Utah Lawmaker May Propose Cutting Use of Epidurals to Save Money
Thursday, August 19, 2010 at 10:33AM
By Jill—Unnecesarean
From the Daily Herald:
Under the theory that perhaps thousands of Utah college students are having babies paid for by Medicaid that they could pay for themselves, one lawmaker has a plan: cut all elective epidurals and elective C-sections.
Sen. Dan Liljenquist, R-Bountiful, has vowed massive Medicaid reform in next year’s legislative session, and first on the list is people who may be freeloading. Medicaid pays for 15,000 births a year in Utah, a third of the total, Liljenquist says.
“Do we save some kid or make birth easier?” he said, noting that the waiting list for Medicaid in Utah just for the disabled has reached 4,400 people.
Liljenquist says the state could save millions. Epidurals, a shot given in the spine, are a common method of relieving pain during labor. At Utah Valley Regional Medical Center in Provo, 86 to 87 percent of women who deliver babies at the hospital get an epidural; studies show about 65 percent of births nationwide happen with an epidural.
Denying patients epidural anesthesia is a great way to put misogynistic, classist douchebaggery into action. Rich women will be able to afford paying for pain relief and poor and middle class women will not have access to it. It’s about as thoughtful a move as trying to force more women to breastfeed by making formula available by prescription only.
Dick Morris tried to scare the public last year into believing that the Obama administration had plans to force women to go through “natural childbirth”, telling Bill O’Reilly of The O’Reilly Factor that “right now the government is telling people, cut back on cesarean sections, go through natural childbirth. It’s a lower cost.” It never happened and neither will this.
Utah already has the nation’s lowest cesarean rate at 22.2 percent.
Hat tip: Woman to Woman’s new Facebook page.
Reader Comments (58)
I always appreciate a good application of the word 'douchebaggery.' It is hard for me to imagine something like this passing, as much as we like to screw the poor and young. After all, childbirth is the WORST THING IN THE WORLD and we must be compassionate and save women from it with technology. As an aside, is the 65% epi rate accurate? I always thought it was in the 90s.
Playing devil's advocate here, I do have to say, there's a difference between what people have a right to have if they themselves are paying for it, and what they have a right to have paid for by other people. After all, you could take this one step further and say that everyone has a right to free postpartum help during their 12 weeks of recovery from the c-section that they got for free, which they needed because of the free epidural they got which was another step in the cascade of free interventions they received during their free hospital stay.
If a state's budget only allows for so many services, they have to prioritize. And I'm sorry, but an epidural is not as necessary as some of the other services that medicaid recipients might require instead. And who says that just because someone is poor, they're entitled to receive everything under the sun?
My husband lost his job last week. Our third child is due in a couple weeks. When this baby is born, we will have no health insurance. Even if he finds a new job this week, our new insurance wouldn't kick in until the beginning of the next month, after the birth. And yet we couldn't get government assistance if we wanted or needed it, because our income last year and the first part of this year disqualifies us. Mind you, we will be birthing at home and won't need hospital maternity services, but what if we did? We'd be paying out of pocket for my epidural and IV and c-section. Why should someone else get these things for free just because they want (not need) them? This is the first time my husband has been unemployed in his 17-year career; we have always worked hard for what we have. And yet in the case of our upcoming birth, it would have been better for us to not go to college, not work hard, and not have to think about where everything we want in life would be coming from. Then at least I might have health insurance for this birth, right?
I'm not for denying people the things they need. It's just that, as a (recent) taxpayer, I don't think I should have to pay for things people just WANT. Like epidurals.
I think maybe they should concentrate on the root of the problem here: Inductions. Pitocin makes labor just about unbearable and often is the first of many interventions that lead to an otherwise unnecessary c-section. Stop inducing women before the baby is ready (unless, I suppose, they reach that magical 42 week mark) and you'll have fewer interventions, including epidurals and c-sections.
I just edited this (1:54pm) to include the link to the article. Someone mentioned on the Facebook page that she read the article and linked to it. I wondered what the deal was since it was already linked... but I never linked it. Sorry.
Interesting discussion on FB.
Karen, I hear what you're saying. I question anything that gets into a situation where women can't freely chose what to do with their bodies. Obviously there are exceptions to every sweeping statement like that, but I don't like anything that gets into forced birth territory.
