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March of Dimes Comments on Proposed Rule to Redefine Child Under SCHIP
Honorable Thomas A. Scully
Centers for Medicare and Medicaid Services
Department of Health and Human Services
Room 443-G
Hubert Humphrey Building
200 Independence Avenue, SW
Washington, DC 20201
Attention: CMS-2127-P
May 6, 2002
Dear Mr. Administrator:
The March of Dimes is pleased to submit comments on a proposed rule published March 5, 2002 in the Federal Register that would revise the definition of child under the State Children’s Health Insurance Program (SCHIP) to include children “from conception to birth through age 19.” Specifically, the Notice of Proposed Rulemaking states: “In order to provide prenatal care and other health services, this proposed rule would revise the definition of ‘child’ under SCHIP to clarify that an unborn child may be considered a ‘targeted low-income child’ by the State and therefore eligible for SCHIP if other applicable State eligibility requirements are met. Under this definition, the State may elect to extend eligibility to unborn children for health benefits coverage, including prenatal care and delivery, consistent with SCHIP requirements.”
In addition to this letter the March of Dimes would also like to associate itself with comments submitted by the American College of Obstetricians and Gynecologists and the Alan Guttmacher Institute as well as those submitted by the American Academy of Pediatrics.
Background
More than one in six women of childbearing age (15-44) – or 11 million women – were uninsured in 2000, according to data prepared for the March of Dimes by the U.S. Census Bureau. These women accounted for almost 30 percent of all uninsured Americans. More than half of these women (57 percent) had family incomes below 200 percent of poverty ($30,040 for a family of three in 2002).i Hispanic and Native American women in this age group were more than twice as likely as whites to be uninsured: 37 and 33 percent, respectively, compared with 17 percent. African-American and Asian women were also more likely than whites to be uninsured.ii Although more generous Medicaid eligibility for pregnant women has resulted in better rates of coverage for them than for women in general, there remains considerable room for improvement. In 1999, 13.4 percent of pregnant women (more than 420,000) were uninsured, an increase from 11 percent in 1990. iii
Prenatal care is fundamental to a healthy pregnancy resulting in a healthy baby. And as numerous studies have shown, lack of insurance can be a significant barrier to prenatal care.iv As is true for Americans in general, pregnant women’s use of health services varies by insurance status. Uninsured pregnant women receive less care than those who are insured. According to the most recent data available, 18.1 percent of uninsured pregnant women in 1996 reported going without needed medical care during the year in which they gave birth. This compares with 7.6 percent of privately insured pregnant women and 8.1 percent of pregnant women covered by Medicaid.v
In addition to improving access to health care for uninsured pregnant women, the March of Dimes supports elimination of any income eligibility disparities between mothers and newborns. By establishing a uniform threshold of eligibility for coverage, states could improve maternal health, eliminate waiting periods for infants and streamline the administration of publicly supported health programs. Currently, thirty-four states have income eligibility thresholds that are higher for infants than for mothers.vi Encouraging states to eliminate this disparity by allowing them to obtain the higher funding match rate available through SCHIP should be a policy priority for the U.S. Department of Health and Human Services.
The March of Dimes recognizes and appreciates the Administration's commitment to improving access to prenatal care for uninsured pregnant women. This goal is consistent with the mission of the Foundation, which is to improve the health of babies by preventing birth defects and infant mortality. Although the March of Dimes shares the Administration’s goal of extending coverage to uninsured pregnant women, we respectfully disagree with the approach taken in the proposed regulation. Specifically, we believe coverage should be extended directly to the uninsured mother. As written, it is our view that the proposed rule does not meet the well-established, clinically-based standards of care for pregnancy developed and approved by the American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) and published in “Guidelines for Perinatal Care.”vii
Standard of Care for Pregnancy Services
SCHIP should provide the standard of care recommended by AAP and ACOG for all income eligible pregnant women. These standards establish clinical mileposts for antepartum, intrapartum and postpartum care. Health professionals are expected to abide by these guidelines that are followed by both private plans and in publicly supported programs. In fact, Medicaid law and regulation offers a useful illustration of how public programs rely on these well-established standards [see Medicaid-covered pregnancy-related services under §1902(l) of the Social Security Act, as defined in §1902(a)(10)(G)(clause VII)]. Aside from SCHIP, we know of no other federally funded health program that denies coverage to pregnant women while providing coverage to their infants.
