Poor Payment Putting Maternal Care at Risk

It’s that time of year when a lot of people are pondering the perfect Mother’s Day gift. One I think would be close to perfect is improved maternal health, by way of better primary care reimbursement — an aim the AAFP advocates constantly to achieve.

For more than two decades, I delivered babies in my rural Alabama community. Caring for both mothers and their newborns was one of the most exciting and enjoyable aspects of my practice, and it helped grow our practice. 

Unfortunately, that part of my career is over. 

Somewhere along the way, two of our five partners left the practice and one others stopped providing maternity care. That left me and one other partner with a difficult choice: Give up part of family medicine we loved or be on call every other night and every other weekend indefinitely. 

Although we were discouraged for ourselves and our patients, we found that our practice actually made more money when we stopped deliveries because staying in the clinic allowed us to see more patients. Deliveries take time and energy, are often complex and should be reimbursed accordingly. 

Obstetric deserts are a small piece of a bigger crisis. More than 400 rural hospitals are at risk of closure, according to a report released earlier this year. Add to that alarming number the fact that, during the past two decades, nearly 200 rural hospitals closed or converted to emergency or outpatient centers.

The problem, as is often the case in health care, is rooted in payment. Facilities (and physicians) cannot indefinitely offer services that lose money.  

Rural hospitals lack the more diverse payer mix that more urban and suburban hospitals benefit from, making it harder to offset indigent care. In Alabama, more than 40% of births are covered by Medicaid, and roughly 15% of women of childbearing age were uninsured in 2021. Nationwide, we know that people living in rural areas are more likely to live in poverty and lack insurance. 

Rural uninsured rates are nearly twice as high in states that have not expanded Medicaid compared to expansion states. Alabama is one of 10 remaining holdouts, even though expanding Medicaid in the state would extend coverage to an estimated 174,000 people. 

A hospital in a neighboring county stopped offering maternity care in 2023 after losing nearly $1 million in one year. Another hospital in my county continues to offer maternity care — for now. After losing $750,000 last year, that facility is looking far and wide for additional funding.  

If that local hospital closes its maternity ward, pregnant patients will have to travel close to 100 miles to reach the next-closest hospital. 

Rural patients often face issues with access to care, and closing hospitals not only complicates access to acute care but also has a ripple effect on primary care because recruiting and retention become more difficult in areas that lack facilities and services. According to the Kaiser Family Foundation, more than 74 million Americans live in designated primary-care health professional shortage areas. In states that have passed restrictive laws involving medical care in the past two years, retention and recruiting are getting even more difficult.

There is some good news. As of March, 46 states (including Alabama) had taken the option, under the terms of the American Rescue Plan Act of 2021, to extend Medicaid postpartum coverage from 60 days to 12 months. 

According to the CDC, more than half of pregnancy-related deaths occur between one week and one year postpartum, during which time many postpartum individuals lose Medicaid coverage. The AAFP continues to advocate for requiring one year of postpartum Medicaid coverage as an important way to address the disparities in maternal health and improve outcomes.

In the big picture, that’s just a baby step. But it’s an important change for mothers, babies and their doctors. Many more such changes are needed. That’s why the AAFP and its constituent chapters will continue to advocate for maternal health and better reimbursement, two issues that are most definitely connected.