The use of the word "elective" in this article is intended to mean desired but not medically necessary (as opposed to the term "elective cesarean", which has come to mean a non-emergency c/s). The full article shows that there's punitive reasoning behind the wanting to cut these specifically, as he sees these women as freeloaders.
I used to question why some insurers covered maternal request (not elective) cesareans. Courtroom Mama pointed out in the comments here that it had potential to getting into a situation in which women were being forced to give birth vaginally against their will. On top of that, it perpetuates a system in which the rich have access to choices that the poor do not.
This is the problem with any government-sponsored health insurance. What is considered "necessary" care, and what is considered "elective" care?? These are difficult questions, and once the population has ceased to consider healthcare a service that they purchase, and begin to view it collectively as a right they deserve, this gets increasingly difficult. Epidurals are far from the only medical service that will come under scrutiny. If a person's quality of life is improved by an elective procedure, is it necessary? Do we make these decisions on a case-by-case basis, or on a broader level? People focus on the hot-button items - care for the elderly, abortion, birth control, prenatal and birth services, but these issues will cross into all medical disciplines. Could it be argued that those breast implants are necessary because the patient is severely depressed about her small boobs (the implants may be cheaper than therapy)? Or could we argue that because that last-ditch treatment only has a 5% success rate we won't cover it because the cost-benefit ratio is too low (if you had a 5% shot at seeing your kids grow up, would you want the right to decide to try it?)?? It's naive to think that medical services will only be provided as deemed necessary by medical professionals in consultation with their patients - this will be at least in part a political and economic decision.
@Karen: How do you determine whether a woman's request for an epidural is a "want" or a "need"? It seems to me that if a woman is requesting an epidural, it is because she feels she needs it -- whether that need is based in actual pain, perceived pain, a need to rest, emotional or physical issues that are affected by or reactive to the birth process, or something else entirely. Good luck with your upcoming birth! I hope you have the peaceful homebirth you have planned.
I live in Utah, and this cuts to the core. We have a high birth rate here, as well as a high epidural rate. I know a LOT of women who will kick and scream if they're denied an epidural because of funding concerns. I doubt this will pass, but even the notion is upsetting. Personally I don't choose an epidural or elective cesarean, and I support unmedicated birth as well as home birth. I actually had Medicaid with my last pregnancy but chose to pay out of pocket for a home birth instead. However, I also support each woman's right to choose, and taking an option away that over 80% of women choose is utterly ridiculous.
I guess I understand the throught process. But still, major FAIL. Pain relief is not considered "elective" in any other branch of healthcare, nor should it be.
Pain relief only considered "elective" when needed by women, doing something only women do! Thanks, misogynistic, classist douchebaggery! (Definite win on that phrase.)
The FB discussion is pretty interesting! It made me realize that I simultaneously believe the following:
1) Epidurals are a useful tool in labor and I have seen them used very effectively
2) Epidurals can be the beginning of, or an intermediate step in, the cascade of interventions
3) A woman has the right to an elective epidural if her hospital offers them, and to deny them to women who cannot pay is a violation of her rights
4) A perhaps surprising number of hospitals do not offer them because they do not have in-house anesthesia, and (as long as they offer other modes of pain relief) that is not a violation of the rights of their patients
5) Many women who are induced will need an epidural for pain relief, and I would venture to say that inducing without an epidural available infringes on a violation of the rights of the patient (and yes I have seen this done and it was awful)
Thoughts?
I think that in some ways this is a horrible idea, in some ways it is a great idea. What if moms prepared for an un-medicated birth (which they would be more likely to do if they had to pay for their epidurals out of pocket. If they were well educated, the induction rates would go down, the cesarean rates would drop, etc.
So while I like that aspect of it, I think that it would be seen as punishing "poor" women. So what if instead all women had to pay for their epidurals, not just Medicaid moms? What changes would we see in the birthing culture?