Many pregnant women require medical care that benefits both mother and fetus. Examples of such care include treatment for anemia, diabetes, hypertension, seizures and asthma. However, there are also specific medical needs of the mother that are distinct from those of the fetus. Such situations include breast masses, influenza (flu) vaccination and peptic ulcer disease. Under the proposed rule, it is not at all clear that the mother, while pregnant and during the period immediately following pregnancy, would be covered for the services required to treat these conditions and recommended by AAP and ACOG. In particular, the March of Dimes is concerned that postpartum treatment of hemorrhage, infection, episiotomy repair, and postpartum depression are not explicitly addressed in this proposed rule.
Alternative to NPRM
To ensure that pregnant women receive appropriate coverage that meets established medical standards of care, the March of Dimes recommends a statutory change to SCHIP. A legislative remedy that confers eligibility on the woman would permit states to provide the necessary scope of services recommended by AAP and ACOG. If this change in federal law were made and all states elected the option, studies done in 1999 and 2001 for the March of Dimes by Dr. Ken Thorpe demonstrate that up to 41,000 uninsured pregnant women could be covered.viii Several bills pending before Congress would allow states the flexibility to extend SCHIP coverage to pregnant women 19 and older.ix A statutory change would be permanent, has broad support, including the endorsement of the Administration, and the favorable federal matching rate would encourage states to amend their SCHIP programs to offer coverage that meets the established standards of medical care as outlined above.
Once again, thank you for your consideration of March of Dimes’ concerns related to the proposed rule.
Sincerely,
Nancy S. Green, M.D.
Acting Medical Director
i Thorpe, Ken. 2001. “The Distribution of Health Insurance Coverage Among Pregnant Women, 1999.” A report prepared for the March of Dimes.
ii Bureau of Census, 2001. Unpublished data prepared for the March of Dimes.
iii Thorpe, 2001.
iv Institute of Medicine. 1988. “Prenatal Care: Reaching Mothers, Reaching Infants.” National Academy Press. Washington, DC.
v Bernstein, Amy. “Insurance Status and Use of Health Services by Pregnant Women.” March of Dimes by the Alpha Center, December, 1999.
vi Center for Medicare and Medicaid Services. 2002. “The State Children’s Health Insurance Program Annual Report, October 1, 2000 – September 30, 2001. February 6, 2002, and National Governors’ Association. 2000. “Income Eligibility for Pregnant Women and Children.” MCH Update.
vii American Academy of Pediatrics and the American College of Obstetricians and Gynecologists. 1997. “Guidelines for Perinatal Care.” Fourth edition.
viii Thorpe, 2001.
ix Current legislation pending before the Senate includes:
- S. 724, the “Mothers and Newborns Health Insurance Act,” co-authored by Senators Bond (R-MI) and Breaux (D-LA) and cosponsored by Senators Cochran (R-MS), Collins (R-ME), Daschle (D-SD), DeWine (R-OH), Dodd (D-CT), Landrieu (D-LA), Lieberman (D-CT), Lincoln (D-AR) and Lott (R-MS). This bill has been endorsemed by HHS Secretary Thompson on behalf of the Administration, the National Governors’ Association, the National Conference of State Legislatures, and twenty-five national organizations.
- S. 1016, the “Start Healthy, Stay Healthy Act,” co-authored by Senators Bingaman (D-NM) and Lugar (R-IN) and cosponsored by Senators Chafee (R-RI), Corzine (D-NJ), Lincoln (D-AR), Lugar (R-IN), and McCain (AZ).
- S. 1244, the “FamilyCare Act,” co-authored by Senators Kennedy (D-MA) and Snowe (R-ME) and cosponsored by Senators Baucus (D-MT), Bingaman (D-NM), Breaux (D-LA), Chafee (R-RI), Clinton (D-NY), Collins (R-ME), Corzine (D-NJ), Daschle (D-SD), Edwards (D-NC), Graham (D-FL), Kerry (D-MA), Lincoln (D-AR), Rockefeller (D-WV), and Torricelli (D-NJ).
Current legislation pending before the House of Representatives includes:
- HR 2610, the “Mothers and Newborns Health Insurance Act,” co-authored by Congresswoman Lowey (D-NY) and Congressman Hyde (R-IL) and 60 cosponsors.
- HR 2630, the “FamilyCare Act,” authored by Congressman Dingell (D-MI) and 47 cosponsors.
- HR 3675, “Improved Maternal Health and Children’s Health Coverage Act,” authored by Congresswoman DeGette (D-CO) and 65 cosponsors.
- HR 3729, “Start Healthy, Stay Healthy Act of 2002,” co-authored by Congressman Strickland (D-OH) and Congressman Ney (R-OH) and 33 cosponsors
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