Ensuring poor women have insurance coverage for up to a year after giving birth, instead of just two months. Using payment reform to reduce the number of pre-term births. Requiring the same clinically proven standards of care at all birthing facilities.
Lawmakers approved these and other Democratic-led proposed reforms Tuesday during a joint meeting of two Assembly panels focused on improving New Jersey’s system of maternal care, which has come under growing scrutiny in recent years.
Despite the overall high quality of healthcare in the Garden State, it ranks 47th nationwide in terms of its maternal mortality rate — with more than 37 fatalities per 100,000 live births — and black women are roughly five times more likely to die than white women, according to the Assembly.
To address these concerns, members of the Health and Senior Citizens and Women and Children committees in the Assembly took testimony regarding a package of 14 maternal health bills — all but one introduced just last week. A proposal to expand Medicaid coverage for doula care which has received growing attention and support in recent years, dates back to 2016 and has already cleared two Senate panels, leaving it poised for final adoption in that house. (Doulas, who are nonclinical birth coaches, are playing a growing role in perinatal care.)
“We believe doula care is an essential element” of quality maternal services, explained Barbara May, a program director with the Southern New Jersey Perinatal Cooperative, one of three state-funded regional collaborations; the South Jersey group is now leading a doula-training pilot project. “Right now, these are a privilege available only to insured families and those who can afford to pay privately.”
Several of these measures are modeled on successful programs in other areas, including California and New York City, and at least five are focused on changes to the Medicaid program, which is funded by a mix of state and federal dollars. In 2014, Medicaid covered more than two in five births and spent greater than $700 million on these procedures, according to the Assembly, so improvements — and savings — achieved through these reforms could have a large impact on public health and finances.
Qualified support from providers and insurers
The proposals were generally well received by patient advocates and care providers, some who have long called for such changes. Officials from the New Jersey Hospital Association, which represents the state’s 49 birthing facilities, also offered support for several of the measures, but urged lawmakers to acknowledge in the bills efforts already underway at these facilities, including programs designed to share best-practices.
In addition, the New Jersey Association of Health Plans, the trade group for the insurance companies paying healthcare claims — which often raises concerns about legislation designed to expand coverage — agreed to back a number of the bills, including a measure to ensure women are covered by Medicaid for up to a year after giving birth.
Ward Sanders, AHP’s president and CEO, said his members also support the plan to expand Medicaid coverage for doulas, but would like clarification on what training or certification would be required and where these services would best be focused.
“We need to be evidence-based about this,” Sanders said. “I think there are a lot of questions that need to be answered as part of this, but we do believe that doulas can help provide, A, good health outcomes and B, be economical in that.”
Maternal-health issues have become a priority for state officials under Gov. Phil Murphy, who approved $7.5 million in additional funding for women’s health services and expanded access to contraceptive care shortly after taking office. The state Department of Health, led by Dr. Shereef Elnahal, has also invested $4.7 million in expanding maternal care, particularly in underserved communities, and is now working to create New Jersey’s first maternal-health report card.
Elnahal will join First Lady Tammy Murphy, Department of Human Services Commissioner Carole Johnson and others on Wednesday in Camden to discuss these and other initiatives. The event is scheduled to mark the state’s second-annual Maternal Health Awareness Day, an effort launched by patient advocates to elevate women’s voices and improve care.
A look at the details
The bills approved by the joint committees on Tuesday include:
A-1662, led by Assemblywomen Eliana Pintor Marin (D-Essex), Angelica Jimenez (D-Hudson) and Shavonda Sumter (D-Passaic), would amend existing state law to include “doula care” in the definition of comprehensive maternity care services that must be covered by New Jersey’s Medicaid program. It would also require the DHS, which oversees Medicaid, to obtain federal permission for the change and to adopt rules to determine eligibility and coverage. This bill was the only one with a history; first introduced in the Assembly in the June 2016, during a previous session, the measure did not gain traction until recently. A companion bill has already cleared two Senate panels last year and now heads to the full Senate for a vote.
A-4930, sponsored by Sumter and Assemblywoman Lisa Swain (D-Bergen), would change the licensing requirements for hospital birthing facilities to include specific protocols, or “patient-safety bundles,” that have been proven to improve care elsewhere, according to national healthcare-quality organizations. Under the proposal, the DOH would oversee the change, which would require hospitals to develop plans to address nearly a dozen specific conditions or concerns, including: screening patients for depression, anxiety and opioid use; reducing blood clots, hemorrhaging and surgical errors; limiting unnecessary cesarean births; and reducing ethnic disparities in care.
