I would like to propose Medicare for All Pregnancies and will explain why we need it and why it makes sense. Ready for my #thread? 1/n

Even before #COVID19, maternity care was in crisis in the United States. Alarms were ringing and major commitments were being made to focus resources on maternal health, especially eliminating racial disparities. 2/n

Presidential candidates had plans to address it, and there was bipartisan support for a major legislative package in Congress incorporating some of these plans--the #Momnibus. 3/n https://www.healthaffairs.org/do/10.1377/hblog20190625.583781/full/

In fact, on March 3, the U.S. had 126 cases, but here I am with the Surgeon General @JeromeAdams at an event where he and Governor @NedLamont spent half a day rolling out a major initiative to address maternal death and serious morbidity in CT. 4/n https://twitter.com/perinatalQI/status/1234969926860824577

So we already knew we needed to make a major investment and commitment to fix things. Now, let’s talk about how we currently pay for maternity care. 5/n

49% of births are paid for by private insurance and 43% are paid for by #Medicaid or CHIP. Pre-COVID, maternal and newborn admissions were the most common and costly hospitalizations for both types of payers. Now, #COVID19 presents unique challenges for both groups. 6/n

In the private insurance market, most plans are tied to employment, and of course we are seeing rates of job loss that are an order of magnitude higher than previous records. Many, many people will lose their pregnancy coverage. 7/n

They will get their ins from the ACA or they will become eligible for Medicaid. W/ ACA, the most affordable plans have high deductibles. Pregnancy almost guarantees you will hit your deductible-maybe twice if youre unlucky enough to get pregnant in 1 year and deliver the next.8/n

For a family, that’s $16,300 (or up to $32,600 if pregnant in two calendar years). Who has that saved up? Especially now?? 9/n

For people with Medicaid or CHIP coverage, out-of-pocket costs can be low, but access is limited and quality is often poor. Many are cared for in public clinics and hospitals--the so-called “safety net.” But our safety net is failing right now. 10/n https://twitter.com/midwifeamy/status/1247301549656887296

Also, something we don’t often talk about is that Medicaid pays only about 1/2 what private insurers pay for birth, even though the needs of Medicaid-insured are often greater. 11/n

#OBGYN practices deal w/ this by not accepting Medicaid at all, or by optimizing the “payer mix” to subsidize the care of Medicaid-insured by having enough w/ private insurance or doing enough revenue-generating procedures, like surgeries. 12/n

This also means that these practices are going to see a massive loss of revenue as a large # of patients lose their insurance and switch to Medicaid plans. This is on top of all the lost fee-for-service revenue from cancelled primary care visits, surgeries, and testing. 13/n

The surge will also have a huge impact on state budgets. @NYGovCuomo is America’s hero now, but he’s still planning to cut Medicaid rates in NY, which will worsen outcomes for pregnant people and newborns and widen racial and economic disparities. 14/n https://www.nytimes.com/2020/01/21/nyregion/medicaid-budget-ny-cuomo.html

The reality is that states truly can’t afford the growing cost of Medicaid. It has increased unchecked for decades, thanks to runaway prices and the high cost of our poor outcomes, like preterm birth, cesarean overuse, and maternal morbidity. 15/n

States were also hit hard by the pharmaceutical industry that drained budgets for high-priced drugs with little or no benefit, like the 100x increase in the price of a popular preterm birth prevention drug that turned out not to work. 16/n https://twitter.com/midwifeamy/status/1188510529087856640

So, neither employers nor states can manage the cost of pregnancy, birth, and postpartum care for their populations, especially when we already knew before this crisis that we needed to invest MORE not LESS in maternity care. 17/n

The federal government will have to choose the investments it is going to make in our society, health, and prosperity over the coming months and years. An obvious investment, to me, is #MedicareForAllPregnancies 18/n

One federally-funded plan that covers all pregnancy-and newborn-related healthcare costs, throughout pregnancy, birth, and a full year postpartum. #MedicareForAllPregnancies 19/n

This would lift that burden so families, businesses, and states can get back on their feet more easily. But it could also have a major impact on quality, safety, and innovation.
20/n

With 1 payer, we could more readily invest in care models that work and incentivize outcomes that matter. Take for example, #midwife-led #birthcenters. 21/n

A major federal study called #StrongStart showed this model resulted in reduced preterm birth, cesareans, & costs, and higher satisfaction. 22/n https://innovation.cms.gov/innovation-models/strong-start

But efforts to scale it have been stalled by a patchwork of Medicaid and private insurers that are not structured to pay for this care and have little incentive to solve the problem. 23/n

There are countless other evidence-based care practices and delivery models that could be implemented, evaluated, and scaled if each practice wasn’t dependent on such a broken payment system. 24/n

Maternity care is seen as an obvious candidate for #bundledpayment schemes that link payment to quality and value. But implementation has faced challenges in the fragmented payment market. https://khn.org/news/maternity-care-bundling-payments-insurance-cesarean-sections/ 25/n (3 final thread tweets in replies!)

With the federal government paying for all pregnancy, birth, and mother/baby care, bundles and other value-based payment schemes will be much easier to administer. 26/n

#MedicareForAllPregnancies would also, of course, be an important incremental step toward #MedicareForAll, but easier to transition because the population is easy to identify. 27/n

I’m sure I’m not the first person to think of this, and I’m sure there are issues and logistics that would need to be sorted out, so I’d love to hear others’ thoughts. How can we get a movement started for #MedicareForAllPregnancies ? /end