Poverty and pregnancy should not be fatal in Georgia

Recently the Department of Community Health decided not to move forward with a plan to improve health care access for the uninsured people of the state. Georgia officials said the plan was just “too costly, with administrative costs alone estimated at $3.5 million.”

Dr. Carla Roberts
Dr. Carla Roberts

Georgia has among the highest rates of uninsured people among the 50 states, and many of Georgia’s uninsured live in rural areas, where access to care is already somewhat limited.

The plan that was scrapped by the state would have included federal matching of Medicaid dollars to set up pilot sites that would help provide coverage to those uninsured. These sites would have initially included Grady Memorial Hospital in Atlanta, Memorial Health in Savannah and a small group of rural hospitals.

This plan would not be considered the kind of Medicaid expansion that is suggested by the Affordable Care Act. But it would have been an innovative way to keep Georgia taxpayers’ dollars — which have already been collected — working within our state to help our uninsured, rather than going to fix other states’ health-access deficiencies.

The 1115 waiver plan was modeled after the Cleveland MetroHealth Care Plus program in Ohio, which was found to markedly reduce state health care costs. But Georgia officials say these plans to improve access to health care in the state are “just too costly.”

Meanwhile last week, two Georgia hospitals, Emanuel Medical Center and Barrow Regional Medical Center, closed their labor and delivery units, citing high costs and low reimbursements. They were the latest among many. Georgia now has fewer than 75 hospitals with labor and delivery units, out of more than 180 hospitals currently operating in the state. This is a health care issue that is truly “costly” in our state of Georgia.

In 2012, Georgia had 130,280 deliveries, which makes us the state with the seventh-highest number of deliveries. More than 78,000 of those women will lose their health care coverage within six weeks of delivery. But Georgia also has a high maternal mortality rate, meaning the rate of women who die within a year of giving birth. Our infant mortality ranking is 41st out of 50 states. Continuing the bad news, we rank 4th in recurrent teen pregnancies.

Where the ‘war’ talk applies

Politically, most Republican-led states see any form of Medicaid expansion as giving the Democrats a win and swelling the size of government.  Some in the Democratic Party respond to the Republican position with the mantra “war on women,” claiming that the GOP’s real intention is to restrict women’s health care and erode protections for them and their families. The political rhetoric is overheated, with vocal women on both sides of the party divide.

I say that today in Georgia, there is a real “war on women.” It can only be called a war when so many mothers are dying within a year after they deliver a baby. And it is a problem that rests on the shoulders of both parties.

Pat Cota, the executive director of the Georgia Obstetrics and Gynecological Society, reports that “40 counties in Georgia, or 1 in every 4, have no delivering obstetrician. We are lacking in real programs to address recruitment and retention of these trained women’s health specialists within our state. They are especially needed in rural areas. The state of Georgia is not reimbursing obstetricians fast enough or in the appropriate amount and currently uses outdated information about what women’s health needs are.“

Good prenatal care requires 10 prenatal visits. Georgia Medicaid currently reimburses each physician $300 in toto for these 10 visits. That is $30 per visit. This does not include the delivery fee paid to the hospital or the physician, but that reimbursement is similarly abysmal.

One well-touted way to increase access to care for rural pregnant women is to fill the need with family medicine physicians, but malpractice insurance is just one of the roadblocks to this solution. There is no increase in malpractice insurance for any physician taking care of a pregnant woman within the first 12 weeks of a pregnancy. But once a physician sees a patient in weeks 13 and above, the doctor’s malpractice insurance increases an additional $20,000 or more per year. There has been absolutely no movement in the Georgia Legislature to ease this burden on the physicians trying to improve access for pregnant patients in underserved areas.

Will the public rise up?

When a pregnant woman needs care, it is in effect a two-patient situation. But obstetricians, family medicine physicians and hospitals, which have the knowhow to care for women, pregnant and otherwise, are often just plain unable to stay in business in rural areas.

With the announced obstetrical closings of Emanuel Medical Center and Barrow Regional Medical Center, there are only 46 counties out of 159 in Georgia with labor and delivery units still open. When labor and delivery units close, so do the nurseries. Since 1994, at least one labor and delivery unit has closed each year, and the closure rate has steadily increased in recent years. The whole pattern of where mothers can safely have their babies in this state is changing. To put things in perspective, Augusta is surrounded by 17 counties. There are zero labor and delivery units in those counties. “Between Athens [and] Augusta, there’s no delivery hospital,” Cota says. “There are patients who have to drive 2 hours or more just to deliver their baby.”

Currently in Georgia, females constitute 51 percent of the population. In the 2008 and 2012 general elections, a clear majority of the voters who went to the polls in Georgia were female. It raises the question: Since Georgia’s maternal mortality is already high, what will it take before our state’s politicians work to improve the situation and declare that doing so is not “too costly?” Will it take that majority of the votes cast in the next election to persuade our elected officials to help the women and infants in Georgia? Would a poll help? Although the question can be written many ways, the answer will most assuredly be “Stop letting the mothers in our state die.”

To be fair, Dr. Dean Burke, an obstetrician, sponsored and passed a bill in the 2014 session that formally recognized the need for a committee, with appropriated state funding, to study the maternal mortality crisis in our state. That project is under way.

Undoubtedly, women’s health topics have held a place in the forefront of the recent political landscape. Our state is no exception. The issues are charged and divisive, and while political points have been lobbied and tallied, our state has watched its mothers die. There are thousands of obstetricians and gynecologists in our state who are yearning to work alongside our elected officials to help them craft medically sound legislation that would save our  mothers and babies. They are just waiting to be asked. What will it take for our legislators to work with this army of physicians who are truly the “trained warriors” necessary in the real war against women? Georgia’s pregnant women.

Carla Roberts, MD, PhD, is an expert in women’s health and health policy. Dr. Roberts has practiced in the medical field in Atlanta for over 21 years. She spent almost two decades on the faculty at Emory University School of Medicine in the Department of Gynecology and Obstetrics. She ran for a seat in the Georgia House of Representatives in 2012 and is now in private practice as the founding partner of Reproductive Surgical Specialists at Northside Forsyth Hospital in Cumming. Dr. Roberts is the vice chair of Legislative Affairs for the Georgia Obstetrics and Gynecology Society.