A-4931, sponsored by Assemblywoman Annette Quijano (D-Union) and Herb Conaway (D-Burlington), the chair of the Assembly health committee and a physician, is modeled on a system in California and would update existing law to require the state Department of Health to develop comprehensive policies and procedures to guide care at all birthing facilities. It also calls on these facilities to collect and report specific maternity-care data, which the state would use to create a baseline for birth outcomes and develop metrics for improvements that it would then track over time. In addition, the bill calls on the DOH to build a single, searchable database to store this information, with the cost to be shared by all birthing centers. Department staff would review the data on a regular basis to identify problems and opportunities for better care; they would also need to publish a public report on the findings within a year of the program’s start.
Improvements in care and cost control
Assembly Women and Children chair Gabriela Mosquera (D-Camden) and Assemblyman Adam Taliaferro (D-Salem) introduced A-4932 to establish a three-year perinatal “episode of care” pilot program in Medicaid; “episode of care” models involve bundled payments for all services — in this case prenatal care, birth, labor, postpartum and more — that seek to identify new ways to improve the quality of care and hold down costs.
The “Listening to Mothers Survey Act” (A-4933), by Assemblywomen Britnee Timberlake (D-Essex) and Pamela Lampitt (D-Camden), would require the DOH to develop a survey enabling women to detail their birth experience; the state would collect this information, along with demographic details, to help identify concerns and improve policies. The survey data would also be made available to the public.
A-4934, sponsored by Assemblywomen Verlina Reynolds-Jackson (D-Mercer) and Patricia Egan Jones (D-Camden), would amend current state law to extend Medicaid coverage for pregnant woman for up to a year from the end of a pregnancy. Under current rules, uninsured women who earn too much to traditionally qualify for the program can be covered while they are pregnant and for up to 60 days after they give birth, or the pregnancy ends. Patient advocates said two months is often insufficient to identify post-partum depression or chronic healthcare conditions in the mother or baby.
Introduced by Assembly members Angela McKnight and Raj Mukherji (both D-Hudson), A-4935 would prohibit Medicaid and policies that cover public employees in New Jersey from paying for early-elective deliveries when the procedure is not medically necessary. The bill would ban these plans from paying for induced labor or C-sections for mothers before their 39th week of pregnancy, unless it is required by a health professional for the sake of the mother or baby; patient and provider convenience must not be part of the calculation.
A-4936, sponsored by Assemblywomen Linda Carter (D-Union) and Annette Chapparo, (D-Hudson), would require the DOH to develop a decision-making tool to help birthing centers make the right choices on clinical care. The model would need to incorporate decision aids to benefit patients and their families, like fact sheets and brochures. The health commissioner would need to establish a three-year pilot project to evaluate the tool’s benefits and use those findings to improve care.
In A-4937, Assembly members Mila Jasey (D-Essex) and Gordon Johnson (D-Bergen) call on the DOH to seek out additional federal funding for maternal mental-health programs, something community providers said was a critical need. They urged state officials to look at the 21st Century Cures Act in particular.
A-4938, by Assemblywomen Cleopatra Tucker (D-Essex) and Nancy Pinkin (D-Middlesex) calls for the DOH to establish a “My Life, My Plan,” program, a family-planning initiative based on a national model. It also directs the health commissioner to work with community organizations, healthcare providers and others to reduce the proportion of pregnancies that are unplanned, now estimated at nearly 50 percent nationwide.
Steps to guard against post-partum issues
A-4939, introduced by Assembly members Yvonne Lopez (D-Middlesex) and Benjie Wimberly (D-Passaic), would amend existing law to require the DOH to develop “inter-conception care” resources for providers and patients to help improve the health of women between pregnancies. The bill calls for patient-education materials with plain-language descriptions of worrisome post-partum symptoms, self-care strategies and treatment options to help new mothers and newborns, as well as best-practice guides to help providers become more effective.
A-4940, introduced by Assembly members Joann Downey (D-Middlesex) and Jamel Holley (D-Union), calls on the DOH to develop a standardized perinatal-care curriculum for community health workers — front-line professionals who are playing a growing role in maternal care. This is not currently part of their standard training.
Assembly members Valerie Vainieri Huttle (D-Bergen) and William Spearman, (D-Salem) sponsored A-4941 which requires the DOH to develop a public-health campaign around maternity care, with a user-friendly website serving data on outcomes, regular public reports on these outcomes, resource links and information about effective care models.
Lastly, A-219, by Assemblywomen Shanique Speight (D-Essex) and Carol Murphy (D-Burlington), encourages the DOH to adopt “respectful” birth standards similar to those now in place in New York City, which supporters said have helped empower women and reduce discrimination. The measure requires birthing centers to adhere to the standards and for the department to conduct a public campaign around the program.