The pregnant mom who contacted me last November, two weeks before Thanksgiving, was so upset she could barely speak.
She had just been told by the Oregon Health Authority that they would not provide coverage for her to have a home birth attended by midwives even though she had previously given birth at home with no complications.
Home birth is legal in Oregon. And low-income Oregonians who get their insurance through the Oregon Health Plan are eligible for home birth, as long as they do not have health factors that put them at risk of birth complications.
But this healthy low-risk second time mom was being denied insurance because she did not want to have an ultrasound.
Though most pregnant women opt to have ultrasounds, even the American College of Obstetricians and Gynecologists does not consider them necessary for medical reasons during pregnancy.
At the same time, there is scientific evidence linking ultrasound exposure to brain anomalies.
And many many other good reasons to forego ultrasound for a low-risk pregnancy.
Though ACOG has chosen to ignore it, one of the country’s top neurologists, Dr. Pasko Rakic, M.D./Ph.D. of Yale University, has conducted research on mice that shows that ultrasound exposure changes the fetal brain and told the medical community that they should be using the same caution with ultrasound as they do with X-rays (also once considered safe and routinely used on pregnant women) and eliminate medically unnecessary ultrasound exposure to the fetus.
But a bureaucrat in a dingy office in Salem arbitrarily decided that an ultrasound was necessary for this pregnant mom.
And now the mom’s plan was to have an unassisted home birth.
Pregnant, stressed out, and unsure what to do, she decided she couldn’t speak to the press about being denied insurance. (She has since given birth to a healthy baby at home. I do not have the details but I was told that the midwife who did her prenatal visits was never paid.)
After I was hired by Jefferson Public Radio to investigate what was going on, many other pregnant women and young moms came forward to tell their stories.
The result was this 3-part series on how the Oregon Health Authority is unfairly–and maybe illegally–denying low-risk women insurance coverage.
Highlights from the investigation:
The Oregon Health Authority estimates they denied Open Cards to 250 of the 1,000 Oregon women who applied in 2015, “due to inadequate documentation or assessed risk.”
One letter states that because the applicant previously delivered a breech baby at home without a midwife or doctor present, and the baby was large, she was not eligible for home birth. Yet no obstetrical guideline or Oregon rule indicates that a previous unassisted breech birth would make a subsequent midwife-assisted birth unsafe.
Some midwives and other experts believe that these Oregon insurance denials violate federal Medicaid law that requires providers be paid for work done within their scope of practice.
The Oregon Health Authority refused repeated interview requests and has not been willing to talk to Jefferson Public Radio to explain their side of the story. They sent written answers to questions via email. In these answers, OHA confirmed that even if they grant a woman’s request for insurance, they can revoke coverage for an out-of-hospital birth at any time; during labor or even after the baby is born.
Midwives believe that low-income Oregonians who do not want to give birth in the hospital are actually being coerced by the state denial of insurance to have unattended home births, which puts them and their babies at risk.
Oregon moms who have had previous cesarean births are now being told they may not birth at birth centers or at home, despite evidence that this is a safe and reasonable choice. We know that vaginal birth is safer and healthy than cesarean birth, for both the mother and the baby. At the same time, in smaller cities in Oregon, like Klamath Falls, doctors are refusing to allow women even a trial of labor for a vaginal birth, sometimes because of hospital policy, sometimes because of the doctor’s bias against VBAC. This means that the state is using a pre-existing condition–a previous surgical birth–to deny women insurance coverage, which may also be a violation of the Affordable Care Act.
There seems to be a systemic and unexplained bias at the Oregon Health Authority against women who want to have home births, even though these births are much less expensive for the state.
This letter from a member of the Health Licensing Office’s board that regulates direct-entry midwifery was sent to the Governor, the members of the Board, and some state legislators at the beginning of March. It is a public document, as is all correspondence with our public servants.
The letter has not yet received a response. In case you are skimming, I’ve highlighted the most relevant sections.
Dear Governor Kate Brown:
I am the public member of the Health Licensing Office’s Board of Direct-Entry Midwifery. I am the senior-most member and serve as Vice-chair, having served two full terms, and am holding over pending the approval of a new public member. Though in my years on the board we have re-written the regulations for the profession, and dealt with a mountain of disciplinary actions, this is the first time I have had a concern I wish to bring to the attention of the governor and her staff.
