```

[Senate Hearing 107-747]
[From the U.S. Government Publishing Office]

                                                        S. Hrg. 107-747
 
   UNINSURED PREGNANT WOMEN: IMPACT ON INFANT AND MATERNAL MORTALITY
=======================================================================

                                HEARING

                               BEFORE THE

                     SUBCOMMITTEE ON PUBLIC HEALTH

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS
                          UNITED STATES SENATE

                      ONE HUNDRED SEVENTH CONGRESS

                             SECOND SESSION

                                   ON

EXAMINING THE IMPACT OF UNINSURED PREGNANT WOMEN ON INFANT AND MATERNAL 
                               MORTALITY

                               __________

                            OCTOBER 24, 2002

                               __________

 Printed for the use of the Committee on Health, Education, Labor, and 
                                Pensions

                           U.S. GOVERNMENT PRINTING OFFICE
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___________________________________________________________________________
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          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

               EDWARD M. KENNEDY, Massachusetts, Chairman

CHRISTOPHER J. DODD, Connecticut     JUDD GREGG, New Hampshire
TOM HARKIN, Iowa                     BILL FRIST, Tennessee
BARBARA A. MIKULSKI, Maryland        MICHAEL B. ENZI, Wyoming
JAMES M. JEFFORDS (I), Vermont       TIM HUTCHINSON, Arkansas
JEFF BINGAMAN, New Mexico            JOHN W. WARNER, Virginia
PAUL D. WELLSTONE, Minnesota         CHRISTOPHER S. BOND, Missouri
PATTY MURRAY, Washington             PAT ROBERTS, Kansas
JACK REED, Rhode Island              SUSAN M. COLLINS, Maine
JOHN EDWARDS, North Carolina         JEFF SESSIONS, Alabama
HILLARY RODHAM CLINTON, New York     MIKE DeWINE, Ohio

           J. Michael Myers, Staff Director and Chief Counsel

             Townsend Lange McNitt, Minority Staff Director

                                 ______

                     Subcommittee on Public Health

                      EDWARD M. KENNEDY, Chairman

TOM HARKIN, Iowa                     BILL FRIST, Tennessee
BARBARA A. MIKULSKI, Maryland        JUDD GREGG, New Hampshire
JAMES M. JEFFORDS, Vermont           MICHAEL B. ENZI, Wyoming
JEFF BINGAMAN, New Mexico            TIM HUTCHINSON, Arkansas
PAUL D. WELLSTONE, Minnesota         PAT ROBERTS, Kansas
JACK REED, Rhode Island              SUSAN M. COLLINS, Maine
JOHN EDWARDS, North Carolina         JEFF SESSIONS, Alabama
HILLARY RODHAM CLINTON, New York     CHRISTOPHER S. BOND, Missouri

                      David Nexon, Staff Director
                 Dean A. Rosen, Minority Staff Director

                                  (ii)

                            C O N T E N T S

                               __________

                               STATEMENTS

                       Thursday, October 24, 2002

                                                                   Page
Bingaman, Hon. Jeff, a U.S. Senator from the State of New Mexico.     1
Corzine, Hon. Jon, a U.S. Senator from the State of New Jersey...     5
Green, Nancy, M.D., Medical Director, March of Dimes Birth 
  Defects Foundation; Richard Bucciarelli, M.D., Chairman, 
  American Academy of Pediatrics Subcommittee on Access to Health 
  Care; Lisa Bernstein, Executive Director, The What to Expect 
  Foundation, New York, NY; and Laura E. Riley, M.D., Assistant 
  Professor of OB/Gyn, Harvard Medical School and Medical 
  Director of Labor and Delivery, Massachusetts General Hospital.     9

                          ADDITIONAL MATERIAL

Statements, articles, publications, letters, etc.:
    Nancy Green, M.D.............................................    30
    Laura E. Riley, M.D..........................................    32
    Cristina Beato, M.D..........................................    35
    Lisa Bernstein...............................................    36
    Kate Michelman...............................................    38
    Priscilla Smith..............................................    40

                                 (iii)

   UNINSURED PREGNANT WOMEN: IMPACT ON INFANT AND MATERNAL MORTALITY

                              ----------                              

                       THURSDAY, OCTOBER 24, 2002

                               U.S. Senate,
                     Subcommittee on Public Health,
of the Committee on Health, Education, Labor, and Pensions,
                                                    Washington, DC.
    The subcommittee met, pursuant to notice, at 10:07 a.m., in 
room SD-430, Dirksen Senate Office Building, Senator Bingaman 
presiding.
    Present: Senator Bingaman.

                 Opening Statement of Senator Bingaman

    Senator Bingaman. Why don't we go ahead and get started? 
Thank you all for being here.
    First I would like to thank Senator Kennedy for allowing us 
to hold this important hearing with respect to the health and 
well-being both of children and their mothers.
    Our Nation ranks 28th in the world in infant mortality and 
21st in maternal mortality, according to the data from the CDC. 
In infant mortality, for example, our country ranks behind 
Spain and Portugal, the Czech Republic and Cuba. There are 
numerous studies that have shown the importance of providing 
coverage to pregnant women in order to reduce both infant and 
maternal mortality. We, as a Nation, would be remiss to not 
take the simple but critical step of increasing access to 
prenatal and labor and delivery and postpartum care through the 
State Children's Health Insurance Program or SCHIP to help 
prevent birth defects and prematurity, the most common causes 
of infant death and disability, as well as maternal death and 
disability.
    It is with this in mind that a number of bills were 
introduced in this Congress to address these problems by 
allowing states the option to expand health coverage to 
uninsured pregnant women over the age of 18 through the State 
Children's Health Insurance Program or SCHIP. Those bills 
include S. 724, the Mothers and Newborns Health Insurance Act 
that Senators Bond and Breaux introduced. Senator Lincoln and I 
are cosponsors on that. I think Senator Corzine is, as well. He 
is just entering at this moment. There is also S. 1016, the 
Start Healthy, Stay Healthy Act, which again Senator Lugar, 
Senator Lincoln, Senator Corzine, Senator McCain and I all 
cosponsored and there is S. 1244, the Family Care Act that 
Senators Kennedy and Snowe introduced. All of these try to 
address this issue of increasing access to care for pregnant 
women.
    Throughout the early part of the year the Secretary of 
Health and Human Services, Secretary Thompson, issued press 
releases and testified before Congress, wrote letters in 
support of the passage of legislation to cover pregnant women. 
He wrote me on the 12th of April of this year and that letter 
said, ``The prenatal care for women and their babies is a 
crucial part of medical care. These services can be a vital 
life-long determinant of health and we should do everything we 
can to make this care available for all pregnant women. It is 
one of the most important investments we can make for the long-
term good health of our Nation. As I testified recently at a 
hearing by the Health Subcommittee of the House Energy and 
Commerce Committee, I also support legislation to expand SCHIP 
to cover pregnant women. However, because legislation has not 
moved and because of the importance of prenatal care, I felt it 
important to take this action.''
    Now this action that he is referring to was the issuance of 
a regulation to allow the coverage of unborn through SCHIP. The 
rule which was initially proposed this past spring and issued 
in final form on the 2nd of October, allows states the option 
to cover unborn children through SCHIP but not to cover 
pregnant women. It came just 2 weeks after Deputy Assistant 
Secretary Cristina Beato testified at a hearing here in this 
room on Hispanic health that the administration would be 
forthcoming with a letter in support of S. 724 and also 1 week 
after the administration approved a waiver for the State of 
Colorado to cover pregnant women through the SCHIP program.
    Colorado clearly faced the choice of taking the State 
option of covering unborn children as a result of the new 
regulation or the alternative that was more cumbersome and the 
more lengthy process of applying for a waiver to cover pregnant 
women. According to State officials, Colorado chose the more 
cumbersome waiver process because they were unable to implement 
coverage for unborn children. There is no insurance program 
anywhere on which to model that coverage. There were too many 
questions that they could not answer. They were also concerned 
by the gaps in coverage for pregnant women that the regulation 
caused.
    Among other things, since the regulation only provides 
states the option to cover unborn children, a number of 
important aspects of coverage for pregnant women during all 
states of birth--pregnancy, labor and delivery and postpartum 
care--are either denied or in serious question. For example, 
pregnant women would likely not be covered during their 
pregnancy for treatment of some kinds of cancer, medical 
emergencies, accidents, broken bones or mental illness. Even 
life-saving surgery for a mother in certain circumstances would 
appear to be denied.
    Further, during delivery, coverage for an epidural would be 
a State option and allowed only if the health of the child is 
judged to be affected. On the other hand, anesthesia is covered 
for Caesarian sections, so the rule could wrongly push women 
and providers to perform unnecessary C-sections to ensure 
coverage of critical pain relief for pregnant women.
    Finally, during the postpartum period women would be denied 
all health care coverage from the moment the child is born. As 
the regulation reads, ``Commenters are correct that care after 
delivery, such as postpartum services, could not be covered as 
part of SCHIP because they are not services for an eligible 
child.'' Important care and treatment, including but not 
limited to treatment of hemorrhage, infection, pregnancy-
induced hypertension and other complications of pregnancy and 
childbirth, including life-saving treatment, would not be 
covered.
    In contrast, the legislation that we have been proposing 
explicitly covers the full range of pregnancy-related services, 
including postpartum care. This is important as the majority of 
maternal deaths occur in the postpartum period and should be 
covered.
    The legislation is also, of course, about improving 
children's health. We all know the importance of an infant's 
first year of life. Senator Bond's legislation, as amended in 
the Finance Committee with language from the bill that I had 
earlier introduced, provides 12 months of continuous coverage 
for children after birth. In contrast, the administration 
regulation provides 12 months' continuous enrollment to states 
but makes the time retroactive to cover the period in the womb. 
Therefore, if nine full months of prenatal care are provided, 
the child could lose coverage after 3 months following the 
child's birth. This obviously would make it difficult to have 
coverage for well-baby visits, immunizations and access to a 
pediatric caregiver during the first year of life.
    Senators Bond and Lincoln and I tried both on October 2 and 
then again Senator Corzine and Landrieu joined us on October 8; 
we tried to get consent to pass S. 724, the Mothers and 
Newborns Health Insurance Act. This was passed out of the 
Finance Committee without opposition in July. Unfortunately, on 
both occasions our Republicans colleagues objected, citing the 
opposition of the administration.
    To our surprise, Secretary Thompson had reversed his 
position and issued a letter to Senator Nichols on October 8 
dropping his support for passage of the legislation by saying 
that, in his view, ``The regulation is a more effective and 
comprehensive solution to the issue.'' This reversal came 
despite the fact that there are, in my view, at least, glaring 
gaps in the administration's regulation that are acknowledged 
in the rule itself.
    Let me at this point just indicate that the administration 
was invited to testify by Senator Gregg's office and Senator 
Kennedy's office, declined to do so on the basis they had not 
been given adequate notice of the hearing. We respect that 
position. I very much hope that they will submit written 
testimony for us to include in the record, as many other groups 
and parties have indicated they intend to.
    [The prepared statement of Senator Kennedy follows:]

                 Prepared Statement of Senator Kennedy

    One of the most serious aspects of the health care crisis 
that continues to affect so many of our fellow citizens is the 
lack of access by large numbers of pregnant women to affordable 
health care. Excellent prenatal care is available in this 
country, but 14 percent of pregnant women today do not have the 
opportunity to benefit from it and over 11 million more women 
of child bearing age are at risk of not having such care 
because they are uninsured. The lack of prenatal care for these 
women can lead to illness and loss of life.
    In fact, the United States ranks 21st in the world in 
infant mortality and 26th in maternal mortality the highest 
rates of any developed nation. These mortality statistics are 
unacceptable, and it is even more frustrating is that these 
deaths are largely preventable.
    We know that timely prenatal care leads to positive health 
outcomes for mothers and newborns. Such care assures that 
pregnant women receive guidance on proper nutrition and 
encourages the elimination of unhealthy habits such as drinking 
and smoking. It also prevents transmission of disease from 
mother to fetus, and helps to avoid pregnancy-related 
complications.
    CDC has released data indicating that routine screening for 
group B strep in late pregnancy is the most effective way to 
prevent its transmission from mother to child during pregnancy. 
Screening for diabetes can prevent complications during 
pregnancy and birth. Prenatal care can also prevent 
transmission of Hepatitis B and HIV from mother to child. These 
are all simple steps that can prevent illness and death if 
women have access to good health care. Insurance coverage will 
give pregnant women access to the care they need to be healthy 
before and after birth, and give infants a chance for a truly 
healthy start in life.
    Many Senators have introduced legislation to provide access 
to prenatal care services. Senator Bingaman has proposed 
legislation to assure that pregnant women receive effective 
care during pregnancy and after birth, and I commend him for 
his leadership on this important issue. Senator Harkin and 
Senator Snowe are also leaders on this issue, and I commend 
them as well. We need to do all we can in Congress to end this 
key aspect of the nation's health crisis.
    When we provide mothers and their children with access to 
good health care, we are investing wisely in the future of our 
country.