Sheridan,
You definitely hit on a thought there that resonates with me! We really don't have free choice when it comes to a lot of things in birth (and other aspects of health care), because most people have either health insurance or fall under some government program, and must act within those guidelines, or face higher costs. For instance, I often hear of women saying, "I'd have a home birth, but my insurance won't cover it," little realizing that they may end up paying more for their covered hospital birth than their out-of-pocket home birth, particularly if they have to pay 20% of a C-section bill. Plus, most if not all people would make different choices if they had to pay all of the bill, or had to pay it up-front and then get reimbursed. Look at how quickly the circumcision rate has dropped when that was deemed "elective" and "cosmetic," and insurance/Medicaid stopped paying for it. Even though the cost is minimal, in the grand scheme of things (somebody I know said her out-of-pocket cost was $100, I've heard from others up to $400 -- still quite small, compared to thousands of dollars for most cosmetic surgery, or compared to some nursery layettes), when people actually have to pay extra for it, it makes them stop and think.
One of my favorite quotes is from the book, "Rich Dad, Poor Dad," and the author says, "Don't say, 'I can't afford it.' Instead ask, "How can I afford it?' The first statement closes down your mind, while the second opens your mind up to the possibilities!" I use that in a lot of ways, including in this discussion. Hypothetically speaking, if a woman knew she couldn't get an epidural (for whatever reason, whether the choice to have a home birth, some anatomical/medical condition which precluded it, or not being able to afford to pay for it out-of-pocket), she has the choice of thinking, "I won't be able to make it through labor without an epidural"; or "*How* can I make it through labor without an epidural?" Big difference, eh? I bet a lot more women would educate themselves a lot more about some of the alternatives; and I bet hospitals would change their practice/policies too, and perhaps start using gas-and-air (nitrous oxide) like they do in the UK.
" Epidurals, a shot given in the spine, are a common method of relieving pain during labor." Sounds scary even when it's reduced to this incorrect explanation.
Legislators may be looking at this from the wrong angle. Using Obs needs to be restricted to those women with true medical need and the rest should have midwifery care with a clear path for referral and informed refusal. This change alone would reduce recreational epidural use and the cesarean rate, plus we'd have the instant bonus of more true term babies since the induction rates would also fall along with OB use.
If it's about $ let's put more attention on the fact that we're paying a lot for Obs to make preemies with their higher initial and long term cost.
My own new little nephew spent a week in NICU for breathing problems because his Ob moved his due date up by 2 weeks based on ultrasound, induced and AROM'ed my SIL- this was a VBAC- gave her an amnioinfusion, and then a cesarean for fetal distress, cut the baby's face and ear-he was less than 6 lbs-, and my SIL was in ICU for a few days since the epidural shut down her lungs and she almost died. All of this because she trusted her idiot female Ob. who also told her she was sorry that SIL tried to VBAC-blame anything else huh?-and that she can never attempt a VBAC again since she's had 2 cesareans-hello how'd you get through med school asshat? So, like I said before, Ob use should be restricted since they can't be trusted.
Sorry, I don't want to derail this thread with that rant. In short if they want to cut down on epidural use and cesarean sections in the medicaid sector then by all means let's make sure midwives are primary care providers for pregnancy and birth.
I grew up in Salt Lake and went to BYU, just a couple blocks away from the hospital mentioned in the story. I did a couple of my nursing school rotations there and they claim to handle the most deliveries of any hospital in the country. I don't know if that's true but wouldn't be at all surprised. BYU is a Mormon school, and it is deeply ingrained in Mormon culture--especially in Utah--to get married young and have kids shortly thereafter. Married at 19 and a baby at 20 is not at all uncommon. And if you are married, it is pretty much expected that you will have a baby by your senior year. It follows that a huge number of college students are having babies in Utah and are using Medicaid. Compound that with the fact that most BYU students come from out of state (they want to meet other Mormons and get married), and will leave the state as soon as they graduate, never to contribute to the tax base. You can see why this is a huge financial burden for Utah.
What happens is that many students plan to get pregnant before they graduate and get jobs JUST SO they can use Medicaid for it. This is only anecdotal, but I had a lot of friends do just that (they all thought I was nuts for using private insurance when I had my baby). Even people you just meet in passing talk about it because that's what everyone does. These are not the poor. They all go on to graduate and get good jobs, and if they had just waited another couple years to have babies they'd have real jobs with insurance and FMLA. I do think that something needs to be done about this abuse of the system. Perhaps limit Medicaid to Utah residents? I don't know.
But this? Refusing epidurals to all women on medicaid? That includes the college students abusing the system, but it also includes the legitimately poor. NOT okay. It doesn't address the real costs at all. How about limiting the amount of elective inductions (VERY common in Utah--I went to 42 weeks and at 41 weeks I stopped leaving the house because nobody could believe my MW would "let" me go that long, and they kept insisting it was dangerous)? That would save some money. What a stupid, pointless bill.
