While Republican leaders in Raleigh refuse to expand Medicaid, Dr. Dorothy DeGuzman spends her days in rural Yancey County dealing with the consequences.
DeGuzman works for Celo Health Center in Burnsville, a nonprofit, community-owned family practice that serves low-income people in the mountainous county north of Asheville. Most of the center’s patients do not have private health insurance, and their health reflects a lack of access to doctors and preventative programs that would help reduce obesity, hypertension, smoking and substance abuse.
The medical-care gap shows up most profoundly in the pregnant women DeGuzman sees. Many are overweight and smoke, and some are using suboxone, a drug that eases their dependence on opiates, a change they hope will protect the fetus.
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Low-income pregnant women qualify for Medicaid during their pregnancies and for a brief period afterward. But their lack of insurance before conception and after the birth affects their health and that of their babies.
“In the first prenatal visit, I spend most of the time talking about diet and how to be as healthy as possible for their baby, but by then they are usually 12 weeks pregnant,” DeGuzman says.
Expanding Medicaid to include some 500,000 North Carolinians who would qualify under the Affordable Care Act would improve the health of mothers – and fathers. DeGuzman says that improvement would increase the chances of a child being born at full term without injury or birth defects that ultimately cost the taxpayers in hospital care and education expenses.
“There is more and more data that preconception health is very important to the health of the baby,” DeGuzman says. “I think (Medicaid expansion) could improve infant mortality and probably maternal mortality as well.”
North Carolina could use some improvement in infant mortality. It stands at 7.1 deaths per 1,000 babies. That compares with 6.0 nationally and with rates as low as 4.8 in California and 4.4 in Massachusetts, two states that have expanded Medicaid under the Affordable Care Act to include all low-income adults.
After rating among the worst states for infant mortality – the rate was 9.2 in 1995 – North Carolina made strides in reducing it. Help came through county health programs and coordinated care for pregnant mothers under a program run by Community Care of North Carolina, a nonprofit that oversees the delivery of health care to Medicaid beneficiaries. On any given day, there are about 17,000 pregnant women on Medicaid. Pregnancies covered by Medicaid account for 55 percent of the state’s annual births.
Despite strong efforts, the state’s progress against infant mortality has stalled around the the 7.0 level since 2010. That indicates that lowering infant mortality further may require more than access to medical care during pregnancy. Now efforts need to focus on the health issues women bring to pregnancies: hypertension, diabetes, obesity. If the father is in poor health, that also contributes to potential birth defects and can add to financial stress during the infant’s first year.
Rob Thompson, policy director of the nonprofit NC Child, said there should be a greater sense of urgency about the loss of newborns, especially about the higher rates of infant deaths among African-Americans. The gap between black infant mortality and white infant mortality has widened in the last 20 years.
“We’re still well above the national average,” he says, “and we still have these shameful racial and ethnic disparities, and there is no way we can be complacent with where we are.”
What’s needed is a new surge to save more infants. In 2014 in North Carolina, more than 800 babies died in their first year.
“We’ve done what it has taken to get where are, but we have in some ways hit a wall,” Thompson says. “If we want to make significant progress, we have to take some bold steps, and the easiest one is Medicaid expansion.”
Sarah Verbiest, a clinical associate professor and executive director at the UNC Center for Maternal and Infant Health, says there is no “silver bullet” that will sharply lower infant mortality, though expanding Medicaid would help.
Verbiest says there needs to be a broader response that focuses on the root causes of high infant mortality: poverty, violence and stress of coping with racial prejudice. About a dozen areas of the state contribute most to the disparity in the infant mortality rate between African-Americans and whites, Verbiest says, and resources should focus on improving the general health of people in those areas.
The obstacles to further reducing infant mortality are daunting, but Verbiest says they can be overcome. As evidence she points to states that have rates well below the national average.
“We should at least aspire to reach what other states have achieved,” she says. “They have shown that it’s not a pipe dream. It can happen.”