    Senator Bingaman. Let me go ahead with our first panel of 
witnesses here. We are very fortunate to have Senators Lincoln 
and Corzine. Let me just give a very brief introduction to both 
of them. They have both been real champions on this issue since 
the beginning. Senator Lincoln, as she stated on the Senate 
floor a couple of times, is not only a champion of the bill but 
an expert on the subject. She is one of the Senate's leading 
advocates on the issues of children and women's health. She had 
one of the very first pieces of legislation to expand coverage 
to pregnant women in the previous Congress, legislation 
entitled ``The Improved Maternal and Children's Health Act of 
2000.'' In this Congress she has been a supporter of both S. 
724 and S. 1016, a cosponsor of both, and successfully helped 
push for the passage of S. 724 out of the Senate Finance 
Committee in July.
    Senator Corzine has been a strong champion of this 
legislation, as well. He was an original cosponsor of S. 1016. 
He has worked closely with me at every stage of getting this 
legislation passed. He has taken the next step of putting his 
interest into direct action in New Jersey and is working with 
the What to Expect Foundation on helping low-income mothers 
receive prenatal care and literacy education to improve their 
pregnancies and subsequent parenthood. Based on that work, we 
have begun to initiate a similar program in New Mexico and I 
want to thank him and Lisa Bernstein both, who will be 
testifying on the second panel, for their dedication and 
testimony today on this important issue.
    Let me call on Senator Lincoln first and then Senator 
Corzine on any comments they have and then we will move to our 
second panel.

 STATEMENTS OF HON. JON CORZINE, A U.S. SENATOR FROM THE STATE 
 OF NEW JERSEY; AND HON. BLANCHE LINCOLN, A U.S. SENATOR FROM 
                     THE STATE OF ARKANSAS

    Senator Lincoln. Mr. Chairman, I am going to allow my 
colleague to have a few comments, as he has got to run to the 
floor and open the Senate. So I am going to defer to him.
    Senator Bingaman. Senator Corzine, we are glad to hear from 
you first.
    Senator Corzine. I appreciate Senator Lincoln yielding. I 
have about a 10-minute open in the Senate and then put us into 
recess. So I apologize that I have to leave and come back and I 
will join you.
    I congratulate you, Mr. Chairman, for your efforts on this 
very important subject, and Senator Lincoln and others, because 
it is one that we are not giving the right attention to and I 
join your comments.
    Senator Bingaman. Thank you very much. And when you return 
I obviously invite you and Senator Lincoln to participate here 
in the rest of the hearing on the panel.
    Senator Lincoln, go right ahead.
    Senator Lincoln. Thank you, Mr. Chairman. Certainly a 
particularly overwhelming thank you to you, Chairman Bingaman, 
for allowing me to participate today and for making this 
hearing happen. Your dedication to women and children's health 
is absolutely exceptional. As a mother and as a senator, I am 
proud of the leadership that you have demonstrated time and 
again on this very important issue.
    As you know, the Senate currently has the historic 
opportunity to enact legislation, the Mothers and Newborns 
Health Insurance Act, S. 724, which you have commented on, that 
could drastically improve the lives and health of thousands of 
women and children throughout our Nation. This bipartisan 
legislation, which we both cosponsored and helped to pass 
unanimously in the Finance Committee this summer, gives states 
the option, simply the option, of covering pregnant women in 
their Children's Health Insurance Programs. Most importantly, 
the bill allows coverage for prenatal care, delivery and 
postpartum care.
    Mr. Chairman, the statistics you have often cited about 
infant and maternal mortality in this great country of ours are 
absolutely inexcusable. According to the Centers for Disease 
Control and Prevention, the U.S. ranks 28th in the world in 
infant mortality. We rank behind countries like Cuba and the 
Czech Republic. It is amazing to me that the United States lags 
far behind these nations in this area.
    Another shocking statistic from the CDC is that the U.S. 
ranks 21st in the world in maternal mortality. The World Health 
Organization estimates that the United States maternal 
mortality rate is double that of Canada.
    The chart right here that I have brought to share with you 
all today, the graph shows the data from the CDC on maternal 
mortality in the U.S. from 1967 to 1999. The data shows that 
the rate of maternal mortality has dramatically decreased since 
the' 60s but this decrease has leveled off, and you can see as 
it begins to flat-line down there.
    In 1999 there were 8.3 maternal deaths per 100,000 lives 
births in the U.S., far above the CDC's Healthy People 2000 
goal of 3.3 maternal deaths. In fact, you can see on the graph 
that the maternal death rates have been steady or rising since 
the mid-1980s. This means that since 1983 the United States has 
made no progress in achieving its own goal of a 3.3 maternal 
death rate.
    Even more upsetting is that in the United States an 
African-American woman's risk of dying from pregnancy or 
pregnancy-related complications is four times greater than the 
risk faced by white women. This is one of the largest racial 
disparities among public health indicators and one that we 
really see in Arkansas, where the maternal mortality rate for 
African-American women is 12.4. That is 66 percent higher than 
the national maternal mortality rate.
    I am absolutely ashamed of these statistics. When we are 
ahead of every other Nation in almost every other arena I am 
ashamed we have not taken a course of action that would prove 
to the rest of the world that we truly do value life in this 
country and that we want to do all we possibly can to ensure 
the healthy delivery of children, as well as the health of 
their mothers.
    The fact is we know how to address this problem. The 
solution lies in prenatal and postpartum care. Studies have 
shown that this care significantly reduces infant mortality, 
maternal mortality, and the number of low birth weight babies, 
not to mention the quality of life of these individuals later 
on.
    Not only is prenatal care essential for quality of life; it 
is also cost-effective. For every dollar we spend on prenatal 
care we save more than $6 in neonatal intensive care costs, not 
to mention the cost to the woman who is giving birth. Preterm 
births are one of the most expensive reasons for a hospital 
stay in the United States, not to mention the difficulties 
these children have later in life, whether it is learning 
disabilities or health care issues and complications. There are 
a number of things that give us reason why it is so important 
to make this investment in prenatal care.
    I cannot emphasize enough the great opportunity that we 
have here in the Senate to drastically improve the lives and 
the health of women and babies in our country. We must pass S. 
724 as soon as possible. The states want to cover pregnant 
women under SCHIP and the Federal Government should give them 
the option.
    Mr. Chairman, I was proud to join you and Senator Bond on 
the Senate floor in recent weeks to try and bring up and pass 
S. 724 and I am so frustrated that both our attempts to pass 
this bill were blocked. It is a shame that some of our 
colleagues have made a political issue out of trying to ensure 
a healthy start in life for babies and their mothers.
    I am disappointed that Secretary Thompson has recently 
withdrawn his support for S. 724 in favor of the 
administration's final regulation to provide SCHIP coverage to 
unborn children. I do know what it is that has all of a sudden 
crossed his mind to change his mind about the effectiveness of 
the legislation that we have presented back earlier this year.
    All of this concerns me because the regulation fails to 
cover the full scope of medical services needed by a woman 
during and after pregnancy that are recommended by the American 
College of Obstetricians and Gynecologists and the American 
Academy of Pediatricians. We are not just saying this because 
some of us have been through it. We are not just saying it 
because our constituents think it is important or that they 
want it. We are saying it because medicine and science tells us 
how important this is.
    I am certainly glad that representatives from these groups 
are here today to better explain these clinical standards of 
care and why they are critical to improving maternal and child 
health.
    Many things concern me about the administration's 
regulation, Mr. Chairman. First, the regulation specifically 
states that postpartum care is not covered. Postpartum care is 
essential in treating serious pregnancy-related complications 
for the new mother, complications that can often lead to death. 
Where does that leave a newborn child?
    According to the National Committee for Quality Assurance, 
hemorrhage, pregnancy-induced hypertension, infection and 
ectopic pregnancy continue to account for more than half of all 
maternal deaths. Why would we not want to guarantee insurance 
coverage for postpartum care to ensure that women will receive 
proper treatment for these complications? Consider our 
country's efforts to reduce maternal mortality rates. The 
regulation's silence on this issue is extremely disturbing.
    Postpartum care is covered by Medicaid and most private 
insurance. What if the new mother has a hemorrhage, an 
infection, she needs an episiotomy repaired or has postpartum 
depression? The administration's regulation would not cover 
such services because in their words, they are not services for 
an eligible child.
    Given this huge gap in coverage and the political 
complications of this regulation, I am worried that states will 
ignore it and continue to try to provide coverage to pregnant 
women through the HHS waiver process, which many states have 
already done. But governors and State legislators have argued 
that this waiver process is lengthy and cumbersome. They prefer 
a State option that is easier to administer and that is 
permanent. That is why they support S. 724.
    The regulation also causes me to wonder about provider 
reimbursement. Under the regulation, doctors will not be 
reimbursed for providing care that they have been trained to 
provide and likely feel that they are ethically obligated to 
provide. In the modern practice of obstetrics, postpartum care 
is a critical part of the treatment the woman receives 
prenatally and during labor and delivery. With rising medical 
malpractice rates, particularly for obstetricians and 
gynecologists, these doctors may simply decide to stop serving 
SCHIP patients. This regulation may become yet another 
disincentive for doctors to participate in public programs 
serving low-income populations.
    Finally, I must say as a woman I am offended by the 
administration's regulation. How they can leave the woman 
totally out of the equation when talking about pregnancy is 
beyond me, Mr. Chairman. Women's bodies change and they grow 
during the pregnancy. Her psyche may change, too. Many of you 
husbands have witnessed that and believe me, it is not easy.
    S. 724, on the other hand, puts mother and baby on equal 
footing by guaranteeing that they both have access to the 
recommended clinical care that they both need.
    Having given birth to twins 6 years ago, I can personally 
attest to the importance of prenatal and postpartum care. 
Because I had this care, I was blessed with two healthy boys 
and a relatively trouble-free pregnancy and delivery. Both boys 
and I were able to come home from the hospital within 2 days to 
a healthy beginning for our entire family. I was able to nurse 
my children with the guidance of my physicians and the guidance 
that I could get in my postpartum care. No one should stand in 
the way of encouraging healthy pregnancies for the most 
vulnerable women in our country.
    On behalf of our Nation's mothers, fathers and their 
babies, we in the Senate have the serious obligation to pass 
this legislation as soon as possible. If we truly value life, 
as we say we do, we will take action on something that will 
provide us and those families the ability to do all that they 
possibly can to ensure a healthy delivery and a healthy start 
for these children.
    Let us come together in a bipartisan way and pass S. 724, 
legislation that will make a difference not only in a child's 
life, a woman's life, a family's life, but certainly, Mr. 
Chairman, in our Nation's success.
    I thank you again, Mr. Chairman, for holding this hearing 
and certainly for your leadership in this arena. I look forward 
to hearing the testimony today that will likely underscore the 
need for passing S. 724 as soon as possible. And on behalf of 
the women and children and families out there, I do encourage 
us all not to let this become a political issue but more 
importantly, to recognize its importance. Thank you, Mr. 
Chairman.
    Senator Bingaman. Thank you very much for your very strong 
statement. Why do you not join us up here if your schedule 
permits? We are anxious to have you participate in the question 
and answer part of this.
    Senator Bond is the prime sponsor on the legislation and, 
as Senator Lincoln has pointed out very eloquently, it is 
bipartisan. We have strong support from many of our Republican 
colleagues for moving ahead with this bill, S. 724, and we hope 
that we are able to do that when we come back into session.
    If all the witnesses would come forward, let me introduce 
all of the witnesses in a group here and then we will just call 
on them to testify.
    Dr. Nancy Green is with the March of Dimes Foundation. Dr. 
Green is a pediatrician and the medical director for the March 
of Dimes Foundation in White Plains, NY. Dr. Green also serves 
as associate professor of pediatrics and cell biology at the 
Albert Einstein College of Medicine, is a leading national 
expert on topics in pediatric hematology, oncology, immunology 
and genetics.
    Dr. Laura Riley is with Massachusetts General. She is here 
on behalf of the American College of Obstetricians and 
Gynecologists. Dr. Riley is a nationally recognized expert on 
the delivery and care for at-risk pregnant women and is 
testifying today on behalf of this American College of 
Obstetricians and Gynecologists. She is the medical director of 
labor and delivery at Mass General Hospital in Boston, is the 
current chair of the Obstetrics Practice Committee at the 
American College of Obstetricians and Gynecologists.
    Dr. Richard Bucciarelli is with the University of Florida 
Department of Pediatrics and is here on behalf of the American 
Academy of Pediatrics. He is a long-time authority and advocate 
for the American Academy of Pediatrics for the betterment of 
children's health. He is a nationwide expert on improving 
health coverage and quality of care for children with special 
health care needs. He is currently a professor and associate 
chairman in the Department of Pediatrics at the University of 
Florida College of Medicine and a professor at the Institute 
for Child Health Policy in Gainesville, FL.
    And Lisa Bernstein is with the What to Expect Foundation. 
