Health Reform and Coverage during Pregnancy

An Independent’s Guide to the Iowa Legislators’ Election:
Pregnant Women without Health Care Coverage
– A New York Times Exposé Waiting to Happen

“What Killed Harmon Ball-Stribling?” is a New York Times article from Aug. 11, 2024, that details the death of a Mississippi Delta pregnant woman who “lived in a rural health care ‘desert,’ a county with no obstetrician or certified nurse midwife and no hospital that delivered babies.” She had health insurance. “Her story is a case study of how powerful social, economic and environmental forces conspire” against women like her.

Next year in Iowa, an estimated 1,270 uninsured women with incomes between $32,500 and $56,250 (215% to 375% of the federal poverty level) will become pregnant and will not be able to obtain health-care coverage via Medicaid or privately. (Private insurance via the federal Health Insurance Marketplace will not be available for them until January 2026.)

This new development occurs because an Iowa law passed and signed this spring, which expanded Medicaid coverage for women from three months to 12 months postpartum, also disqualified newly pregnant women within the above income levels from obtaining coverage through Medicaid. Unfortunately, these women do not qualify for early enrollment in the Marketplace’s insurance plans, as pregnancy is not a “qualifying life event.”

These women have no safety net. The Iowa Division of Insurance has told insurance agents that the is no provision for early insurance issuance, and the Iowa Department of Health and Human Services has twice told me that there is no governmental option for health-care coverage for these women.

The United States has the highest maternal mortality rate despite the most health-care spending. Over 80% of these deaths are likely preventable. Women who do not receive prenatal care are three to four times more likely to die from pregnancy-related complications. Infants born to mothers who do not receive prenatal care are three times more likely to have a low birth rate and five times more likely to die in infancy. It is only logical that newly pregnant women without health-care coverage will be at increased risk of morbidity and mortality due to aggravated mental illness, given that “mental health is the leading cause of death of pregnant women and new mothers in the United States,” according to a JAMA Psychiatry’s Special Communication and confirmed by Iowa Department of Health and Human Services staff.

The perfect storm is completed by the ongoing progression of obstetrical deserts in rural Iowa. Denison and Newton gave up obstetrical services in their cities in the last two months.

This set of circumstances occur at a time when Gov. Kim Reynolds in her 2024 State of the State Address to the Iowa Legislature said, “To continue building a robust culture of life, we must also do everything in our power to ensure new moms and their families – especially those who are struggling – have what they need to make ends meet.” She also said, “Let’s do more to help moms, babies and their families get off to a good start.”

Similarly, Iowa Department of Health & Human Services Director Kelly Garcia said on an Iowa PBS program, “All day, every day, Erin. That’s our job. We work with Iowans who need to navigate the eligibility (health-care coverage) process every day.”

How do we solve this situation? Six options, at least, have been determined:

  1. Make pregnancy a qualifying life event for purposes of the federal Health Insurance Marketplace, allowing early health insurance access by federal rule.
  2. Make pregnancy a qualifying life event for purposes of the federal Health Insurance Marketplace, allowing early health insurance access by federal law.
  3. Return Medicaid eligibility to pregnant women in this income category.
  4. Make Iowa a state-based Exchange and then make pregnancy a qualifying life event for purposes of allowing early health-insurance access.
  5. Expand Iowa’s Children Health Insurance Program (HAWK-I) to include this set of pregnant women. (Six states enroll pregnant women in CHIP-funded coverage.)
  6. Expand HAWK-I to cover unborn children. (Fifteen states, including Minnesota and California, provide separate CHIP coverage to approximately 327,000 unborn children.)

At a Sept. 20 meeting, Iowa Department of Health & Human Services staff indicated that they had no options available to their department to help these women except to encourage “all Iowans to secure health-insurance coverage ahead of any health-related issue.” Department staff said it required a legislative “fix.”

Given that the Iowa Department of Health & Human Services recommended that interested Iowans turn this issue over to the Iowa Legislature, and as an avowed independent voter in Iowa who believes that the Legislature serves the will of the electorate, I believe every state legislative candidate in Iowa should be asked at meet and greets, candidate forums, editorial board meetings and debates how he or she would pursue solving this problem quickly to prevent harm to these 1,270 women and their 1,270 unborn children.