My lookout on the Board is the interests of the consumer, both in terms of their safety as well as other interests of the consumer, such as the ability to make safe health choices without hindrance or coercion.
The concern that prompted me to write is of the latter type: the way the HERC guidelines have been implemented has made it impossible for most OHP members to choose a home birth, regardless of risk status. I was a member of the Board when we completely re-wrote the regulations for the profession, and we took pains to base each parameter on the best data available. This caused us to narrow the scope of practice, and during the same period licensure was made mandatory. Thus I know, in some detail, that the scope of practice we permitted should preclude high-risk pregnancies unsuited to trial of labor at home.
I understand that pregnant women with any of the gamut of risk factors may initially consider home birth, and that many women have a strong desire for a natural birth inconsistent with their circumstances, and so might wish to make choices that fall outside the low-risk category. This is where regulatory oversight and review of services can be appropriate. Unfortunately, the implementation of coverage has been severely diverted in practice. The reimbursement for midwifery care, hopefully leading to trial of labor at home, is being broadly denied even in very low-risk circumstances. This is effectively using money to coerce low-risk, lower-income women into hospital birth against their wishes.
I do not see financial coercion of medical choices as compatible with the public consumer’s interests, nor indeed with basic human rights.
The claims are being routed through a bottleneck at an office where staffers’ personal bias against trial of labor at home is being used to reject open-card claims, diverting the original goals and scope of the HERC guidelines and OHP reimbursement. As this falls under the executive branch, I wished to bring it to the attention of the governor. These claim rejections came before the board by the dozens and I was able to see them first-hand, because the office considering open-card OHP claims initially made dozens of complaints against licensed Direct-Entry Midwives merely for serving clients within their regulated scope of practice. That inappropriate reporting has been stopped, but is indicative of the personal attitude being pursued. It is an egregious vendetta by one or two state employees to bend the healthcare practices in the state to their personal preference, defeating the purpose of the HERC rollout.
As a result, most consumers on OHP are unable to choose midwifery care and trial of labor at home, even when they are not high-risk. Their coverage is denied, and while they are free to choose to pay for their care out-of-pocket, OHP beneficiaries do not have money to spare. As the member representing the interests of the consumer, this is very troubling to me.
For healthy, low-risk pregnancies, midwifery care and home birth costs a small fraction of the cost of hospital birth. In terms of economics, the situation is clear: state reimbursement saves enormously for every woman who chooses home birth. In The Netherlands, for pregnancies considered healthy and low-risk, the state pays only for home birth, and if a mom without a compelling medical reason wishes to birth in hospital she must pay out of pocket for the extra expense. In Oregon, even when a transfer of care becomes necessary after trial of labor at home, the total expense is unlikely to go beyond the same birth in hospital. So the argument that paying for births with direct-entry midwives is more costly is absurd.
I hope that, in respect of my years of volunteer service for the state assuring the safety of home birth with direct-entry midwives, the governor and staff will take seriously my concern on this matter, and act diligently to bring the situation back into balance.
Since the JPR investigation aired on the radio, I’ve been told that Washington State midwives and pregnant women faced a similar situation years ago. Washington ended up reimbursing every woman who had been forced to pay out of pocket for their home birth.
If you are a pregnant woman who feels you were unfairly denied health insurance, you can write, call or e-mail all of the following people with your concerns:
Governor’s Hotline 503-945-6904
Kim Wentz, DMAP Medical Director
Trevor Douglass, Manager of Provider Clinical Support Unit
Cate Wilcox, Maternal and Child Health Section Manager for the State of Oregon
Jeremy Vandehey, Governor’s Health Policy Advisor
Jefferson Public Radio reviewed more than half a dozen denial letters from the Oregon Health Authority. The majority were signed by Barbara Fahey-Ries, RN: Barbara.firstname.lastname@example.org. Her phone number is 503-945-5800.
I hope the state of Oregon stops these unfair, unethical, and likely illegal denials. In the meantime, I predict a lawyer well versed in the Affordable Care Act is going to have a lot of fun with this case.
Jennifer Margulis, Ph.D., is an award-winning investigative journalist, book author, and Fulbright grantee. Her writing has appeared in the New York Times, the Washington Post, and on the cover of Smithsonian Magazine. Her new book, The Vaccine-Friendly Plan, co-authored with Dr. Paul Thomas, M.D., will be published in August by Ballantine. Find her on Facebook and Pinterest. Follow her on Twitter.