She is co-founder and executive director of that foundation in 
New York City. The foundation takes its name from the best-
selling What to Expect pregnancy and parenting series that was 
co-written by the foundation's president, Heidi Murkoff. The 
What to Expect series has been described by women across 
America as their pregnancy bible. The What to Expect Foundation 
is a nonprofit organization dedicated to assisting low-income 
women also to share in the knowledge and understanding of how 
to have healthy pregnancies and safe outcomes for themselves 
and their children through the Baby Basics program, which 
provides prenatal education to low-income women.
    We have, as you can see from these introductions, a very 
distinguished set of witnesses. Dr. Green, why do you not 
start? We are eager to hear your testimony.

  STATEMENTS OF NANCY GREEN, M.D., MEDICAL DIRECTOR, MARCH OF 
  DIMES BIRTH DEFECTS FOUNDATION; RICHARD BUCCIARELLI, M.D., 
CHAIRMAN, AMERICAN ACADEMY OF PEDIATRICS SUBCOMMITTEE ON ACCESS 
TO HEALTH CARE; LISA BERNSTEIN, EXECUTIVE DIRECTOR, THE WHAT TO 
  EXPECT FOUNDATION, NEW YORK, NY; AND LAURA E. RILEY, M.D., 
   ASSISTANT PROFESSOR OF OB/GYN, HARVARD MEDICAL SCHOOL AND 
 MEDICAL DIRECTOR OF LABOR AND DELIVERY, MASSACHUSETTS GENERAL 
                            HOSPITAL

    Dr. Green. Thank you, Mr. Chairman. Good morning
    I am Dr. Nancy Green. I am the medical director at the 
March of Dimes Birth Defects Foundation. The mission of the 
March of Dimes is to improve the health of babies by preventing 
birth defects and infant mortality, so this is an issue that is 
near and dear to our hearts.
    I am pleased to be here today to discuss with you the 
importance of providing all pregnant women access to health 
insurance coverage and therefore access to a comprehensive set 
of basic maternity services. Lack of health coverage continues 
to be a significant problem for many Americans. Particularly 
troubling are the statistics on women of child-bearing age. 
11.5 million women or nearly one in five women of child-bearing 
age went without health insurance in 2001, a higher rate than 
for other Americans under age 65. That means that some 28 
percent of uninsured Americans are women of child-bearing age 
and several of you know that that lack of coverage is not 
equally distributed across our country. Women of Hispanic 
origin, Native Americans, African-Americans are 
disproportionately affected by this lack of health insurance.
    Numerous studies have shown that having health insurance 
coverage affects how people use health care services. In a 
report issued earlier this year by the Institute of Medicine, 
researchers concluded that, and I quote, ``Like Americans in 
general, pregnant women's use of health services varies by 
insurance status. Uninsured women receive fewer prenatal care 
services than their insured counterparts and report greater 
difficulty in obtaining the care that they believe they need.''
    We know how important prenatal care can be. In its report 
on pending legislation, the Senate Finance Committee stated 
that, ``Recent studies have shown that infants born to mothers 
receiving late or no prenatal care are more likely to face 
complications which can result in hospitalization, expensive 
medical treatments, and increased cost to public programs. 
Closing the gap in coverage between mothers and their children 
will improve the health of both while reducing costs for 
taxpayers.''
    At the March of Dimes our overarching goal is to improve 
the health of mothers and their children. To further this goal, 
the foundation has worked throughout this Congress to obtain 
support for a modest incremental step to improve access to 
health service for uninsured pregnant women by amending the 
SCHIP program.
    Mr. Chairman, S. 724, which includes provisions from your 
bill, S. 1016, the Healthy Start, Stay Healthy Act, would bring 
the SCHIP program into alignment with every other Federal 
health insurance program, all of which extend coverage to 
pregnant women and their babies. The provisions of S. 724 that 
are particularly important to advancing the mission of the 
March of Dimes include number one, allowing states the 
flexibility to extend SCHIP coverage to pregnant women 19 years 
and older and number two, automatically enrolling their 
newborns in the program and providing them with coverage for 12 
months following birth.
    Mr. Chairman, on several occasions throughout the year we 
were pleased that HHS Secretary Thompson endorsed legislation 
to achieve these important objectives. However, the March of 
Dimes is disappointed to learn that the administration has 
apparently withdrawn its support for legislation and instead 
will rely on a regulation that permits states to cover unborn 
children.
    We are deeply concerned that this regulation fails to 
provide the mother the standard scope of maternity care 
services recommended here today by my colleagues at the 
American College of Obstetricians and Gynecologists and the 
American Academy of Pediatrics. Of particular concern, the 
regulation explicitly states that postpartum care is not 
covered. When a new mother goes home following delivery the 
March of Dimes wants to be sure that she is healthy enough to 
support herself, to breast-feed, to care for her newborn, and 
to participate in her family's life.
    S. 724 has broad bipartisan support and the National 
Governors Association has called on Congress to give states 
this option. In addition, 26 national organizations have 
endorsed this initiative.
    In short, S. 724 would give us and other organizations 
committed to improving the health of women and children the 
opportunity to work in states across the country to expand 
access to comprehensive basic maternity services, as 
recommended by obstetricians and pediatricians.
    On behalf of the March of Dimes, thank you for your 
commitment to improving the health of children and their 
families and for this opportunity to testify on the issues of 
critical importance to pregnant women and infants.
    Senator Bingaman. Thank you very much.
    [The prepared statement of Dr. Green may be found in 
additional material.]
    Senator Bingaman. Why do we not just go right down the 
table here? I think that is probably just as logical as 
anything else.
    Dr. Bucciarelli, why do you not go right ahead?
    Dr. Bucciarelli. Thank you, Mr. Chairman. Mr. Chairman, 
members of the committee, I am Richard Bucciarelli, a 
practicing neonatologist at the University of Florida, 
testifying today on behalf of the American Academy of 
Pediatrics.
    As a practicing neonatologist, I am the physician that 
often takes care of the babies that are born too small, too 
sick to sometimes survive or even live up to their full 
potential. I am a former chairman of the American Academy of 
Pediatrics Committee on Federal Government Affairs and serve as 
the chairman of the Academy's Subcommittee on Access to Health 
Care. And on behalf of the Academy, I would like to thank the 
committee for the opportunity to present this statement.
    Mr. Chairman, the Academy commends you and your colleagues 
and thank you for your leadership and determined efforts to 
dramatically reduce the number of uninsured children and 
pregnant women in this country. We look forward to actively 
working with you to bring health care coverage to all of our 
Nation's children and pregnant women.
    The American Academy of Pediatrics is an organization of 
57,000 pediatricians dedicated to the health, safety and well-
being of infants, children, adolescents and young adults. A key 
principle for the Academy is that all children and pregnant 
women have the right to access age-appropriate quality health 
care.
    Toward that end, the Academy is pleased to testify today in 
support of the Mothers and Newborns Health Insurance Act of 
2002, S. 724. This legislation would give states the option of 
covering pregnant women with their State Children's Health 
Insurance Program and very importantly, it appropriates the 
additional funds to states to provide these necessary services. 
The Academy believes it is critically important that pregnant 
women receive the full range of medical services needed during 
their pregnancy and the postpartum period. These services are 
spelled out in the Guidelines for Prenatal Care, Fifth Edition, 
which was developed jointly by the American Academy of 
Pediatrics and the American College of Obstetricians and 
Gynecologists. These guidelines describe the components of 
prenatal care that are needed by both the fetus and the 
pregnant woman to ensure early identification of risk factors 
and appropriate treatment of maternal fetal conditions.
    As we all know, the administration published a final rule 
expanding SCHIP coverage to unborn children. The Academy is 
concerned that as written, this regulation falls dangerously 
short of the clinical standards of care outlined in our 
guidelines, which describe the importance of all stages of a 
birth--the pregnancy, delivery, and postpartum care. The 
Mothers and Newborns Health Insurance Act ensures that pregnant 
women can receive the critically important full range of 
prenatal and postpartum care.
    This legislation, unlike the recently published rule, 
recognizes the important impact of the mother's health on the 
fetus. There is no doubt, for example, that maternal diabetes 
can directly affect the fetus and lead to increased mortality 
and morbidity and would be covered. But what about a mother 
with asthma in need of coverage to pay for her medications? 
Denial of coverage could result in a severe asthmatic attack, 
pneumonia, and could deprive the fetus of oxygen and lead to 
even premature delivery.
    Or what about the mother with a severe infection of the 
gums of the mouth, gingivitis, and dental caries? How is this 
related to the fetus? Well, there is an increasing amount of 
data to indicate that chronic infection of the gums and bad 
dental health greatly increase the chances of a premature 
delivery with its increased morbidity, mortality and cost. And 
these are just two examples that demonstrate the importance of 
covering both the fetus and the pregnant woman with appropriate 
health benefits.
    One of our biggest challenges we face as a Nation, and we 
have an opportunity to address that here today, is reducing the 
number of uninsured children and pregnant women in the United 
States. We believe the Mothers and Newborns Health Insurance 
Act takes an important step to decrease the number of uninsured 
children by providing 12 months of continuous eligibility for 
those children born to mothers under this act. It has been 
demonstrated that intermittent coverage compromises continuity 
of care, delays necessary therapy, and adds administrative 
costs for outreach and reenrollment efforts.
    Additionally, this provision prevents newborns eligible for 
SCHIP from being subject to enrolment waiting periods, ensuring 
that infants receive appropriate health care in their first 
year of life. This legislation ensures that children born to 
women already enrolled in Medicaid or SCHIP are immediately 
enrolled in the program for which they are eligible. These 
provisions would provide presumptive and continuous eligibility 
for children covered under the act, guaranteeing essential 
uninterrupted access to health care throughout their first year 
of life, for it is within that first year of life when parents 
need the most assistance in dealing with their new child. It is 
within that first year of life that immunizations, timely 
immunizations, are most critical. And it is within that first 
year of life that making the correct diagnosis and initiating 
the appropriate therapy is so important.
    We must make health care for America's children and 
pregnant women available, accessible and affordable. Providing 
children, adolescents and pregnant women access to quality care 
with an emphasis on prevention is truly an investment in our 
Nation's future. Thank you very much.
    Senator Bingaman. Well, thank you very much.
    Ms. Bernstein, why do you not go right ahead?
    Ms. Bernstein. Mr. Chairman, members of the committee, I am 
honored to come before you today to urge passage of S. 724, the 
Mothers and Newborns Health Insurance Act of 2001.
    First, let me just tell you a bit of how I have come to be 
here and why the What to Expect Foundation was formed. The What 
to Expect Foundation takes its name, as you have heard, from 
the best-selling What to Expect pregnancy and parenting series 
that was written by the foundation's president, Heidi Murkoff, 
and her mother, the late Arlene Eisenberg.
    This series of books has helped over 20 million families 
from pregnancies through their child's toddler years. ``What to 
Expect When You're Expecting'' is often referred to as 
America's pregnancy bible. According to a USA Today poll, it is 
read by 93 percent of all mothers that buy a pregnancy guide. 
The What to Expect series of books are not only the three best-
selling parenting books in the country; they are among the 
best-selling books in the country on any topic. This week 
``What to Expect When You're Expecting'' is number three on the 
New York Times Bestseller List.
    But I am sorry to say, as many parents as the What to 
Expect books have helped, they have missed many more. As we 
know, our Nation's infant mortality rate is higher than 28 
other countries. We are right behind Cuba. And even if a mother 
could afford to buy a prenatal guide she might not be able to 
read it. The literacy rate in the United States is a continuing 
problem. Today 21 to 23 percent or adults or some 40 to 44 
million people across the country read at less than a fifth 
grade level.
    Thus, the birth of the What to Expect Foundation, a new 
nonprofit organization dedicated to helping mothers in need 
receive prenatal health and literacy education so they, too, 
can expect healthy pregnancies, safe deliveries, and can learn 
to become parents. We believe that a woman, when she becomes a 
mother, needs to learn how to read because a mother who can 
read can raise a child who can read.
    The Basic Basics program provides prenatal education that 
takes into account the special health, economic, social and 
cultural needs of low-income women and gives prenatal providers 
culturally appropriate health literacy tools and support.
    By 2003 we will have provided over 200,000 women across the 
country with the Baby Basics program in English and Spanish and 
we are now building Baby Basic model health literacy sites at 
prenatal clinics across the country.
    While researching the Baby Basics book and program I had 
the opportunity to speak to hundreds of pregnant low-income 
women and the doctors, midwives, nurses, outreach workers, 
educators and social workers that care for them. From across 
the country I heard the pregnancy stories of the country's 
poorest women. Some of them were also the stories of just every 
woman--swollen feet, indigestion, back pain. Others were about 
hopes and fears that cut across income and education. Will I be 
a good mother? Will I know how to hold a child? Will I be able 
to provide for my baby?
    But too many of these stories broke my heart. Teens who 
were pregnant because they wanted someone to love and to love 
them. Women pregnant with no health insurance, who worked long 
days for little income and hah to take off unpaid time to sit 
in a hard chair for hours waiting for an unscheduled five-
minute free appointment at a crowded clinic. Women who saw a 
doctor for the first time the day their water broke because 
they could not afford care.
