Bill incentivizes home birth for the poor

The Minnesota legislature, as part of a special session agreement with the governor, passed legislation to allow reimbursement for home births for poor or disabled women, and to pay more for them. House File 2, the Omnibus Health and Human Services bill includes a provision that clears the way for Medicaid to pay for home births and pays nurses and midwives at the same rate as a physician.

The bill also reimburses the homeowner for “supplies” normally billed to the insurance company managing the Medicaid policy. While it might feel good to bill the government $16 for an aspirin and $73.25 for airplane slippers, it’s just a bad idea to pay poor people to not go to the hospital.

Delivering a baby at home is not a new concept. Only six of 45 US Presidents were born in a hospital. With advanced home health care delivery options and improved technology, more women are choosing to give birth at home. Now, with pricey doulas and midwife services available to wealthier patients, advocates are demanding Medicaid moms have access to home delivery.

While some studies show planned home births have comparable outcomes when conditions are perfect and predictable, the factors that make things perfect are far less predictable for the poor as compared to the rich. Many advocates are the highly educated, wealthy folks who, for their own care, demand and receive concierge-level services often paid for in cash. They truly do want to help lower the maternal death rate for low-income women, but (as so often is the case when wealthy people propose public health policy for poor folks) they just make things worse.

The fact that only about 2% of child births in the US are home births has a lot to do with the fact that childbirth was a leading cause of death for most of human history. I 1900, nearly one-in-ten babies and one-in-100 mothers died as a result of each childbirth.

A 2022 Minnesota study found that black women were 2.3 times more likely to die from a childbirth-related event than white women. Given that 72.9% of all pregnant black women are served by Medicaid in Minnesota, this population is at a significantly higher risk for complication and possible death during childbirth. Keeping them out of the hospital will make that worse, not better.

Significantly, pregnant women of color are being told that hospitals are inherently unsafe. The number of black women who delivered at home tripled in the years 2016-2023. While there are challenges to care for marginalized populations, scaring them away from hospitals is just plain dangerous.

A hospital is safer than home for childbirth. With nursing services, access to operating rooms for emergency cesarean delivery, blood products, and access to care for high-level neonatal care if things go south, delivering at home rather than a hospital increases the chances of maternal and fetal death. According to the American College of Obstetricians and Gynecologists (ACOG), the chances of a baby dying in childbirth at home are twice as high as a delivery in a hospital.  

The bill aims to lower the risk of life-threatening complications by limiting the opportunity to only those pregnancy considered to be “low risk.” Patient consent is also required.

However, incentives are provided tip the scales toward home delivery for Medicaid patients. Nurses and other “eligible providers” are paid 100% of physician rates if they assist in a delivery in a home Medicaid setting. This would normally be a Certified Nurse Midwife. Doula services are also a covered benefit for Medical Assistance and because there is no clarifying language in the bill, their rate is unclear.

Significant costs that would normally be billed to an insurance company for hospital supplies can now presumably be billed for and collected by the owner or renter of the place of birth. An earlier version of the bill provided for a global payment to the pregnant woman or owner of the home. “The payment for facility services, pertaining to the place of services for the home birth, must be paid at 70 percent of the statewide average for a facility payment rate.” That would almost certainly be thousands of dollars.

Providing a financial cash incentive for poor women to give birth at home with the promise of a safer delivery, when it is actually much riskier is just making things worse for low-income women. The policy, (though driven by condescension and ignorance, not malice) should be challenged.