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Oregon’s Medicaid Program Frustrates Midwives And Mothers-To-Be

TC-Torres via Pixabay

Low-income women in Oregon who want to have their babies at a birth center or at home are covered by the Oregon Health Plan if they meet certain criteria. OHP is Oregon’s Medicaid program.

But midwives from around the state say it’s so difficult to get state insurance approval that women’s choices in childbirth are in jeopardy.

Anna McDonald’s baby’s due next week.

“I am extremely excited about having this baby,” she says. “It’s our first, and it was very planned, so it’s just a dream come true for us.”

McDonald’s husband is a dishwasher and she is currently unemployed. She lives in Lebanon, Oregon and gets her insurance from the Oregon Health Plan, the state’s Medicaid program.

McDonald wants to deliver her baby at a freestanding birth center close to her home, which is run by state-licensed midwives who offer a homebirth style of care for women wanting to have a more natural birth experience.  

However, McDonald’s request to deliver her baby at Growing Family Birth Center was denied. Judging by case documents reviewed by JPR, the denial was based on administrative reasons, not health or safety concerns. Anna and her midwife appealed the denial.

“We requested an expedited hearing,” she says, “so we could get it taken care of before the baby’s here because I am 38 weeks 4 days pregnant right now today and they denied my expedited hearing because they said it wasn’t a medical emergency and when we did finally find out when my hearing was supposed to be, it’s set for 12 days after my due date.”

Given the advanced state of her pregnancy, Anna McDonald requested an expedited appeal hearing of the decision to deny her coverage for giving birth at her local birth center. The Oregon Health Authority denied her request for an expedited appeal hearing, and subsequently scheduled a hearing nearly two weeks after her due date.

McDonald’s midwife, Debbie Cowart, owner of Growing Family Birth Center, is perplexed.

“It doesn’t make any sense,” she says, wearily.

Cowart’s voice sounds tired because she’s been up all night, having just delivered two babies in two days.

She’s a state-licensed midwife with 25 years of experience in out-of-hospital births. She says that the Oregon Health Authority makes it unnecessarily difficult for pregnant women to have midwife-assisted out-of-hospital births.

Cowart says what’s happening to McDonald is emblematic of the problems Oregon midwives have to deal with when they try to use the Oregon Health Plan.

“It’s very stressful for us as providers but extremely stressful for pregnant women who are under enough stress as it is just navigating their pregnancy, wanting to have this plan and always feeling like at any moment they can just deny their request.”

In fact, pregnant women who are approved to deliver out of the hospital can have that approval revoked at any time, even after their baby is born. Combined with the low reimbursement rates for out-of-hospital birth care, this has put so much financial and emotional stress on midwives and their clients across the state that many midwives no longer take Medicaid clients.

Cowart says she’s one of the only midwives in Linn County who continues to accept OHP.

“The majority of the midwives I know in the mid-Willamette valley—Albany, Corvallis, Lebanon, and north—have withdrawn from being Oregon Health Plan providers,” she says.

Cara Frantz is a homebirth midwife who has been practicing in Southern Oregon for nine years. She recently decided to no longer care for women on OHP.

“They have a system in place that allows them to claim that they’re supporting choice of birth,” Frantz says. “But in function they make the system so difficult and so many hurdles to jump through that it’s forcing midwives to stop accepting it."

The Oregon Health Authority declined JPR’s repeated requests for an interview.

This is the statement the Oregon Health Authority e-mailed to JPR in lieu of the interviews we requested.

In written materials, the agency claims it has a growing number of midwives eligible to request coverage for their out-of-hospital clients. Though it declined to say how many claims are actually submitted by those midwives, the agency also says it currently approves 90 percent of requests.

The agency says the only way a woman could be denied coverage after birth is “if her provider had never obtained approval before delivery.”

But it is that very approval that Anna McDonald has been trying to obtain. So she’s in a holding pattern, not sure if her baby will come before or after the hearing.

“This is a completely absurd situation,” she says. “I think they are taking advantage of someone like me, who’s in kind of a precarious position here. You know, I could have my baby any day, and they’re just saying, ‘tra la la, we’ll figure it out when we figure it out.’”

A spokesperson from the Oregon Health Authority would not comment on Anna McDonald’s situation, citing privacy concerns. The agency says it quote “supports the ability of every mother covered by the Oregon Health Plan to deliver in a safe, supportive, and comfortable environment.”

But if Anna McDonald’s experience is any indication, it looks like the agency is falling short of that goal.

Jennifer Margulis, Ph.D., is a regular contributor to the Jefferson Journal and also produces radio features for JPR. She's a former senior fellow at the Schuster Institute for Investigative Journalism at Brandeis University. Her writing has appeared in the New York Times, the Washington Post, and on the cover of Smithsonian magazine.