    Secretary Thompson did an important thing and is to be 
congratulated when he realized that many pregnant women could 
not afford prenatal care. One look at the infant mortality rate 
and he did look for ways to fix it. He also realized that 
SCHIP, a dramatically successful program for families, had the 
funds and the ability to reach out to help in our constant 
battle against infant and maternal mortality. And I applaud him 
for finding a stopgap measure that was within his domain to 
help states provide prenatal care quickly and efficiently by 
extending the care to the fetus, with an implicit understanding 
that this was a quick fix, one that would be remedied by 
legislation.
    Now, frankly, I am confused. In his recent letters to you, 
Senators, he seems to have changed his mind, saying such 
legislation is no longer needed; his quick fix is enough. But 
the quick fix put forward by the administration is not really a 
fix at all because now we have created even more problems. 
After we have spent so much time and money promoting prenatal 
care, we have gone and created an entirely new funded medical 
program called fetal care because fetal care and prenatal care 
are not the same thing. Please let me tell you why.
    This September Secretary Thompson, Senator Kennedy and 
Senator Hatch, along with our foundation's president, Heidi 
Murkoff, spoke at Robert Wood Johnson's Covering Kids 
celebration honored SCHIP's fifth anniversary. Mothers and 
fathers explained how Child Health Plus helped their family. 
These were working families with two jobs working double 
shifts, to keep their families afloat.
    One family, suddenly unemployed, had no idea how they were 
going to pay for their daughter's continuing diabetes care 
until they found out about SCHIP. Another hard-working mother 
spoke about SCHIP paying for surgery that saved her boy's life. 
These parents were heroes to their children and to the 
audience. With the help of SCHIP, they have provided for their 
families. Because SCHIP had been carefully crafted, marketed 
and promoted as help for working families and children, these 
parents were able to retain their dignity and were proud of 
their ability as parents to provide the health care their child 
needed when they needed it. Just as offering prenatal care to a 
woman can help her afford to do the best for her unborn child, 
it is friendly help that is offered with dignity and can be 
accepted with pride.
    Offering fetal care? That is a slap in the face. This new 
regulation makes clear that fetal care is about the fetus 
first. Extras, like epidurals and pain medication, will only be 
available if a case can be made that they are for the health of 
the fetus. Fetal care offers the mother no dignity, devaluing 
her life, which she has risked by sharing her body with an 
unborn child.
    Prenatal care acknowledges that there are two things that 
grow when a woman becomes pregnant. First, of course, there is 
the fetus, growing to become a healthy baby. And second, no 
less importantly, there is the woman, who must also grow. She 
must grow to think of herself as a mother, a parent, a 
provider. Inextricably linked in a dance as old as creation, 
mother and child grow together, both nurtured with love and 
care.
    Fetal care unbinds those ties, breaks those bonds. It is 
about the government choosing fetuses over women, providing the 
fetus with all of its health care needs while saying to the 
woman we cannot help you.
    Prenatal care provides a woman with the comprehensive 
health coverage she needs to have a baby. It cares for her body 
and her health. It helps her stay strong so she can be strong 
as a mother. It provides for her needs before and after the 
delivery and gives her the chance to recover so she has the 
strength and the health to nurse her precious new bundle.
    Fetal care tells mothers that once they have had the baby, 
they are on their own. Like Cinderella after the ball, once the 
baby is delivered, no more fairy godmother. Suddenly her health 
care is gone. No glass slipper. Even her 48 hours guaranteed 
hospital stay is out of the picture.
    Prenatal care is about family values. It helps create 
parents. It does what Early Head Start, Head Start, Healthy 
Start and Even Start do so well. It gives parents the strong 
shoulders they need to make sure no child is left behind. It 
fosters optimism.
    Fetal care throws the parent out with the bathwater. It 
fosters pessimism and an early pervading sense of failure. From 
the start, it fails to acknowledge that a parent is a child's 
first and best teacher. To me, fetal care fosters foster care.
    Prenatal care fills hospital wards with healthy babies. 
Fetal care fills hospitals with wards of the State.
    Senators, so many good things can happen when a woman gets 
proper comprehensive prenatal care, as you have heard from my 
colleagues. The What to Expect Foundation links prenatal care 
to literacy training so women learn how to read and learn how 
to read to their babies. Healthy Start and other programs 
across the country are linking prenatal care to all kinds of 
positive self-esteem-building social programs--parenting 
skills, job training, long-term housing planning, financial 
planning.
    We have trouble in this country getting women into prenatal 
care. Why would we ever want to put any barriers to prenatal 
care up?
    Secretary Thompson has done an honorable thing by opening 
the door to prenatal care for thousands of women each year but 
imaginary barriers, liberal barriers, conservative barriers, 
unintended barriers, no matter what we want to call these 
barriers, regardless of their politics or their intent, they 
are unnecessary barriers to care.
    I am here to tell you that hundreds of providers, 
practically every doctor, midwife and nurse across the country 
agrees that this fetal care quick-fix must not stand as a 
barrier. And every mother, including this mother, and the 
mothers who have told millions of mothers across the country 
what to expect, agree. Our job is to knock down the barriers. 
Passing S. 724 will remove those barriers. Then we can roll up 
our sleeves and get back to work because only a healthy parent 
can provide a healthy future for a healthy child. Thank you.
    Senator Bingaman. Thank you very much.
    Dr. Riley, you are the clean-up hitter on this panel. We 
are anxious to hear from you, too.
    Dr. Riley. These are hard acts to follow.
    Thank you, Mr. Chairman, and members of the HELP Committee. 
As an obstetrician-gynecologist, I welcome the opportunity to 
speak with you this morning on behalf of the American College 
of Obstetricians and Gynecologists, 45,000 partners in women's 
health care. I look forward to discussing measures that will 
increase access to medical services for pregnant women.
    I would first like to thank you, Senator Bingaman, for your 
leadership on this issue. I would also like to thank and 
acknowledge Senators Lincoln and Corzine for appearing before 
the committee today and for their commitment to uninsured 
women.
    My name is Dr. Laura Riley and I am an assistant professor 
of obstetrics and gynecology at Harvard Medical School and the 
medical director of labor and delivery at Massachusetts General 
Hospital in Boston. I also chair the Committee on Obstetric 
Practice at ACOG.
    I am pleased and honored to speak before the committee 
today on an issue that is extremely important to me. The focus 
of today's hearing is to discuss how being uninsured can impact 
maternal and fetal morbidity and mortality. For uninsured 
pregnant women, lack of prenatal and postpartum services can 
have devastating and lasting effects on both the mother and her 
fetus. There is no question that increasing access to prenatal 
care and appropriate postpartum services is of the utmost 
importance.
    Unfortunately, one of great barriers to this care remains 
lack of insurance. I believe passage of Senate Bill 724, the 
Mothers and Newborns Health Insurance Act of 2001, would help 
us achieve this important goal. ACOG strongly supports S. 724, 
a bipartisan comprehensive bill that permits states to extend 
health coverage to pregnant women, enabling them to have full 
access to a range of services, including perinatal and 
postpartum medical care, and urge the Senate to quickly pass 
this legislation. ACOG, along with the Academy of Pediatrics, 
spells out recommendations for prenatal and postpartum care for 
the mother and the fetus in Guidelines for Perinatal Care, 
Fifth Edition. If we pass S. 724, we can deliver this care to 
many underserved and uninsured women.
    I would like to take a moment to comment on the Department 
of Health and Human Services' recently issued regulation that 
allows states to provide prenatal and delivery benefits under 
the SCHIP program to mothers and the fetus, regardless of the 
mother's immigration status. We appreciate the administration's 
interest in expanding prenatal coverage to uninsured pregnant 
women. Their efforts to extend access is appreciated. However, 
this regulation, as it stands, raises some questions.
    We at ACOG believe that it is unrealistic to exclude the 
mother and provide services solely to the fetus. It is 
impossible to separate mother-baby pairs and expect a good 
outcome for either of them. Our three principal concerns are 
the need for postpartum care, the need for essential components 
of prenatal care, and the logistical problems of implementing 
the administration's proposed legislation.
    ACOG is very concerned that mothers will not have access to 
appropriate postpartum services. The rule clearly states that 
``Care after delivery, such as postpartum services, could not 
be covered because they are not services for an eligible 
child.'' Physicians regard postpartum care as essential for the 
health of the mother and the child.
    Covering the fetus as opposed to the mother also raises 
questions of whether certain services will be available during 
pregnancy and labor if the condition is one that principally 
affects the woman. Postpartum care is especially critical for 
women who have preexisting medical complications and for those 
whose medical conditions were induced by their pregnancies, 
such as gestational diabetes or hypertension. Even women with 
uneventful deliveries and recoveries can develop conditions 
postpartum that require extra visits or even surgery. A woman 
may go home feeling well and return with problems.
    I recently treated a 20-year-old Hispanic woman 8 days 
after an apparently uncomplicated vaginal delivery. She 
complained of 2 days of severe headache. Her blood pressure was 
200 over 115 and upon arrival to the hospital, she suffered a 
grand mal seizure. There are many more stories like this, some 
even more tragic. Clearly when new mothers develop postpartum 
complications, quick access to medical care is absolutely 
critical.
    I would also like to touch upon a population that may be 
most at risk for developing complications during and after 
pregnancy and why we must ensure that obstacles do not prevent 
them from seeking care. African-American women, Hispanic women 
who have immigrated to the United States, and American Indian 
and Alaskan native women are at greatest risk for maternal 
mortality.
    The statistics are startling. CDC notes that African-
American women are four times as likely to die of pregnancy 
complications compared with white women and American Indian and 
Alaskan native women are nearly twice as likely to die. In a 
14-year national study of pregnancy-related deaths in the 
United States, CDC found that the pregnancy-related mortality 
ratio for African-American women was 25.1 deaths per 100,000 
live births and 10.3 deaths per 100,000 live births for 
Hispanic women, versus six per 100,000 live births for white 
women. Poverty and lack of insurance clearly and certainly play 
a significant role in these alarming statistics. We are 
concerned that women without postpartum coverage, the very 
women that need the most help and who experience the highest 
rate of maternal morbidity and mortality, will be 
disproportionately affected.
    As I have stated before, prenatal and intrapartum services 
are essential. It is inconceivable that there are diseases that 
affect the mother principally and have no overall effect on the 
fetus. Diseases such as diabetes and hypertension clearly have 
defined fetal effects. Maternal obesity, which requires 
nutrition counseling, behavioral interventions, and anesthesia 
consultation, is not a health condition limited to the mother.
    For example, another patient of mine in her 8 month of 
pregnancy arrived in the emergency room clutching her head with 
pain and developed confusion over time. A CT scan revealed a 
large brain tumor. Yes, this is a maternal condition but you 
can imagine that the effects of neurosurgery and postoperative 
pain management all had an impact on her developing fetus.
    Finally, Mr. Chairman, I want to share our concerns about 
the implementation of the administration's regulation and the 
impact it will have on OB-GYN practices. Already the health 
care system prevents physicians from spending needed time with 
patients. Skyrocketing medical liability premiums, onerous 
regulatory paperwork, and continued Medicare payment cuts can 
dramatically undermine our ability to serve our patients. All 
of these factors have combined to limit access to care and we 
urge Congress to support efforts to address these issues, as 
well.
    I fear this regulation will create even more bureaucracy 
and red tape for physicians. For my patient who was 8 months 
pregnant with a brain tumor, figuring out which components of 
her care would be covered by such restrictive services would be 
an impossible task. Because this regulation also limits 
coverage to services directly related to the health of the 
fetus, OB-GYNs will be unsure whether medically necessary care 
can be covered. In most cases physicians will simply provide 
the care and deal with the coverage issues later, knowing that 
a tremendous amount of staff time and effort will be expended 
to recover minimal payment.
    Furthermore, pregnant women may wonder if even they have 
the ability to access coverage for nonobstetric conditions or 
injuries and decide simply to not seek treatment. This 
uncertainty about coverage will discourage physicians from 
participating and deter women from seeking appropriate 
necessary care.
    Mr. Chairman, in closing, I urge the Senate to quickly pass 
S. 724. I also encourage the administration to support 
enactment of this bill to expand coverage to uninsured pregnant 
women, ensuring access to comprehensive prenatal and postpartum 
coverage. It is the right thing to do. Thank you.
    Senator Bingaman. Thank you very much.
    [The prepared statement of Dr. Riley may be found in 
additional material.]
    Senator Bingaman. I thank all four witnesses for just 
excellent testimony.
    Before we start some questions let me defer to Senator 
Corzine for any comments or statements that he would like to 
make.
    Senator Corzine. Thank you, Mr. Chairman. Again let me 
congratulate you and compliment you on your leadership on this 
issue throughout this year and over a long period of time. 
Universal access to health care is certainly something that I 
think all of us would like to see but if we do not have the 
ability to provide that, providing it to the Nation's children 
and pregnant women is something that I think all of us can 
believe needs to be done.
    I have a lengthy statement I will put into the record but I 
do want to reemphasize that we are creating controversy where 
there need be none. We are creating confusion, as we just heard 
Dr. Riley talk about, for our medical community where there 
need be none. And we are creating an unbelievable conflict 
between the health of the mother and the health of the fetus 
that need not be done. So I hope that we can resolve this and 
move forward quickly with respect to it.