If such a question is asked and answered, please communicate that response to your friends, family and other Iowans. Let’s help Iowa avoid harm to our fellow citizens and avoid a New York Times exposé. Remember that Harmony Ball-Stribling had health insurance; these women will not.

Health Reform and Homeless Unborn Children

In the mid-2000s, the state of Iowa committed to having every Iowan belong to a medical home. To accomplish that effort, Iowa created the Medical Home Advisory Committee. Some of the necessary components for one to be in a medical home include that the individual has health-care coverage and that family physicians, pediatricians and internists are available to care for that individual. Continue reading

Health Reform and the Evolution of COVID from Pandemic to Endemic

I am in my fifth day of quarantine due to COVID; I return to work tomorrow. My only symptoms have been those of a mild upper-respiratory illness, which has now nearly resolved.

I diagnosed the first case of COVID in our area on March 17, 2020. I went nearly 22 months without contracting COVID, despite seeing COVID-positive patients in the hospital and, with the recent surge of the Omicron variant, potentially positive patients at the clinic, all with proper protective equipment. I am fully vaccinated for COVID and have received the booster.

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Health Reform and Obamacare

Obamacare lives. After hundreds of votes by the then-Republican U.S. House of Representatives; after a narrow win in the then-Republican U.S. Senate, courtesy of now-deceased Senator John McCain; after four years of failed promises by President Trump; and now, most recently, after a vote by the U.S. Supreme Court in favor of Obamacare — the third overall, Obamacare remains the law of the land and appears to be now unhappily accepted by Republicans as the status quo. Continue reading

Health Reform and COVID-19 Testing

The content below is a Des Moines Register analysis that includes my comments about the need for widespread, quick testing for the virus that causes COVID-19. The Register’s post, which includes live links to included graphics and social media, is here.

Register analysis: Iowa lags most states in COVID-19 tests per capita

Nick Coltrain, Des Moines Register
April 11, 2020

Iowa’s COVID-19 testing on a per-capita basis lags behind most other states, according to a Register analysis of public testing data.

As of Friday afternoon, Iowa reported 15,953 total test results for COVID-19, the respiratory disease caused by the new coronavirus. That equals about 524 tests per 100,000 Iowans — or No. 39 on the rankings of all 50 states and Washington, D.C.

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Health Reform and the Role of Private Insurance

As a family physician and health-care advocate, I have fought for universal health-care access for more than 25 years.

In 1997, I advocated for the proposed Healthy and Well Kids in Iowa (HAWK-I) program by writing in an op-ed that a “child with a laceration on the arm goes to the school three days after the injury happened. The wound is held together with a bandage of rags and electrical tape. The child has no insurance.”

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Health Reform and Explosions in My Knee with Every Step

Three weeks and 1 hour ago, I ruptured my quadriceps tendon (tendon above the kneecap (patella)) while playing tennis. Five hours later, my quadriceps tendon was surgically re-attached to my patella using three drill holes and wire sutures. The surgeon said, upon opening my knee, that it looked like a “bomb” had exploded. I can sympathize with that statement because, for two weeks after surgery, every step with crutches felt like an explosion had occurred again in my knee.

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Health Reform and a Primer for Democratic Presidential Candidates in Iowa

What every presidential Democratic candidate many of whom will be speaking at the Iowa State Fair this week should know about Iowa health reform:

1. Iowa suffered greatly by having a Republican-dominated state government (governor, Senate, and House) during the aftermath of the enactment of the Affordable Care Act (ACA). With a Republican governor and most recently a Republican Senate and House in Iowa, we had a miserable attempt at a Marketplace/Exchange; no support for our attempt at a health-care Co-Op (Co-Oportunity Health, which had 120,000 members in one year of operation); passage of association health plans, which allow for discrimination against persons with co-existing conditions; and, overall, an unbelievably negative atmosphere in general regarding anything that concerned the ACA.

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