Just a few things as I am cleaning out my interesting article bucket:
Health Affairs has an intriguing study from Minnesota on the effectiveness of doulas to control costs for Medicaid births by encouraging fewer high intensity interventions:
Evidence suggests that when low-income individuals and people of color have access to doula care, they experience better outcomes than Medicaid recipients in general; that is, those with doula support have lower cesarean delivery rates and higher breastfeeding initiation rates.24,25 Thismeans taxpayers who finance 42% of births in Minnesota through the Medicaid program may see better value for the state’s financial investment in childbirth care when coverage benefits for pregnancy and childbirth also include the services of a doula….
Medicaid beneficiaries with doula support had a cesarean rate of 19.0% (95% CI=7.4, 20.5), significantly lower than the cesarean rate in the regional Medicaid population of 34.2% (95% CI=33.8, 34.5). Unadjusted for potential confounders, average preterm birth rate was not statistically different for doula-supported births, compared with Medicaid-funded births regionally.
From a cost control point of view, the big winner is the reduction in C-section rates by 15 points. That is massive. A non-complicated vaginal birth will cost slightly more than half that of a simple C-section. Recovery time for the mom tends to be less as she will have avoided major abdominal surgery as well. Doula’s are effectively professional advocates who can push back against our systemic desire to make everything a high tech enterprise that layers costs into everything even when the pay-off for those added costs are not significant. This to me is intriguing as hell.
And then there is this article from Benefits Pro concerning the proportion of births covered by private/commercial coverage:
A recent study published in the New England Journal of Medicine finds that PPACA has led to an increase in the percentage of births covered by private insurers, presumably as a result of the health law’s provision that requires insurers to cover the children of their beneficiaries until the age of 26.
The 2.5 percent increase in privately insured births among young mothers may seem small, but it represents a shift of hundreds of thousand of births to a different payment system.
Indeed, the rise in privately insured births has corresponded with a decline in the percentage of baby deliveries covered by Medicaid as well as drop in the number of uninsured deliveries.
It is good that more births are being covered as some previously uninsured births are now getting covered through either the Exchanges or through the U-26 stay on parents’ insurance provision of PPACA. Some births are being shifted from Medicaid (the payer of last resort for maternity care) to private insurance.
As a policy objective, I question whether it is a good idea to shift births from Medicaid to commercial insurance because commercial insurance costs a lot more per unit of service. It is the same quantity of services being consumed at a much higher unit rate. That is the crux of the American cost control problem.
JerryN
Not to be a prick about it (well, OK, exactly to be a prick about it) but your concern about the cost shifting is at odds with mocking any effort to move single payer. You’re seeing a very predictable outcome of increasing coverage via private insurance.
currants
@JerryN: I think Richard’s been pretty clear about the benefits of single payer. I understood the mocking to be at the idea of our current political ability to establish single payer. AKA being realistic about our actual political environment, which is dismal, IMO.
JerryN
@currants: But we have a choice of either engaging in the effort to move to single payer or to just focus on hanging bags off the side of kludges made to patches to a poorly designed system. It sounds to me like the latter is all that the folks who were so dismissive of Sanders’ plan want to do.
WereBear
I think the crux of this article is that we can reduce costs while getting even better outcomes.
And yet… and yet… and yet… moving to this superior system will be incredibly difficult.
That is the problem of the entire country right now. Common sense solutions that the majority of the people want are not getting to them.
I don’t blame Obama.
Baud
@JerryN:
If we can only do one or the other, we have to focus on the kludges, because otherwise we leave the existing system in the hands of the GOP.
But since we can do both, it’s all academic.
JerryN
@Baud: well, right now, the two Democratic front runners are offering an either-or. Clinton’s plan as best I can tell is all about defending the current status quo with a couple of tweaks around the edges. While it may well be realistic, it’s sort of the bare minimum that you would expect a Dem candidate to propose.
Baud
@JerryN:
So then vote for Bernie if you prefer his approach.
I'mNotSureWhoIWantToBeYet
@WereBear:
You’re right, but I’d amend that slightly. Common sense is often wrong – e.g. Krugman’s right that when everyone wants safe investments, the thing to do is spend like a drunken sailor. During those times, prudence is a vice.
But you’re right that the huge problems facing the nation (and the world) are solvable problems. We know enough to know how to solve them, or at least make them substantially better. We don’t have to create new technologies or new physics (tabletop fusion reactors, quantum transporters, faster-than-light trucks) to solve them. We have the technology, the organizational skills, and the resources necessary to do it.
We simply have to fix our politics so that we can start down the path of addressing them.