    I thank the witnesses for their testimony. It is far more 
articulate than I can be with regard to this, but this is 
something that I think the Nation ought to put high on its 
agenda and address quickly.
    Senator Bingaman. So thank you very much to all of you and 
your excellent testimony.
    Thank you very much, Senator Corzine, for your strong 
advocacy of this legislation here throughout this Congress.
    Let me start with a couple of questions and then defer to 
Senator Lincoln and Senator Corzine for questions they have. 
First I wanted to allude to a very disturbing statistic that I 
am well aware of and that is that when you look at the various 
states in the Nation as to who has the biggest problem with 
regard to women of child-bearing age lacking appropriate 
insurance, my State of New Mexico is first in the Nation. There 
are 32 percent of the women of child-bearing age in New Mexico 
who do not have insurance coverage. Second to New Mexico is 
Texas. Twenty-eight percent of the women of child-bearing age 
there do not have any insurance coverage.
    So it is a very serious problem and, of course, the 
statistics in our State I think add to or contribute to the 
very unfortunate national statistics that several witnesses 
have referred to.
    Let me just ask any of you, starting with Dr. Green, I 
think the concern that I have had and a major motivation for 
introducing the legislation I introduced in this Congress and 
supporting Senator Bond's legislation, along with my 
colleagues, has been trying to deal with this problem of high 
mortality of newborns, high mortality of women in the delivery 
process. This legislation seemed to be the most effective thing 
we could do at the national level to try to deal with this.
    Is there something else? Is there something other than 
passage of this type of legislation that would also be a 
significant contributor to solving this problem? I think we are 
sort of looking to you as experts to tell us what can be done 
to deal with these problems. I did not know if any of you have 
insights as to whether this is the most effective thing or 
whether there are others that we ought to be pursuing, as well.
    Dr. Green, did you have any thoughts on that?
    Dr. Green. Thank you. I think a number of the states have 
already identified that between Medicaid and SCHIP coverage, 
that is a lot of families affected who can be covered 
effectively by those programs. In fact, many states have 
increased the threshold for eligibility for SCHIP to 185 
percent and in some states 200 percent of the poverty level.
    So I guess the theme of my suggestion would be the increase 
in coverage both from Medicaid and through SCHIP and to that 
end then, this bill would be serving.
    Senator Bingaman. Let me put a chart up that we have that 
tries to show the problem in my State. I asked Bruce Lesley, 
who has been the great champion on this, to put this chart 
together. The thatched part up at the right starting after age 
18 is the area that we are trying to cover through this 
legislation. Medicaid does cover people up to 185 percent of 
poverty in my State. The SCHIP program covers anyone up to 235 
percent of poverty through age 18 but then after that, of 
course, there is no coverage once a person is 19 years old, so 
we believe that this is an option that should be available to 
our State to pick up.
    Dr. Green. The March of Dimes commissioned a study from 
Emory University to estimate the potential number of eligible 
pregnant women who could be covered by this legislation that 
gives states the option to enroll income-eligible pregnant 
women in the SCHIP program. Those estimates are 41,000 women 
nationwide would be eligible for coverage under this bill.
    The Congressional Budget Office has recently released some 
estimates of their own--about 30,000 newly eligible pregnant 
women could be covered. So between 30,000 and 40,000 women 
could be affected by this regulation. That is a lot of 
families.
    Senator Bingaman. Right. Very good.
    Let me ask Dr. Riley, you went into some depth about the 
problems that you see with trying to sort out what is covered 
under this new regulation that has been issued and Senator 
Corzine just referred to that sort of needless complication 
that we are adding to the system for physicians and all.
    Two, I think that you mentioned are diabetes and 
hypertension, questions about whether those kinds of things 
would be covered. Would you want to elaborate on that at all as 
to how you think obstetricians would make those decisions?
    Dr. Riley. I think that obstetricians are going to have a 
tough time deciding what component of treatment for 
hypertension is going to get covered because it directly 
relates to the fetus, yet this part is really for the mom's 
long-term health.
    Hypertension may not even be the best example. I think a 
very good example is my patient with the brain tumor. I mean 
the brain tumor was not going to affect her fetus directly but 
certainly the neurosurgery that we did and lowering her core 
body temperature probably had some effect on her fetus.
    I think that there are definitely going to be some medical 
illnesses that complicate pregnancies for which you cannot 
separate the mother and the baby. You may not be able to define 
the fetal effect but there is probably a fetal effect. I do not 
think that we want to allow physicians to then be more confused 
and start making arbitrary decisions about what treatment they 
will give and what treatment they will not give.
    Senator Bingaman. Dr. Bucciarelli, did you have any 
thoughts on this? You are in the business of providing 
pediatric care.
    Dr. Bucciarelli. Right. I agree with agree Dr. Riley. When 
we go into a delivery room or we go in consultation with the 
perinatologist, we are working on a unique situation in which 
there are two lives that are inexorably bound together and 
there is virtually nothing that I can think of that would 
affect the mother and not directly or indirectly affect the 
fetus.
    One of the examples given earlier is if a mother breaks an 
arm, how does that affect the fetus? Well, the stress, the 
hormones that are put out when somebody has that kind of injury 
cross the placenta and those kinds of hormones, small peptides, 
greatly affect blood flow and very commonly blood flow to the 
brain, which is what we are trying to preserve. We have babies 
that are born with a completely normal delivery process that 
have devastating defects in the long run, probably because of 
these kinds of things, stresses in the mom that we are not 
aware of.
    So I just cannot think of anything that would go on in a 
mom that would not directly or indirectly affect the fetus and 
I would agree with Dr. Riley that separating those two would 
make it so difficult to take care of these patients.
    Senator Bingaman. Senator Lincoln, go ahead with any 
questions you have.
    Senator Lincoln. Thank you, Mr. Chairman.
    Well, a little bit to expand on that, when you talk about 
that you cannot think of anything that would be different or 
where you could separate those two, my understanding of the 
regulation is that it would be left up to the states. So 
basically you are going to have different states deciding what 
is covered, what is not, different care given to mothers 
depending on where they live and where they seek services and 
all of a sudden you are going to have physicians again trying 
to make these decisions. Is this a procedure that I follow the 
clinical guidelines, which you all obviously have clinical 
guidelines, or do I follow another path or another pattern 
because I want to take care of both of these but I cannot do it 
and get reimbursed or get paid for services in that way.
    To me, that sounds enormously confusing and I cannot 
imagine that physicians, particularly in light of some of what 
Dr. Riley has brought up in regard to liability that we have 
seen with obstetrics and gynecology and other difficulties that 
they have, I mean what do you all see in terms of the 
confusion, the logistical complications that this would present 
and finally, I guess, perhaps the lack of reimbursement or the 
knowledge of that for whether it is prenatal or postpartum 
care? How his that going to affect the willingness of providers 
to actually serve or participate in these SCHIP programs?
    Dr. Riley. I think that it will lead to more and more 
physicians not participating at all. It is too much paperwork. 
It is too much confusion. You leave yourself open to a great 
deal of liability, giving half the care you should give. I 
think that people will just say I do not want to take care of 
this segment of the population.
    Then again it will get us right back to where we started 
from, where there is lack of access.
    Senator Lincoln. It is so counterproductive to what we want 
to accomplish.
    Dr. Riley. Absolutely.
    Senator Lincoln. Dr. Bucciarelli, I know I delivered at a 
university hospital and I can remember my father, who is a 
wonderful man but he is a basic dirt farmer from East Arkansas. 
I had never seen my father cry until I went up to the neonatal 
intensive care unit with him, took him up to see one of our 
twins, who had to spend about 24 hours under some oxygen from a 
pneumothorax, and we were very fortunate. I went full term. The 
boys were big, good size babies and all of that, but right next 
to Bennett was a twin. They were born at, I think, like 24 
weeks, 25 weeks, maybe even 23 weeks, and one of the twins 
survived; one of them did not.
    It was incredible to see that baby and as I said, I had 
never seen my father cry until he looked at that child. The 
comment that he said, which was not only is that amazing to 
see, but he said that poor individual is going to have 
complications all his life.
    When we talk about the lack of prenatal care and we talk 
about how important it is for the health of the family and the 
child we are not just talking about delivery. We are not just 
talking about postpartum. Can you kind of expand on some of the 
things, too, when you have a delivery without the adequate 
prenatal care and without the adequate postpartum care, what do 
we see in developing pediatrics and in children down the line 
in terms of developmental disabilities and other health care 
complications, even the statistics on incarceration, when you 
are talking about those kinds of situations?
    Dr. Bucciarelli. Well, there can be a life-time loss for 
the family and the child. Certainly the age group that you 
refer to have a high mortality and those that survive often 
have some disabilities, from mild to very severe. But, you 
know, although I marvel when I am in the NICU, as well, at the 
advances that we have made but I am absolutely convinced that 
we get handed a healthier baby and it makes my job easier 
because of what is happening in obstetrics and gynecology and 
the prenatal care, the intrapartum care gives me a child that 
is healthier and allows me to use the technology that is 
available.
    So 10 years ago we had a lot of the technology we have 
today but that child would not survive. The difference is the 
prenatal care, the ability to treat these kinds of conditions 
of high blood pressure and disability, so the obstetrician 
hands me a baby that is screaming, pink, and almost ready to 
feed.
    May I just make one other comment that I think you alluded 
to? That is the issue of breast feeding. That is so important 
in the outcome of children, that they get the right kind of 
initial exposure to immunoglobulins to decrease the amount of 
infections, to allow their gut to develop appropriately. And we 
have made great strides in our country in having women breast 
feed and that is purely a postpartum service. You do not talk 
about breast feeding in prenatal care, maybe a little during 
the delivery, but it is a postpartum service and without 
coverage for lactation consultants and without coverage of the 
physician's time to talk to the mother about breast feeding, 
breast feeding in our country will disappear very, very rapidly 
and it will be a tremendous loss to the health of our children.
    Senator Lincoln. That is so true. I can remember asking to 
be able to see a lactation consultant and they said, ``What?'' 
It is interesting.
    Miss Bernstein, thank you so much for such a moving 
statement. I have to say that I was one of those millions of 
women who had ``What to Expect When You're Expecting'' on my 
shelf. I have read it and I was very interested to see my 
husband, who happens to be an OB-GYN, how much he enjoyed 
reading it. We did read it together. It was something that 
provided us, I think, a great perspective on many of the 
different things we would see. He certainly knew the medical 
aspects but for me it was a tremendous help when I was carrying 
my sons. But, as you've said, not all women have been so lucky 
to be able to read the book or get the kind of prenatal care 
that they need.
    In my home State of Arkansas there are about 97,000 women 
of child-bearing age, between 15 and 24, who do not have health 
insurance. We rank 35th in the Nation in this regard and when 
you look at Senator Bingaman's chart there, we only cover 133 
percent of poverty in Medicaid and we go to 200 percent of 
poverty with SCHIP.
    But you talked a bit about the effects that providing 
health care to only the fetus would have on mothers. I would 
like for you maybe to share with us from your experience with 
Baby Basics programs and the people that you have met, maybe 
describe some hypothetical situations concerning pregnant 
women. Or maybe you have some situations that you have in mind 
that you have seen that you would like to share, some low-
income, maybe some that do not speak English, perhaps.
    Ms. Bernstein. I think this brings kind of an answer to 
Senator Bingaman, also, that I would like to talk about. One of 
the things that I have noticed about access to care, to early 
childhood care and prenatal care, is that a lot of people do 
not know what does exist for them. A lot of mothers come in 
late because they do not know their rights. They do not know 
what is available.
    One of the things that I have watched with SCHIP that is a 
marvelous program is that families do not know it is for them. 
They do not know that they can get this and it is not until by 
accident they hear--I mean I have heard stories of people 
hearing about it on the radio by accident and realizing, oh, 
wait, I fit into that.
    One of the things I think we should think about is when 
this is successful, which I hope it will be, how we can use 
this as a continuum of care because women do go in for prenatal 
care and you do not sign them up for SCHIP; they do not find 
out about it. With this, we have expanded the entry to the 
SCHIP program. You get pregnant women in there and you get them 
signed up with their children and then you have expanded the 
SCHIP program to reach the thousands of families that we have 
been unable to reach.
     I think that what I have learned from doing this Baby 
Basics program, and I will tell a story that Heidi Murkoff and 
I watched happen together. We are at Reikers Island at a 
parenting program and this was really the impetus for starting 
the program. We gave out copies of ``What to Expect When You're 
Expecting'' to pregnant mothers in prison, who dove into these 
books. They looked like every middle class mother I have ever 
seen who immediately wants to know everything that is going on 
inside their bodies because an alien life is growing. It is a 
shocking and exciting and a marvelous time and you want to know 
everything.
    A woman at the end walked up. She was emaciated except for 
a swollen belly and it was pretty clear that she probably had 
been just incarcerated and was there for drug use and was 
probably getting the best care she had ever had because she was 
in prison. She asked Heidi, ``They told me I need to have an x-
ray of my tooth and I just read in the book that it's going to 
hurt the baby. Should I have one?''
