officials, policy experts and others to share their thoughts and feelings about health reform.  They received an overwhelming response to their invitation.  Here are a few of the many interesting blog entries:

Kerri Marrone Sparling, who chronicles her life with diabetes on the very touching Six Until Me blog wrote:

"I don't know enough about the health care reform bill to speak eloquently about the details.  I am only exposed to what the media shows me, and what my research procures, and what pages of the bill I'm actually able to pour through and understand.  And I know that talking politics on the blog (just like talking religion) can be a very tough topic, because PWD (people with diabetes) have so many varying opinions and stances on these issues.  But I'm a person with diabetes.  And I'm hopeful.  I'm hopeful that this could be the beginning of diabetes not dictating my insurability.  I'm hopeful that people with diabetes will have the option to work in fields that inspire them, not just ones that insure them."

Lisa Shapiro of First Focus wrote:  "As we mark the six-month anniversary of the passage of health reform, families have much to celebrate today as several key provisions of the new Patient Protection and Affordable Care Act go into effect for children.  While there are a wide array of opinions on both sides of the aisle on the new law - from those that say health reform goes too far to those who lament that it doesn't go far enough, the impact for children cannot be disputed. Children and families will be better off today and for many years to come because of a long list of new child-focused policies that were included as part of national health reform."

Laura Tellado who lives with spina bifida and created the Holdin' Out for a Hero blog wrote:

"Nearly six months ago, I sat in front of a desktop PC with tears brimming in my eyes. I was watching history unfold before me, when Pres. Barack Obama signed into law the Patient Protection and Affordable Care Act. I had been waiting for this for years, and now it seemed surreal that it would finally come to pass. Maybe it seemed surreal to me because it seemed that it had taken forever to accomplish. Or maybe because it felt like my needs and the needs of millions of other Americans were being heard and understood."

Please check out what others had to say and leave your own thoughts in the comments section.

I had a chance to go to a fantastic event this morning sponsored by Secretary Sebelius on the Connecting Kids to Coverage Challenge, which aims to reach the nation's 4.7 million uninsured children who already are eligible for Medicaid or CHIP.  She made a compelling pitch that nothing is more important to our future than the health of America's children and that is why Medicaid and CHIP were created.  Thanks to these programs, tens of millions of Americans have the peace of mind that comes from knowing that their child is safe.

In recognition that millions of our children are heading back to school this week, the event also featured Education Secretary Arne Duncan who tackled the issue from an education perspective.  He argued that some foundational things have to be in place for students to be able to excel.  If they can't see the blackboard, or if they are coping with untreated asthma, it is pretty tough to expect them to do well.  He pledged to work with some of the major school districts in the states that have the furthest to go in covering uninsured children.  (California, Florida, and Texas account for 40% of all uninsured kids, according to powerful new data released today by the Urban Institute.  See my colleague Martha Heberlein's blog for more on the report).

The star of the morning, though, was probably Bonnie, a mom from Maryland.  "I speak to you as a mother and as an American," she began before going on to explain that her husband is an auto-mechanic who doesn't have any affordable employer-based coverage.   So, when she lost her job, she found her family uninsured.  Luckily, she hooked up with a community-based organization that helped her file an application for child health coverage.  It took only 15 minutes from start to finish, and within 24 hours she got a call that her son qualified.  Since her son has asthma, it was an enormous source of peace of mind in a time of need.  As she concluded, "No mother, no parents should have to choose their mortgage and utilities over health care" for their child. 

I left encouraged about the level of commitment shown by two key leaders in the Obama Administration, as well as impressed by the broad array of national organizations they've already signed up to work on the Connecting Kids to Coverage Challenge.

By Amanda Jezek, March of Dimes

Health reform is giving pregnant women throughout the U.S. a far more valuable package than anything they could ever unwrap at a baby shower -- access to maternity coverage.

Coverage for maternity care is crucial because, without it, women face much more difficulty in obtaining needed health services.  Women who have insurance coverage for maternity care are more likely to receive screening and diagnostic tests that can help to identify problems; services to manage developing and existing problems; and education, counseling, and referral to reduce risky behaviors like substance abuse and poor nutrition.

Prenatal care can help reduce infant mortality and improve birth outcomes; postpartum care can help women appropriately space pregnancies, which can reduce the risk of preterm birth.

According to U.S. Census data prepared for the March of Dimes, a whopping one in five women of childbearing age is uninsured. Now consider that 50 percent of pregnancies are unplanned. Those who tried to get coverage on the open market were in for a rude awakening: insurers considered pregnancy to be a pre-existing condition and would therefore often deny coverage.  Needless to say, many women found themselves facing this dilemma.

Consider a March of Dimes family in Virginia who signed up for private insurance because their COBRA coverage from a previous job was about to end. They took the precautionary step of adding a maternity rider, which had a six-month waiting period before covering pregnancies. They didn't think there would be any issue as they used fertility treatments to conceive their first child. Despite being told by doctors that they had only a five percent chance of getting pregnant naturally, four months into the six-month waiting period, they discovered they were expecting. At that point, no other insurance company would pick-up coverage determining that the pregnancy was "a pre-existing condition." It cost the family $20,000 out-of-pocket.

Thanks to health reform, the practice of pre-existing condition exclusions will be prohibited in 2014 (earlier for children).  But the pre-existing condition exclusion was only one of many hurdles that pregnant women faced to obtaining coverage -- and that health reform will fix. 

In 2006, a Georgetown University study commissioned by the March of Dimes found that 19 states had adopted laws to require coverage of maternity care. However, these laws varied in scope, and only five of the states (MA, MT, NJ, OR and WA) required all insurers in the individual market to cover maternity care. In states without such requirements, maternity coverage is typically available only through an expensive rider to the underlying policy -- and then with a waiting period or outright denial if the woman is already pregnant.

Health reform will require insurers to cover an essential benefits package that includes maternity care.  Insurers will no longer be able to exclude this critical benefit from policies.

While these private insurance reforms are a tremendous step forward, over 40 percent of pregnant women rely on Medicaid for their coverage.  Health reform makes improvements for these pregnant women too.  Beginning in 2011, all state Medicaid programs will be required to cover tobacco cessation counseling and pharmaceuticals for pregnant women. Given that pregnant women in Medicaid are 2.5 times more likely than other pregnant women to smoke and that smoking dramatically increases the risk for numerous poor birth outcomes (such as preterm birth and low birth weight), this policy will provide much needed assistance to millions of pregnant women.  The U.S. Preventive Services Task Force has found that tobacco cessation interventions are very successful in helping pregnant women quit, and these services have even been found to save money.

Health reform also gives states the option to start covering more low-income women before they get pregnant using Medicaid family planning expansions.  States previously needed a waiver to extend this coverage, but now they may use a simple state plan amendment.  In addition to appropriately spacing pregnancies, women whose pregnancies are planned are more likely to begin prenatal care early, increasing the likelihood of a healthy birth.  And Medicaid family planning expansions have been found to save money at both the state and federal levels.

The daunting task of implementation awaits, but women throughout the country can at least be assured that when they become pregnant, they will have coverage for maternity care to help provide their children with the healthy start they deserve.

Editor's Note: The views expressed by Guest Bloggers do not necessarily reflect the views of the Center for Children and Families. The photo of the mother and baby was provided by the March of Dimes Foundation and may not be reprinted without that organization's permission.