An Action plan for Affordable Maternity Care in California in 2013

by faithgibson on February 17, 2013

in Physician Supervision Issues, Uncategorized

A personal invitation to 40 LMs to join me for the next 40 days in “furthering” the political action in the right direction!

Dear CaLMs,

I love thinking of California licensed midwives as a CaLM – calm, caring, competent, compassionate, good for California’ childbearing families.

Right now the politics of licensed midwifery in California is part of the Senate’s Sunset Review process. It’s an opportunity that it will introduce changes in California law that would remove the decades-long barriers to affordable maternity care by changing the professional relationship between Ca LMs and physicians so that it worked for all of us.

As a former quilter and video-editor, I see the politucal problem/goal of affordable maternity care in California as a large complex quilt with many pieces. As a quilter/video editor I know that the secret to making a big project is a plan bigger than I think can ever be accomplished, followed by consistent, persistent, one-at-a-time attention to each individual piece.

While video-editoring is a solitary experience, quilting bees are not. In the 1980s, a Santa Cruz-Palo Alto group of mothers and midwives called “MotherSong” meet in my backyard on the first Friday of every month for a quilting bee/gabfest/sing alone. We all sat side by side and worked together on a big quilt stretched over a stand-alone wooden frame, each of us putting in our share of tiny quilting stitches while we chatted and discussed the meaning of life.

When we do this kind of work well, we are eventually rewarded with something of beauty that far exceeds the limitations of our individual mental skills.

When it comes to a revolution in California maternity care for healthy women, I am suggesting two entwined ideas.

First is a new way to think about these issues — that as individual midwives we take a small ‘corner’ of the quilt and work on that piece to the best of our ability. As we slowly integrated our unique contribution into the overall process, we will be doing our part to end the stale status quo by politically empowering mothers and midwives and taxpayers.

Since passage of the nurse midwifery practice act in 1974, California taxpayers have been systematically taken to the cleaners by organized medicine. By insisting on the obstetrical supervision of midwives, they were able to institutionalize their monopoly over all revenue streams for maternity care in California. Midwifery was technically ‘legal’, but insurance companies wouldn’t reimburse families for maternity care provided by independently practicing professional midwives and Medicaid-MediCal wouldn’t pay for their OOH birth services.

The second part of this strategy is seeking out new, highly innovative ideas for getting what we need from the political process. Think of the “Arab Spring” and other political situations that have recently toppled one-sided power.

Think Wayne Le Pierre  and his’s extreme brand of NRA politics — his type of rhetoric use to rule the roust, no matter how illogical or reprehensible. The NRA lobby even controlled who got elected by defeating candidates for public office that supported responsible gun laws. After decade of what seemed so immutable that many of us had given up altogether, we are seeing a dramatic shift in this problem, which had many political characteristics in common with the ‘midwife problem’ of 1910. It seems to me that both of these ‘hopeless causes’ are experiencing a dramatic positive shift into the not only possible but probable!

I am convinced that now is the time for affordable maternity care for California families. Here are my ideas for how to ‘further the action’, one midwife, one mother, one ‘quilt square’ at a time.

The goal:

* Affordable maternity care in California by making physiologically-based midwifery care in birth centers and other non-medical settings easily available to Medicaid-MediCal eligible women by licensed midwives.

What does this means? Promoting legislation that:

** Includes the independent practice of licensed midwifery in the Medicaid reimbursement scheme so LMs qualify as Medicaid providers

** Requires health insurance companies (once again) to reimburse families for birth services provided by LMs

** Provides LMs with access to the consultative and collaborative services of physicians as a normal obligation of the doctor’s licensed to practice medicine in the state of California

** Requires med-mal carriers to cover any incidental liability as a normal part of the physician’s liability coverage

** Provides mfry clients with normal unfettered access to necessary obstetrical services, by insuring non-discrimination by other medical services providers (labs, ultrasound, referral to perinatal regional centers, etc)