    And we could not help but stop and say this woman probably 
was not eating, she was probably doing crack cocaine. This was 
a few years ago. She loved her baby. She had no idea--she came 
from a different world than I came from. She did not know what 
to do to help her baby. She did not know what it was going to 
take to have a healthy pregnancy. Once we started giving her 
the information, once we started showing her what she needed to 
do, she was as eager as any mother.
    Much of it is about access, about education. The things 
that we think come naturally that you know, whether it is 
nutrition, whether it is basic hygiene, if you did not grow up 
with that, you do not even know to begin there. To deny that to 
a mother is an awful thing to do to the mother because she 
wants to make that baby healthy. The more help and the more 
information you can give her, the more that she will take 
control. She will become a parent, which is really what our 
goal is.
    That, I guess, is the point of what I am saying, is the 
more that you take that control away from the mother, the less 
that she will grow to take that responsibility. And I think 
that is what our goal should be, is to create parents, not just 
healthy babies, but to create parents who can give their babies 
that health.
    Senator Lincoln. That is a continuing thing.
    Thank you, Mr. Chairman. I may have another one but I would 
like to give my colleague over there an opportunity.
    Senator Bingaman. All right, Senator Corzine?
    Senator Corzine. Thank you, Mr. Chairman.
    I do not really feel like asking the question I am going to 
ask after that statement because I think that is really getting 
at the heart of the matter of how we bring our kids into the 
system and how we frame their futures and their lives, but let 
me ask a bureaucratic question. Dr. Bucciarelli or Dr. Green 
may be the appropriate source.
    The administration argues that states can apply for waivers 
in this process. New Jersey is a State that has done this. 
Checking with the people who are responsible, it was difficult. 
Dr. Bucciarelli, Florida's Healthy Kids program, I guess, has 
done the same. Do you think this will be a procedure that will 
flow smoothly and easily under the regulations and therefore 
this legislation is unneeded or what will be the difficulties, 
the stops, the road blocks? Aside from the other issues about 
confusions that come into doctors' minds, what will be the 
confusions in the states and the conflicts? Any of the 
panelists can comment on that.
    Dr. Bucciarelli. Well, in regard to the waivers, we have 
had experience in filing other waivers in the State of Florida. 
They were very complicated. They took a long time before we got 
through. It was, I think, a significant waste of money and time 
in administration in doing that. When something like this can 
be done by legislation as an option, purely as an option, 
without having to go through all that process, to me, it makes 
more sense to allow the states to take an option to be able to 
move that, instead of going through the waiver process.
    Dr. Green. I would like to add an additional comment to 
that important statement just made. That is that with the 
legislation, then Federal funding becomes available to the 
states and, as we all know, states are not exactly flush these 
days. So I think when we talk about something as critical as 
health care coverage for our vulnerable citizens, then the 
additional financial incentive from the Federal support of the 
program through the legislation would be enormously important.
    Senator Corzine. I suspect we all understand the difference 
between authorization and appropriation and it is even more 
difficult when you are applying for waivers where there is 
lacking an authorization.
    One other slight difference. Aside from the judgmental 
issues that I think really get at the heart of a controversy 
that need not be, do I understand it correctly that the 
administration's program only attends to the newborn child for 
3 months, as opposed to a year, which is the element that is 
involved in the legislation? What are we missing as we look 
after our children in the start of their life along these 
lines? Anyone on the panel.
    Dr. Bucciarelli. Certainly there is a tremendous amount of 
information that says the first year of life is critical to the 
child's health and further development and the American Academy 
of Pediatrics for some time has been a proponent of presumptive 
eligibility and continuous eligibility through that first year 
of life to allow immunizations to be done on time and the other 
kinds of well visits for not only screening but diagnosis and 
treatment of conditions. Certainly within the first 3 months a 
lot of that will be known but after that it certainly will not. 
And as I understand the legislation, it is a year coverage but 
it could go back to early pregnancy or conception, so 9 months 
of the year is covered at that time and then there are only 3 
months afterwards.
    I think a good example, if I might, is the issue with 
hearing impairment. Most states have a requirement to do 
hearing screening and they are done in the newborn period. But 
to be able to diagnosis carefully and treat a hearing 
disability, you have to do that several months later. It is 
critical that that be done before 6 months of age because if it 
is not done before 6 months of age, there are long-term losses 
with reading, language, that may never be recovered.
    So if you screen the baby in the newborn period and it is 
covered but it is not covered after 3 months and they are on 
and off or they fall off for a variety of administrative 
reasons and never come back, you have wasted time and effort in 
screening that child. Plus, without the proper diagnosis and 
treatment, we have lost an opportunity to allow a child to 
develop to their fullest potential, and that is a serious loss.
    Senator Corzine. Anyone else want to comment?
    Dr. Riley. I would just add yet another example that comes 
to my mind because it is my area of research but the diagnosis 
of HIV infection in a newborn is a difficult one to make. You 
might start to make the diagnosis at birth but then really you 
have to repeat the studies at 4 months of age to be absolutely 
sure that you have made the correct diagnosis. Certainly these 
are children, just a small segment of the population, but these 
are children that the care in the first year of life really 
will determine how well they do and it is not a case of how 
well they do but whether they live or die and I think that it 
would be horrible to go backwards on all the strides we have 
made in medicine for this group of children.
    Senator Corzine. Let me ask sort of a medical question. Is 
it typical that children have all their immunizations applied 
in the first 3 months?
    Dr. Bucciarelli. No. In fact, at that point we are just 
beginning to get into the immunizations that would go on. Most 
of the primary immunizations are done at the end of the first 
year but even after that there are other immunizations that are 
important. So that continuous coverage, continuous eligibility, 
is critical to make sure children do get the series of 
immunizations they need and that they get them on time.
    Senator Corzine. Thank you, Mr. Chairman. I think we see 
some of the reasons why this is so important.
    Senator Bingaman. Well, thank you very much.
    Let me just ask another question or two here and then if 
either Senator Lincoln or Senator Corzine have more, we will 
obviously hear those.
    I wanted to put up a chart that is very hard for anyone to 
read from the back of the room. If you can read that, we 
certainly will give you some kind of award. I have given each 
of the witnesses a copy of this. What we have tried to do here 
is to set out aspects of the regulation, first of all, and then 
of the legislation, as well, in several areas where we think 
the legislation provides coverage and provides benefits that 
the regulation does not. I wanted to just mention what those 
are.
    Obviously coverage of prenatal care and labor and delivery, 
that is clearly covered under our legislation. The coverage is 
mixed, as we have discussed here, under the regulation. 
Coverage of postpartum care is clearly covered under the 
legislation, not covered under the regulation by its own 
language. Prohibition on waiting periods for pregnant women, 
that again we have made provision in the legislation to ensure 
that there are no waiting periods involved. Obviously if you 
are pregnant you need care; you do not need to wait 6 months or 
a year.
    Prohibition on cost-sharing for pregnant women. Again we 
have made it clear in the legislation that states would not be 
permitted to require any cost-sharing. And then this issue 
about whether or not the child would be eligible for coverage 
or covered for the first 12 months of life and we think that is 
an important benefit of the legislation.
    Finally, the one Dr. Green has mentioned here and Dr. 
Bucciarelli I think maybe, as well, that our legislation does 
provide funds. We have identified ways to fund this additional 
coverage, which I think should be a substantial benefit to 
states because no such funding is provided in the regulation.
    Let me just ask again on this waiver issue, it strikes me 
as sort of perverse that we are saying to states, which I think 
is the administration's position--I had a conversation frankly 
with Deputy Assistant Secretary Claude Allen on the phone where 
his position was if states want to provide this coverage to 
pregnant women, it is not a problem; they can just seek a 
waiver.
    It strikes me first of all that it is a little perverse to 
have a legal structure where if you want to provide coverage to 
pregnant women you have to get a waiver; the provisions of law 
that normally apply need to be waived. This is not an 
experimental kind of a program, as I understand it. I mean we 
are pretty clear that these benefits are real; they have been 
real for a long time.
    The regulation says the secretary's ability to intervene 
through one mechanism--that is, a waiver--should not be the 
sole option for states and may, in fact, be an inferior option, 
which I think is certainly a clear statement, a correct 
statement. Then it says waivers are discretionary on the part 
of the secretary and time-limited while State plan amendments 
are permanent and subject to allotment neutrality.
    I would also just point out for the record here that the 
National Governors Association is on record. They have issued a 
policy that states, ``The governors call on Congress to create 
a State option that would allow states to provide health 
coverage to income-eligible women under SCHIP. This small shift 
in Federal policy would allow states to provide critical 
prenatal care, would increase the likelihood that children born 
to SCHIP mothers would have a healthy start.''
    So I do not know if any of you have other comments on this 
notion that the waiver is a good option. It does not strike me 
as a very good option for states to go in and say please waive 
the applicable laws and let us cover pregnant women.
    Have any of you focussed on that to any greater extent than 
this? No one seems to--Ms. Bernstein, did you have any comment?
    Ms. Bernstein. I was going to say that I think if you did a 
survey of middle class mothers across the country, they all 
think that prenatal care is paid for for everyone. I think that 
most people in this country who do not live in fear of getting 
health coverage have no idea that we turn people away every 
day. The thought of a waiver is that same way of thinking. This 
is a right. Prenatal care should be something that is provided 
for in this country and to have to get a waiver to be allowed 
to do it is bad wording. It is embarrassing, I think.
    Senator Bingaman. Well, I thought the wording in your 
testimony to the effect that fetal care involves throwing the 
parent out with the bath water, I thought that was a good way 
to put it.
    Ms. Bernstein. Thank you.
    Senator Bingaman. Let me call on Senator Lincoln for any 
additional questions she has.
    Senator Lincoln. Thank you, Mr. Chairman.
    Dr. Green, following on that question, I think it is 
interesting. I kind of wanted to find out where the March of 
Dimes was and how active they are at the State level or are 
there any plans to be active to encourage states to expand 
coverage to pregnant women in what we have talked about here? I 
mean we know that the waiver--I agree with the chairman that 
the waiver process and what we are talking about there is 
pretty counterproductive to what we really want to be doing but 
it is an option that if you are faced with, whether you use the 
regulation that the administration is giving us or you go for 
the waiver, which is the most productive to encourage states to 
go toward?
    Dr. Green. Well, the March of Dimes has a chapter, at least 
one chapter in every State, in Puerto Rico and in the District 
of Columbia and I think that you are aware, Senator Lincoln, of 
the energy emanating from these chapters at the State level 
with respect to advocacy.
    Senator Lincoln. Absolutely.
    Dr. Green. So I think that the March of Dimes is active in 
this program on two levels. One is certainly if states did not 
have the option to expand SCHIP to encompass pregnant women, 
then our chapters would be very active in trying to help those 
State legislatures to apply for this waiver program.
    Senator Lincoln. If they do not have S. 724.
    Dr. Green. If they did not have S. 724, exactly. As you 
have heard, it would be enormously expensive in terms of 
resources, time, energy. In fact, we would prefer to have 
passage of S. 724 so that we can focus our attention on another 
level of this kind of issue, namely getting parents, getting 
women, getting children enrolled in the programs that already 
exist because, as we have heard in the news, many states do not 
have complete implementation of their SCHIP program because 
families do not know about it, there are lots of barriers, 
language, literacy, logistics.
    So our chapters are prepared to help states apply for 
waivers but we would really rather help the communities get the 
coverage that they deserve. We will do both if we have to.
    Senator Lincoln. Right. But what I am hearing you say is 
that if you have the choice--if the legislation that we are 
talking about today is not made into law and states are not 
given that option to make that choice, then the March of Dimes 
would not encourage states to take up the option of covering an 
unborn child. They are going to encourage states to take the 
more difficult option because it is more comprehensive, because 
you know that the outcome for the child, for the mother, for 
the family, for the community and the Nation are all going the 
be better if we get more comprehensive care.
    Dr. Green. That is absolutely right, that access to 
coverage for children and pregnant women is one of our major 
foundation priorities, so we will certainly work with states to 
apply for those waivers and we applaud Colorado for their 
slogging through the process.
    Senator Lincoln. Just one comment, Mr. Chairman, and I will 
be finished. There has been a lot of talk about the 
availability and the knowledge, the education of people about 
what is available. We did try a couple of years ago with some 
legislation which we did pass to try and make the SCHIP program 
a little bit more available in the sense that we could 
publicize it and get better ways of getting the message out 
there, whether it is one-stop shopping or making sure that we 
have brochures and information out there in the appropriate 
places, like pediatricians' offices or in other places, as 
well, in our DHS offices and other things.
    So we have tried to do some of that but if you have other 
suggestions, please let us know because we do not need to stop 
there. We know we have not completed what we need to do, but we 
have made an initial step. So I would encourage you to continue 
that dialogue with us.
    Thank you, Mr. Chairman.
    Senator Bingaman. Well, thank you and again thank all of 
the witnesses. I think it has been very useful testimony and we 
will obviously have an opportunity when Congress comes back 
into session once again to pass this legislation. I know 
Senator Lincoln and I and Senator Corzine and Senator Bond will 
be making that effort again and we hope that we can succeed 
with the legislation before Congress adjourns.
    Thank you very much and that will conclude the hearing.