Of course, how we fix the politics (mandatory subcutaneous long-duration Xanax injections for all human males between 15 and 45, maybe?) is a huge problem. :-/
My $0.02.
Cheers,
Scott.
I'mNotSureWhoIWantToBeYet
@I’mNotSureWhoIWantToBeYet: Grr. I used a bad word.
Free me from moderation, please?
Thanks.
Cheers,
Scott.
MomSense
@JerryN:
If you look at how other countries transitioned to single payer, it was exactly through tweaks, and incremental changes over time. Not all countries with universal coverage have a single payer model. There are problems with Sanders’ plan even if it had any chance whatsoever of passing.
WereBear
I understand. I also don’t care. This is a goal. How we get there may well be tweaks and kludges; if you are familiar with Bernie’s strategies as a senator, you will see that is exactly how he gets stuff past the opposition.
This is what disturbs me about Clinton; her ringing rallying cry is “I won’t go back and I won’t advance!”
It’s discouraging to me, when I admire her and so wish I could get enthused.
satby
Doulas, midwives, pretty much anyone who can educate and advocate for pregnant women to help keep them from being steamrolled by the
is really important. Because the unnecessary C-section rate in this country is much higher than in other countries. And advocating for yourself as a young, pregnant, probably worried woman is hard.
True story: when pregnant with my second son after the first was a C-section, it took me a long time to find a doctor that would consider a v-back delivery. And then, when I was actually in labor, that doctor was on vacation, and her partner, who had refused to even consider a normal delivery even if everything was fine was on call. I had hired a midwife for my labor coach, and she was puzzled by the doctor’s insistence that I submit to another major surgery in the absence of any compelling reason. So I switched doctors in the middle of labor to the midwife’s supervising physician, and had a perfectly healthy son via a normal birth.
But not everyone is as bull-headed as I am.
MomSense
@WereBear:
I started this primary season desperately wanting an alternative to Clinton but Sanders and O’Malley have really turned me off for different reasons. I’m going to caucus for Clinton. My parents both prefer Sanders although my mom is getting really annoyed because she thinks Sanders is not as well versed in policy and she didn’t like what he said about PP at all. One son has decided Clinton because he calls Sanders the buzzfeed candidate. The other son is undecided after leaning Sanders.
WereBear
@MomSense: This is what the primary season is for — see how the candidates resonate with us.
I may have an advantage there; I’ve seen Bernie in action for many years, being as I’m two hours from Burlington and often spend a fun day there. The revitalization of that city is nothing short of remarkable.
JerryN
@WereBear: I guess a lot of us are where you and MomSense are. We’ll all support whoever the nominee is, but we’re frustrated with some aspects of each of the current candidates. And, like you, part of my problem on things like healthcare is that Clinton hasn’t really articulated goals beyond not losing ground.
MomSense
Anticipating our next Congress, the goal of not losing ground seems appropriate. Remember it took a dedicated movement of people and tremendous union organizing and funds to get the PPACA passed. I don’t think there is energy to re-fight this now. If we want to do the most good for the people who need it most, it makes much more sense to expand the Medicaid Gap now which would provide low cost (little or no cost to patients) health care to millions of people right now – without new legislation. And we should also work to increase the minimum wage.
This would be a great time for Sanders’ campaign to prove its muscle with some phone calls to all the governors and legislators who are standing in the way of Medicaid expansion.
Scapegoat
Wife is due in two weeks. Using a doula. This is welcome news.
Having gone through Childbirth Education classes recently, was surprised that we were the only couple using a doula.
piratedan7
@JerryN: well there are goals and there are goals… okay, so she hasn’t publicly embraced the public option and has supported Obamacare and to be fair, she could have supported setting herself on fire and the GOP would be in opposition to that….
what matters most to me is that while single payer/national health service is a goal, I choose to be realistic understanding that we have a GOP controlled House and Senate and unless/until those change, I can’t see a sweeping mandate for doing the heavy lifting that would have to be done to get to single payer.
JFK announced that we were going to the moon…. took us a while to get there and to be sure, there’s a damn sight more people opposed to getting health care for all than there was in spending taxpayers dollars to get into space… and he touched upon national pride and had his unfortunate martyrdom to get there… nowadays, I’d just as soon not see the same sacrifice made, especially in the political climate that exists.
Richard Mayhew
@satby: Yep— my wife’s experience for our two kids was 180 degrees different.
Our daughter (the older kid) was an induced labor because my wife’s blood pressure was getting a little high on her due date and do to the fact her due date was before a 3 day weekend, the hospital wanted to get as many elective procedures taken care of before they were short staffed.