** Establishes a mechanism for filing an ‘incident report’ for any circumstances in which denied or delayed medical services  result in a problematic outcome for the client family

** Authorizes independent access for LMs to necessary prophylactic and emergency drugs for the responsible practice of midwifery

How? — We need to turn politics on its head by putting mothers, midwives and California taxpayers in the driver’s seat. Here are my ideas for making that happen:

*** Support CAM’s lobbying efforts and all the time-tested avenues for political activism — letter-writing, personal visits to district offices, etc

*** Think Outside the Box by making creative and targeted use of social media — YouTube, Facebook, Twitter, other web-based opportunities for organizing our activism, including Skype and video conference calls

Action Plan:  

I’m asking for 40 midwives to sign up for doing something everyday (when we are not at a birth or sleeping afterward) that will quietly, with careful tiny stitches, propel the political process forward a bit each day for 40 days.

It would be helpful if we each knew what others were doing so we can cover all our bases. I suggest using the California-midwives site to post our ideas, our activities and eventually, the ‘product’ of our efforts.

What follows are several specific, but certainly NOT the only, possibilities. This “plan” assumes that things unthought of will naturally arise, and new, undreamed of opportunities will open up, such has already occurred with CAM’s experienced and talented lawwyer-lobbyist, who is providing his services pro bono.

I suggest that each of us find some little part of this quilt (or puzzle) that interests us and figure out how to communicate it to those that really matter:

  • The seven California senators who sit on the Sunset Review Committee,
  • Governor Jerry Brown’s administration
  • The zeitgeist or court of public opinion — now called “crowd-sourcing” or the 99%

Personal Letters & Written Testimony for Sunset Review Committee: This can be done directly by sending brief letters (if possible from midwives and client families who live in their districts) to each of these 7 senators (especially Sen. Hernandez). It can also mean writing longer documents that focus on a single issue and  submit this material to the Sunset Review Committee prior to the March 11th hearing as written testimony.

Social Media: Another avenue for effective political activity is social media — collectively we need to fill Facebook, and blogs with 30 second to 3 minute videos (also send via email to the offices of the seven Senators on SR committee) that make a short but cogent case for the legislative ‘remedies’ enumerated above.

I have already posted extensive material on the historical and contemporary events and will add more as time goes by. But obviously there is too much of this material for any one legislator to read in its entirety. However if midwives each choose a small topic as their one ‘square’ of the quilt, the entirety of this valuable information would eventually find its target.

For example, there is the issue of MONEY. By refusing to provide the legally essential service of  supervision to midwives for the last 20 years (40 for CNMs), obstetricians were able to eliminate their only source of ‘competition’ and maintain a virtual monopoly over all maternity services. Lets be blunt here — supervision is not about the activity of providing medical services to client families, but having the right paperwork with a doctor’s name on it. Without this paperwork, midwives and their clients are boxed out of the mainstream system, but we still are able to lawfully provide care.

As mentioned in the material prepared for the Senate B&P Committee, Judge Roman’s ruling provides a method that is legal and also effective at the practical level. It ensures that each client family has appropriate and timely access to necessary medical services, as well as satisfying the intent or “ambit” of the supervisory provision. The LMAR for the last 5 years confirms that we are generally able to meet the non-economic needs of childbearing families.

The only truly effective aspect of supervision is how efficiently it preserves the dominance of obstetrics over an unnecessary medicalized (and expensive) system, while at the same time preventing midwives from being part of mainstream healthcare system or being able to serve low-income women.

For the last 40 years, 40% of Cal families and 100% of California professional midwives have been locked out of the Medicaid/MediCal reimbursement system due the ‘systemic’ barrier (poison pill) of OB supervision. If you read the 1977 document from Gov. Brown’s first administration (MfryBill-AB1896_DCA_4MedBd_Sept1977) and used the State’s  own math over the subsequent 36 years, its easy to see how much money California taxpayers have lost by NOT allowing either midwives or mothers access to the Medicaid program.