    [Additional material follows:]

                          ADDITIONAL MATERIAL

                Prepared Statement of Nancy Green, M.D.
    Mr. Chairman, I am Nancy Green and I am the Medical Director for 
the March of Dimes Birth Defects Foundation. I am pleased to be here 
today to discuss with you the importance of providing all pregnant 
women access to health insurance coverage and a comprehensive set of 
maternity services. I want to salute you, Mr. Chairman, and seventeen 
of your colleagues for sponsoring legislation that would give states 
the option of covering income eligible pregnant women 19 and older 
through State Children's Health Insurance Programs (SCHIP). We would 
like to especially thank Senators Bond, Lincoln and Corzine who 
recently joined you on the Senate floor to discuss the need for S. 724.
    President Franklin Roosevelt established the March of Dimes in 1938 
to fight polio. The March of Dimes committed funds for research and 
within 20 years Foundation grantees were successful in developing a 
vaccine to prevent polio. The March of Dimes then turned its attention 
to improving the health of children through the prevention of birth 
defects and infant mortality. As you might expect, providing coverage 
to both pregnant women and infants is a policy priority and especially 
pertinent to the advancement of our mission because in January we will 
launch a $75 million multi-year campaign to address the growing problem 
of prematurity.
    Today, the Foundation has more than 3 million volunteers and 1,600 
staff members who work through chapters in every state, the District of 
Columbia and Puerto Rico. We are a unique partnership of scientists, 
clinicians, parents, business leaders and other volunteers and we work 
to accomplish our mission by conducting and funding programs of 
research, community services, education and advocacy.
    At the March of Dimes, our overarching goal is to improve the 
health of mothers and children. This is why we are so concerned about 
improving access to health coverage for pregnant women and their 
newborns.
                      the problem of the uninsured
    Mr. Chairman, lack of health coverage continues to be a significant 
problem for many Americans. The Census Bureau recently reported that 41 
million Americans were uninsured in 2001. Particularly troubling, 
Census Bureau data commissioned by the March of Dimes show that in 
2001, 11.5 million women (18.7 percent) or nearly one in five women of 
childbearing age (15-44) went without health insurance a higher rate 
than other Americans under age 65 (15.8 percent). That is, some 28 
percent of uninsured Americans are women of childbearing age. Hispanic 
women in this age group are almost three times as likely as whites to 
be uninsured 38 percent compared to 13 percent respectively. Native 
American (30 percent), African-American (23 percent) and Asian (20 
percent) women were also likelier than whites to be uninsured. New 
Mexico (32 percent) and Texas (28 percent) had the highest rates of 
uninsured women of childbearing age for the 1999-2001 period according 
to the U.S. Census Bureau, compared with a U.S average of 18 percent 
for these years.
    Since the mid-1980's expanded Medicaid eligibility for pregnant 
women has resulted in better rates of coverage for them than for women 
in general. The Congressional Budget Office, citing in part March of 
Dimes supported research, estimates that about 1.7 million pregnancies 
are covered each year by Medicaid. But as the data indicate, 
considerable room for improvement remains.
                  health insurance makes a difference
    Numerous studies have shown that having insurance coverage affects 
how people use health care services. In particular, the uninsured are 
less likely to have a usual source of medical care and are more likely 
to delay or forgo needed health care services.
    In a report issued earlier this year by the Institute of Medicine, 
researchers concluded that ``[L]ike Americans in general, pregnant 
women's use of health services varies by insurance status. Uninsured 
women receive fewer prenatal care services than their insured 
counterparts and report greater difficulty in obtaining the care that 
they believe they need. Studies find large differences in use between 
privately insured and uninsured women and smaller differences between 
uninsured and publicly insured women.'' A study funded by the March of 
Dimes and cited by the Institute of Medicine in its report shows that 
some 18.1 percent of uninsured pregnant women in 1996 reported going 
without needed medical care during the year in which they gave birth. 
That compares with 7.6 percent of privately insured pregnant women and 
8.1 percent of pregnant women covered by Medicaid.
    Mr. Chairman, we know pregnancy represents a significant cost to 
young parents. These families, many of whom work in small businesses 
that don't provide health insurance, face significant costs even with 
the healthiest pregnancies, and for families with a problem pregnancy, 
the financial impact can be devastating. Without access to health 
insurance, many pregnant women will delay seeing a doctor and getting 
the prenatal care they need. As the report that accompanied legislation 
passed by the Senate Committee on Finance stated, ``[R]ecent studies 
have shown that infants born to mothers receiving late or no prenatal 
care are more likely to face complications which can result in 
hospitalization, expensive medical treatments, and increased costs to 
public programs. Closing the gap in coverage between mothers and their 
children will improve the health of both, while reducing costs for 
taxpayers.''
    The March of Dimes' objective is to reduce the number of uninsured 
pregnant women and children and to improve access to medical care. As 
you know, the March of Dimes supports elimination of any income 
eligibility disparities between mothers and newborns. To meet this 
objective, the Foundation has worked throughout this Congress to obtain 
support for a modest, incremental step to help improve access to health 
services for uninsured pregnant women by amending SCHIP. We support 
giving states the flexibility they need to cover income-eligible 
pregnant women age 19 and older, and to automatically enroll infants 
born to SCHIP-eligible mothers. By establishing a uniform eligibility 
threshold for coverage for pregnant women and infants, states will be 
able to improve maternal health, eliminate waiting periods for infants 
and streamline administration of publicly supported health programs. 
Currently, according to the Department of Health and Human Services' 
Centers for Medicare and Medicaid Services and the National Governors' 
Association, 36 states and the District of Columbia have income 
eligibility thresholds that are more restrictive for women than for 
their newborns. Encouraging states to eliminate this disparity by 
allowing them to establish a uniform eligibility threshold for pregnant 
women and their infants should be a national policy priority.
    Mr. Chairman, in January and on several occasions throughout the 
year, we were pleased that on behalf of the administration HHS 
Secretary Thompson endorsed legislation to achieve this important 
objective. However, the March of Dimes is disappointed to learn that 
the administration has apparently withdrawn its support for legislation 
and instead will rely on a regulation issued on October 2, 2002 that 
permits states to cover unborn children. Specifically, we are deeply 
concerned that final regulation fails to provide to the mother the 
standard scope of maternity care services recommended by the American 
College of Obstetricians and Gynecologists (ACOG) and the American 
Academy of Pediatrics (AAP). Of particular concern, the regulation 
explicitly states that postpartum care is not covered and, therefore, 
federal reimbursement will not be available for these services. In 
addition, because of the contentious collateral issues raised by this 
regulation groups like the March of Dimes will find it even more 
difficult to work in the states to generate support for legislation to 
extend coverage to uninsured pregnant women. We agree with the 
Secretary about the value of prenatal care to achieve healthy birth 
outcomes. In fact, as recently as January 31, 2002, Secretary Thompson 
has said that ``[P]renatal care for women and their babies is a crucial 
part of the medical care every person should have throughout the life 
cycle. Prenatal services can be a vital, life-long determinant of 
health, and we should do everything we can to make this care available 
for all pregnant women. It is one of the most important investments we 
can make for the long-term good health of our nation.'' We couldn't 
agree more. When a new mother goes home following delivery, the March 
of Dimes wants to be sure that she is healthy enough to support 
herself, to breast feed and care for her newborn, and to participate 
fully in her family's life.
                               solutions
    Mr. Chairman, you and your Finance Committee colleagues approved S. 
724, the ``Mothers and Newborns Health Insurance Act of 2002,'' in 
early July and similar legislation is pending in the House of 
Representatives. By including important provisions from your bill, S. 
1016, the ``Start Healthy, Stay Healthy Act,'' the Finance Committee-
approved legislation would accomplish these important policy 
priorities. By doing so it would bring the SCHIP program into alignment 
with every other federal health insurance program all of which extend 
coverage to pregnant women and their babies.
    The provisions of S. 724 that are particularly important to 
advancing the mission of the March of Dimes are:
1. Allowing states the flexibility to extend SCHIP coverage to pregnant 
        women 19 and older.
    States would be able to receive federal financing to help provide 
health coverage for income-eligible pregnant women. No waiting period 
would apply for participation in the program, and coverage of the 
mother would extend for at least two months following the birth of the 
child the postpartum coverage timeframe recommended by the American 
College of Obstetricians and Gynecologists (ACOG) and the American 
Academy of Pediatrics (AAP). Estimates of the annual impact of this 
change in law suggest that some 30,000 to 40,000 uninsured pregnancies 
could be covered.
2. Automatically enrolling newborns whose mothers are enrolled in SCHIP 
        and 12 month continuous coverage
    Automatic enrollment of newborns is important to avoid gaps in 
coverage for medically vulnerable infants. Enrollment of infants born 
to mothers eligible for SCHIP should begin the moment the child is 
born. This is especially important when a baby is premature, has a 
birth defect, or is in other ways medically fragile. In addition to 
automatic enrollment in SCHIP, newborns would remain enrolled in the 
program for one year. Many of these newborns would be eligible for 
coverage under current law, but often are not enrolled on timely basis. 
S. 724 establishes continuity of care for infants by guaranteeing 
coverage for the first year of life when access to health care services 
is particularly important for a healthy start in life.
3. Outreach Improvements
    In addition to the positive effects of enrolling pregnant women in 
SCHIP, S. 724 includes provisions to improve outreach. Research and 
state experience suggests that covering pregnant women is a highly 
successful outreach mechanism for enrolling older eligible children. 
Several states have found that expanding coverage to uninsured parents 
results in increased enrollment of eligible children (including 
California, Illinois, Kentucky, Nevada, Rhode Island, and Wisconsin).
                               conclusion
    At the March of Dimes we believe that improving access to health 
care for uninsured pregnant women and their infants should be a 
national priority. S. 724 has broad bipartisan support in both Houses 
of Congress and the National Governors' Association has called on 
Congress to give states this option. In addition, twenty-six national 
organizations have endorsed this initiative. In short, Mr. Chairman, S. 
724 would give us, and other organizations committed to improving the 
health of women and children, the opportunity to work in states across 
the country to expand access to comprehensive maternity services as 
recommended by obstetricians and pediatric practitioners.
    Once again, on behalf of the March of Dimes thank you for your 
commitment to improving the health of children and their families and 
for this opportunity to testify on the issues of critical importance to 
pregnant women and infants.
    I would be pleased to answer any questions the Committee may have.
               Prepared Statement of Laura E. Riley, M.D.
    Thank you, Mr. Chairman, and members of the Senate Health, 
Education, Labor and Pensions Committee, for holding this important 
hearing. As an obstetrician-gynecologist, I welcome the opportunity to 
speak with you this morning on behalf of the American College of 
Obstetricians and Gynecologist's (ACOG) 45,000 partners in women's 
health care. I look forward to discussing measures that will increase 
access to medical services for pregnant women.
    I would like to also specifically thank Senators Bond, Bingaman, 
Lincoln and Corzine, and others, for their strong leadership on the 
issue of uninsured pregnant women. Your efforts to enact meaningful 
legislation are deeply appreciated.
    My name is Dr. Laura Riley, and I am Assistant Professor of Ob/Gyn 
at Harvard Medical School and the Medical Director of Labor and 
Delivery at Massachusetts General Hospital in Boston. I also chair the 
Committee on Obstetric Practice at ACOG. I am pleased and honored to 
speak before the Committee today on an issue that is near and dear to 
me.
    The focus of today's hearing is to discuss how being uninsured can 
impact maternal and infant mortality. For uninsured pregnant women, 
going without needed prenatal and postpartum services can have 
devastating and lasting effects on both the mother and fetus. I have 
seen firsthand the consequences of women whose first visit to a 
physician is in the emergency room upon delivery. I have also seen the 
effects of severe postpartum complications on the health of the mother, 
conditions which, unfortunately, disproportionately affect minority 
women. Many of these conditions could have been reduced or prevented 
had a physician seen them early in their pregnancy. By assuring 
insurance coverage, and increasing access to prenatal care and 
appropriate postpartum services, we can reduce complications. I believe 
passage of Senate Bill 724, the ``Mothers and Newborns Health Insurance 
Act of 2001,'' would help us achieve this goal.
    ACOG strongly supports S. 724, a bipartisan, comprehensive bill 
that extends coverage to pregnant women, introduced last year by 
Senators Christopher ``Kit'' Bond (R-MO) and John Breaux (D-LA) and 
supported by a number of Senators, including Jeff Bingaman (D-NM) and 
Blanche Lincoln (D-AR). S. 724 permits states to expand health coverage 
to pregnant women, enabling them to have full access to a range of 
services, including comprehensive prenatal and postpartum medical 
services, that promote healthy pregnancies and deliveries and healthy 
babies. We urge the Senate to quickly pass this legislation.
    ACOG has long recognized that a full spectrum of health services is 
necessary to ensure uneventful pregnancies, healthy deliveries, and a 
postpartum period free of complications. Recommendations for care are 
spelled out in Guidelines for Perinatal Care, Fifth Edition, which was 
developed jointly by ACOG and the American Academy of Pediatrics. 