Since her blood pressure was a bit elevated but not even close to the danger zone, she was strapped into monitoring and not allowed to leave her bed for a 16 hour labor. The epidural made pushing problematic but our daughter was healthy and happy at the end.
Our son was the other extreme of intervention. Her water had broken at home. He was almost a highway baby as we beat the highway closing down for construction by three minutes. My wife was fully dilated and gave birth within 45 minutes of arrival at the hospital with nothing besides ice chips to help her. This was an unanticipated all natural process. But she was in good shape the next morning and had no major problems when she came home the following day with our son.
We really should have gotten to the hospital a little bit earlier but for a non-complicated birth, she did not need much besides someone to catch the baby and clean her up.
Doulas do a very good job of advocating for women who are stressed, exhausted, emotional and dealing with lots of pain and can not easily ask “WHY THE FUCK IS THIS NEEDED?” and then go “OK…” or “Can we try something else…”
tamiasmin
It sounds as if a doula provides a valuable service. But I wonder how the name was chosen. It’s the ancient Greek word for a female slave, specifically one born to service, as opposed to one captured in a war and then enslaved.
Capri
Childbirth isn’t an illness, but the consequences of a bad outcome are so devastating that most parents embrace all the medicalization that is offered without question. When I had my kids in the mid-eighties and early nineties there was a moderate backlash to medical interventions and VBAC was considered “out there” but in my town you could find doctors that agreed to it. I don’t think that’s the case any more.
My second birth experience, including my second C-section, radicalized me, I had my third under the care of a lay midwife at home (not planned actually, she was going to act as our doula in the hospital, but labor lasted 40 minutes).
Also in the mid-eighties and early nineties my brother was an epidemiologist for the UTenn hospital system. The birth outcomes in their midwife-only center in the poorest county in Mississippi was the same as for every other medical center, including their most delux. Makes you think that we’re doing it wrong somehow.
Matt McIrvin
I’ve heard that part of the problem is that the procedures to deal with anything slightly abnormal without a C-section require much more extensive training, but a C-section is (from the doctor’s perspective, not the patient’s) a relatively straightforward surgery that can deal with a wide range of conditions. So people know how to do C-sections but the other knowledge is going away.
Kay
I went to a community health center for pregnancy care for my first child and it was the best “health care” I have ever gotten. It was one stop- you would see the physician briefly and then they would send you on to various people in the same facility who promote health- diet, exercise, etc. Honestly they were nags, but nagging works. It was much less of a “medical model” than what I experienced later with private health care.
I have to say though there was a lot of discussion among the women there about how we weren’t getting what women who go to private physicians get- they were afraid the reluctance to offer medical interventions (including- especially – pain relief during delivery) were about saving money – they considered this approach “lesser” as if they were being denied care. I later had children with health insurance and I didn’t get “better” care than at that clinic, but of course a lot of women wouldn’t know that.
This was a while ago- that child is actually grown, gone and married himself- but I would be really careful presenting this to them- make sure it isn’t perceived as cost-cutting for the poors and make sure they are on board.
Brachiator
@Richard Mayhew:
This is a very interesting point.
But does shifting births from Medicaid to commercial insurance result in a higher level of medical care? Is there any correlation at all?
Mandarama
I can give another enthusiastic testimony for doula care. The same doula attended for both of our kids, and our care providers were midwives affiliated with the university I work at. They were all awesome. Basically, it means having someone there at your home during labor who knows what childbirth looks and sounds like, who is calm and encouraging, and who can offer ideas for managing each pain. She kept my husband from feeling freaked out and kept my confidence up. Once at the hospital, the midwives watch closely but don’t rush to intervention. In both cases, this model of care prevented me from needing c-sections: son #1 was posterior and son #2 was huge and got a shoulder stuck. I was able to move around and the midwives used manual skills, so out they came.
At the time (2001 and 2004), we asked insurance about paying for the doula and they said no. I’ve heard some companies will now cover it because of the lower-cost outcomes. We found her ourselves and saved up for her fee, which was $700 each time. Well worth it even for the more broke youngsters we were!
pseudonymous in nc
The thing that consistently staggers people from outside the US, regardless of how their own healthcare systems work, is that Americans pay — a lot! — to give birth.
Countries with actual healthcare systems understand that the safe birth of healthy children is an investment in the future, but I suppose that’ll never happen in America, not least because lots of white people think non-white people shouldn’t be having babies.
At very least, PPACA ought to shift priorities away from the world of hospital beancounters — birth as a highly medicalised procedure, quick turnaround for vaginal deliveries, ka-ching ka-ching C-sections — towards what’s best for mothers and children.