It’s shocking and it means that sick people didn’t get care they needed, and school teachers didn’t get paid what they were worth and thousands of other state services were not available available because the money was going to expensive obstetrical care for healthy women. Personally, I think supervision has unconstitutional consequences and is a white collar form of organized crime perpetrated on the taxpayers of California.

Having this story go viral via Facebook and YouTube

Midwives need to interview Medicaid-eligible women and get them to tell their story on audio or video tape. The midwife can either create a written transcript to email to the 7 SV members, or publicly post the short video on Facebook & YouTube. This makes it real clear — no question that obstetrical supervision is a great success at locking healthy, low-income women into the most expensive and interventive possible form of care — the strict obstetrical model — which is currently is their only choice.

The experience of these women have with prenatal and postpartum care in the many MediCal mills is usually a handful of 5-minute appointments with an overworked nurse practitioner or professional midwife. It means the doctor who ‘delivered’ you was someone you never met before or after the 12 minutes he (or she) spent telling you to push harder and then ‘catching’ your baby.

It means that maternity care under the Medicaid-MediCal program is NOT part of California’s health care system — that is, as a process for educating families in healthy life styles that eliminates or reduces disease. For example, high quality prenatal care reduces the likelihood of developing high blood pressure and type II diabetes during the pregnancy, or having an undetected breech at term.

As the gift that keeps on giving in the years following the birth, high-value prenatal and post-partum care helps with family planning and to reduce intergenerational obesity and diabetes in later in that new baby’s life. The average time nationally for an office visits by non-physician primary care practitioners is 20-30 minutes. This make it obvious that 5-minute ‘drive-thru’ appointments of Medicaid mills are a shame — pretend care organized around making a profit for the medical practice.

Legislators need to know these simple facts. 

Likewise, we need to tell the stories of PHB clients who were turned down by OB service providers. This would be the same kind of  brief letters to the gang of seven committee members, or posting taped or written account w/ a picture of the family on Facebook and weblogs.

We need stories from LMs who were denied services (labs, US, etc) or bore the brunt of discriminatory actions by hospitals and the medical profession — for example, not being able to refer women with an affected fetus to perinatal regional centers. It is especially helpful if you have a letter documenting the offensive actions or accusations.

Helpful tactics to organizing our political efforts: 

I’d like to begin a dialogue with other midwives via email or Skype. This would give us a way to identify the little jewels of information from the material that has already been amassed and create a logical process to find a ‘home’ for each of these gems. There is so much to choose from — the independent legacy practice of mfry, the current excellent record of ‘unsupervised’ LMs as revealed in 5-years of stats from the LMAR, our extraordinarily low prematurity and C-section rate, and the exciting future as LM contribute to affordable maternity care for low-income families by being compensated under the Medicaid/MediCal program.

Another potential gold mine is Judge Roman’s incredibly useful ruling, which identifies the legislative intent of the LMPA (i.e., that childbearing women in California have access to the services of trained, state-regulatied LMs). He continues by making a very specific legal case that the care of licensed midwives is different from that of nurses, nurse-midwives and physician assistants, as LMs and ONLY licensed midwives provide the a non-medical or ‘midiwfery’ model of care (i.e. physiological management).

This is itself a logical reason to eliminate any form of pre-determined, pre-defined physician relationship from the LMPA except as based on the medical needs of mother or baby.

Legislators, the public and Governor Brown’s administration all NEED to KNOW these FACTS and its our job to tell them. We can do that pretty efficiently if each LM would commit to communicating just one of these many important ideas.

I hope today will be the first of 40 exciting days with 40 excited midwives, working to make sure that 2013 is a lucky (blessed) year for California — its midwives, its childbearing families, its taxpayers, and the shape of its state budget.

We can do better and we will — I’m confident of it.

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