On an unrelated note, I think the reason the C-section rate is so low in UT (though still too high) is because so many of the mothers are very young and healthy (early 20's). It's not because we don't have high intervention rates, but young, first time mothers bodies are more likely to be resilient against them. That's just my hypothesis though--not based on any actual data, just a guess.
BTW, Jill, I'm a long time reader but a new commenter. I love this site! Thanks for all you do!
The rich will *always* have access to things that the poor do not!
Including somethings which are not good for them. And many which are, of course.
I do not see that as an argument against this law. The government isn't morally required, in my opinion, to pay for anyone's health care. If it is going to pay for it, it is going to have to make decisions about what can be afforded. Because the money used to pay for health care comes from money confiscated from people who worked to earn it, and there is a limited supply of it there! I realize how painful some of these choices will be. My oldest friend lived over a year with Stage IVB pancreatic cancer with Maryland Medicaid paying for her expensive chemotherapy and all the other care that went with it. I was so glad for every day that she lived, and she had a good quality of life, too. Cooked and served us in her kitchen-something she wanted to do-a month before she died. Some people will say that the even more expensive medication she had to switch to when the first one stopped working, which only bought her four or five more months, had just too high a cost. From the point of view of loving my friend I want to say that whatever it cost, it was worth it. But I sadly agree that some choices like this will have to be made.
Given that we are going to be asking some people to DIE sooner because the government just can't afford to pay for everything, I really don't think not paying for something as unnecessary and sometimes harmful as an epidural is a bad choice. And if Medicaid stops paying for it, probably some insurance companies will also, so it will be just the very rich who can choose not to experience their labors.
And yes, if we are going to save money, by all means let's make midwifery care the standard for normal birth. It will certainly be much easier to give birth without an epidural if a woman can move around and has someone taking care of her who knows many ways of dealing with pain which don't involve "sticking a needle in your spine"-(actually I think it is a space near your spine.) Midwives are so much cheaper than OB's and anesthesiologists. And being able to go home within hours of your birth is so much cheaper than staying in the hospital for a couple of days after a C section.
Let's write to the senator and explain this.
Susan Peterson
Sorry, short reply for now.
Heidi, you made me realize that there are some cultural aspects unique to BYU/Provo area that I wasn't aware of.
Susan, the issue of who pays for what in general makes my head spin. Every time I learn more, the sweater unravels and feel like I still don't understand "the system". I agree that my rich/poor dichotomy concerns aren't a strong argument against this proposed cut. However, I don't think that the potential risk of epidurals is a compelling argument, either. In fact, isn't the perception of potential risk/harm how we ended up with VBAC bans?
BTW, what the heck did he mean when he said, “Do we save some kid or make birth easier?" Who is the kid? The college student?
Thanks for all of the comments. I'll see you in a bit.
'some kid' is referring to the waiting list of disabled folks. utah is facing (in the legislator's eyes) spending money on elective epidurals for out of state medicaid mothers or getting disabled children and adults off a long waiting list onto medicaid at all.
"Do we save some kid or make birth easier?"
I took that to mean, if we have to make a choice between paying for life-saving treatment for a child (who may be on the waiting list for Medicaid because there isn't enough funding) or paying for laboring women to have pain relief from an epidural, most of us would think it was more important to save the child. In a world of limited resources, it's good to think about what you have to give up (like giving more people access to Medicaid) when you provide a benefit. Not that I necessarily agree with his proposal...
I wonder if they could save money instead by covering doulas; I'm pretty sure my doula charged less than the hospital bills for an epidural.
My biggest issue with the idea of limiting epidurals is that nothing else is being changed to accommodate the limitation. A women generally needs some labor preparation or a very supportive labor assistant (midwife, nurse, doula) to birth without analgesia. A woman restricted in her movement will generally experience more pain and higher likelihood of wanting an epidural - but there's nothing stating that IVs and continuous fetal monitoring are being limited.
Even if this does go through, does anyone think it will affect the rates of epidural or c-section? Doctors are so quick to rescue women that it seems they'd gladly sign off as deeming the procedure necessary. (sorry, my bias sneaking out...)