Guidelines provides a description of the components of prenatal and 
postpartum care that are important to both the fetus and the pregnant 
woman. If we can pass S. 724, we can deliver this care to many 
underserved and uninsured women and reduce instances of morbidity and 
mortality.
                          new schip regulation
    Recently, the Department of Health and Human Services (HHS) issued 
a regulation that allows states to provide prenatal care and delivery 
benefits under the State Children's Health Insurance Program (SCHIP) to 
mothers and fetuses regardless of the mother's immigration status. We 
appreciate the Administration's interest in expanding prenatal coverage 
to uninsured pregnant women. Increased access to prenatal services is 
essential in our fight to reduce maternal and infant mortality. There 
is no question that as a nation we must do better to address this 
incidence.
    The Administration recognizes that prenatal care is essential to 
ensure healthy pregnancies, however the regulation's approach to 
achieve this goal is a cause for concern. In particular, ACOG has 
several principle concerns with the rule. We hope to work with both 
Congress and the Administration to address these issues.
                        postpartum care critical
    ACOG is very concerned that mothers will not have access to 
postpartum services under the regulation. The rule clearly states that 
``care after delivery, such as postpartum services could not be covered 
as part of the Title XXI State Plan because they are not services for 
an eligible child.''
    The regulation also revises the definition of ``child'' under SCHIP 
to clarify that ``an unborn child including the period from conception 
to birth may be considered a `targeted low-income child.' '' Limiting 
coverage to the fetus instead of the mother omits a critical component 
of postpartum care that physicians regard as essential for the health 
of the mother and child. Covering the fetus as opposed to the mother 
also raises questions of whether certain services will be available 
during pregnancy and labor if the condition is one that more directly 
affects the woman.
    The best way to address this coverage issue is to pass S. 724, 
supported by Senators Bond, Bingaman and Lincoln and many others, and 
which provides a full range of medical services during and after 
pregnancy directly to the pregnant woman. Early access to prenatal care 
can help determine if a mother is at risk, but comprehensive follow-up 
care is also vital to avoid further complications. Pregnancy can 
sometimes signal the onset of new conditions such as diabetes or 
hypertension that require careful attention to the mother and child. 
When new mothers develop postpartum complications, quick access to 
their physicians is absolutely critical.
    Postpartum care is especially important for women who have 
preexisting medical conditions, and for those whose medical conditions 
were induced by their pregnancies, such as gestational diabetes or 
hypertension, and for whom it is necessary to ensure that their 
conditions are stabilized and treated. A wide range of diseases may 
affect the mother during and after pregnancy, such as cardiac disease, 
pulmonary embolism and renal disease; postpartum monitoring is critical 
is these cases.
    Women can go home well and return with problems. I recently treated 
a 20-year-old Hispanic woman eight days after an apparently 
uncomplicated delivery. She complained of two days of headache; she had 
a blood pressure of 200/115 and, upon arrival at the hospital suffered 
a seizure. Another 28-year-old woman had an emergent cesarean delivery. 
She went home and returned later with fever and abdominal pain. She 
remained in the hospital for 13 days on intravenous antibiotics to 
treat bacteria in her blood. She was in too much pain to bond with her 
baby for the first three weeks of its life. There are many more 
stories, some even more tragic.
    We at ACOG believe that it is unrealistic to exclude the mother and 
provide services solely to the fetus. It is impossible to separate 
mother-baby pairs and expect a good outcome for either of them.
                 women at risk will there be coverage?
    According to the Centers for Disease Control and Prevention (CDC), 
``each day in the United States, two to three women die of pregnancy 
complications.'' The CDC further notes that ``childbirth remains the 
most common reason for hospitalization in the United States, and 
pregnancies with complications result in more costly hospitalization.'' 
Half of all maternal deaths in this country might be prevented through 
early diagnosis and appropriate medical care of pregnancy 
complications.
    African American women, Hispanic women who have immigrated to the 
United States, and American Indian and Alaska Native women are at 
greatest risk for maternal mortality. CDC statistics note that African 
American women are four times as likely to die of pregnancy 
complications compared with white women, and American Indian and Alaska 
Native women are nearly twice as likely to die. In a 14-year national 
study of pregnancy-related deaths in the United States, CDC found that 
the pregnancy-related mortality ratio for African American women was 
25.1 deaths per 100,000 live births, and Hispanic women was 10.3 deaths 
per 100,000 live births, versus 6.0 per 100,000 deaths for non-Hispanic 
white women. Poverty and lack of insurance certainly play a significant 
role in these alarming statistics.
    The Administration is right to target prenatal coverage to reduce 
these figures. For many women, especially minority women, however, 
complications also arise after giving birth. And the truth is, 
postpartum women without health insurance are more likely to go without 
care because of economic priorities. The other truth is, sick women who 
recently delivered are less able to care for their babies. In this way, 
a lack of postpartum care harms mothers and their newborns. The 
regulation's omission for postpartum coverage will disproportionately 
affect the very women that need the most help and who experience the 
highest rate of maternal morbidity and mortality.
    As we have stated before, prenatal and intrapartum services are 
essential. It is inconceivable that there are diseases that affect the 
mother principally and that have no overall affect on the fetus. 
Diseases such as diabetes and hypertension clearly have defined fetal 
effects. Maternal obesity, which requires nutrition counseling, 
behavioral interventions, and anesthesia consultation is not a health 
condition limited to the mother. Another patient of mine at 32 weeks 
pregnant arrived in the emergency room clutching her head with pain and 
developed confusion over time. A CT scan revealed a large brain tumor. 
Yes, this is a maternal condition but you can imagine that the effects 
of neurosurgery and postoperative pain management all had an impact on 
her developing fetus.
                        implementation concerns
    Finally, ACOG also has several concerns about the implementation of 
the Administration's regulation and the impact it will have on ob-gyn 
practices. Already, the health care system prevents physicians from 
spending needed time with patients. Skyrocketing medical liability 
premiums, onerous regulatory paperwork, and continued Medicare payment 
cuts make everyday practice an endeavor for most physicians. This 
regulation will create even more bureaucracy and red tape for 
physicians.
    As in the last example, figuring out which components of a 
patient's care would be covered by such restrictive services would be 
an impossible task. Because this regulation limits coverage to services 
directly related to the health of the fetus, ob-gyns will be unsure 
whether medically necessary care will be covered. In most cases, 
physicians will simply provide the care and worry after the fact about 
coverage issues, knowing that a tremendous amount of staff time and 
effort will be expended to recover even some payment. Furthermore, 
pregnant women may wonder if they even have the ability to access 
coverage for non-obstetric conditions or injuries, and decide to simply 
not seek any treatment. This uncertainty about coverage will discourage 
physicians from participating and deter women from seeking appropriate, 
necessary care.
                              enact s. 724
    I urge the Senate to quickly pass S. 724 and encourage the 
Administration to support enactment of this bill to expand coverage to 
uninsured pregnant women ensuring access to comprehensive prenatal and 
postpartum coverage. The recently issued regulation, while misdirected 
in its approach, creates a policy foundation that makes prenatal care 
and healthy babies a priority. We urge Congress to take the next step 
and pass S. 724, assuring women's health and their babies healthy 
lives.
               Prepared Statement of Cristina Beato, M.D.
    Mr. Chairman and Senator Gregg, I want to thank you for accepting 
our request to include a statement for the record. The Secretary has 
asked that I serve as the Administration's witness at hearings covering 
women's health issues of this nature, and the following is my prepared 
statement.
    I would also like to take this opportunity to recognize the members 
of the Senate Health, Education, Labor and Pensions Committee for their 
continued interest in addressing the needs of low-income pregnant women 
and their children. Like their colleagues on the Finance Committee, 
they have demonstrated a clear concern that women and children receive 
the best this country can offer in the way of health care, and we think 
they should be commended for that.
    As Congress and this committee seek input and explore ways to 
address the lack of insurance for many pregnant women, I want to re-
emphasize HHS' commitment to implement policies that will provide more 
women coverage for a healthy pregnancy and safe delivery. The health of 
pregnant women and a healthy start for their children is certainly a 
goal we all share and that we are all working toward in our respective 
roles in government. I want to give some examples of some of the 
avenues we are exploring through administrative authority.
    Current law gives HHS the authority to provide prenatal and 
delivery care to many low-income pregnant mothers and their unborn 
children. The Secretary has exercised that authority and, after 
conducting a thorough regulatory process, including a public comment 
period, a final rule has been published that will allow states to 
extend S-CHIP coverage to unborn children and their mothers. The rule 
will ensure that pregnant women and children who are currently 
ineligible for health care under either Medicaid or S-CHIP are given 
the support they need for a healthy pregnancy and delivery. All 
children deserve a healthy start in life, and this rule is one more 
option states have to fulfill that promise to low-income mothers and 
babies.
    Under the regulation, we are able to reach a broad population of 
vulnerable women and children because we can offer coverage to the 
children of immigrants who are otherwise ineligible for any coverage. 
The legislative proposal S. 724 would not reach this broader population 
of low-income women and children.
    A point of consistency across the legislative proposals and the 
Administration policy is that the benefits, and hence services covered, 
(prenatal and pregnancy related services) are the same, excluding 
postpartum care after hospitalization. While eligibility for these 
benefits extends through the child rather than the mother under the 
rule, the benefits and services covered remain the same. The concern 
that mothers would not receive care while still hospitalized 
immediately following delivery is addressed in the published rule's 
comment and response section, and has again been addressed in 
correspondence with Congress and in discussions with key stakeholders 
in the effort to improve the health of mothers and children.
    The regulation also affords states the opportunity to access 
enhanced-match funds without conditioning this access on any 
eligibility expansions at the regular match rate. Again, the pending 
legislative proposals would condition access to enhanced-match funds 
for some states. And, since states already have the option to raise 
eligibility at their regular match rate and have not chosen to do so, 
we believe the regulation provides them the opportunity to cover more 
low-income pregnant women.
    In fact, President Bush's fiscal year 2003 budget proposed to 
strengthen the SCHIP program by making available to states unused SCHIP 
funds that otherwise would return to the federal treasury. The SCHIP 
law originally required that states that did not use their full SCHIP 
allotment during the previous three years return the unused funds. 
Under the President's plan, these unused funds would be made available 
for states nationwide to expand coverage to the uninsured, especially 
those at the lowest end of the income scale. Congress can be a partner 
in this initiative by enacting at least this component of the 
Administration's budget.
    Adopting the President's proposal on unused SCHIP funds would not 
only complement this new rule, but many of the other initiatives in the 
Administration's larger effort to give mothers and children a healthy 
start and help those who cannot afford health insurance get the health 
care that they need. Already, the Administration has made unprecedented 
strides in assisting states to expand health care services.
    Since January 2001, HHS has approved waivers and plan amendments 
that have expanded eligibility to more than 2 million people and 
enhanced services for 6 million Americans. In August 2001, Secretary 
Thompson launched the Health Insurance Flexibility and Accountability 
(HIFA) Initiative to encourage states to expand access to health care 
coverage for low-income individuals through Medicaid and SCHIP 
demonstrations. The initiative gives states more flexibility to 
coordinate these companion programs and offers simplified applications 
for states that commit to reducing the number of people without health 
insurance. Seven states have approved HIFA waivers: New Mexico, 
California, Arizona, Maine, Illinois, Colorado and Oregon.
    For example, New Mexico's HIFA demonstration will cover uninsured 
parents of Medicaid and SCHIP children, as well as childless adults, in 
partnership with employers in the State. Up to 40,000 currently 
uninsured individuals may be covered under the demonstration with a 
projected implementation date of February 2003. This waiver includes 
coverage for prenatal care, labor and delivery and postpartum care. 
California's HIFA waiver will cover up to 275,000 parents, relative 
caretakers and legal guardians. Arizona expects to expand coverage for 
up to 48,000, and Illinois expects 300,000 additional parents will be 
covered. Colorado's HIFA demonstration expands coverage to 13,000 
uninsured pregnant women. In addition, through the Administration's 
Pharmacy Plus Model Waiver Initiative, states are able to expand drug 
coverage to low-income seniors and people with disabilities. Five 
Pharmacy Plus waivers Florida, Illinois, Maryland, South Carolina and 
Wisconsin have been approved so far.
    Again, while waivers often result in the expansion of coverage for 
health benefits and services, the Administration also has programs that 
help communities provide health services to low-income women directly, 
including prenatal and pregnancy related care. Most of these services 
are administered by the Health Resources and Services Administration 
(HRSA) and, in particular, the Maternal and Child Health Bureau (MCHB). 
Programs supported through Title V of the Social Security Act (the MCH 
Block Grant) provide gap-filling prenatal health services to more than 
2 million women each year.
    In addition, in FY2001, the Healthy Start program funded 106 grants 
to communities with a total of $90 million to improve perinatal health 
and improve prenatal care among at-risk populations. In FY2002, Healthy 
Start was able to extend services further by funding an additional 12 
sites in high-risk communities, expanding outreach, case-management, 
and preventive health services.
    The MCHB has also begun new programs focusing on reducing risk 
factors for adverse outcomes during pregnancy, especially among 
vulnerable women. This includes screening for tobacco use, domestic 
violence, alcohol use, depression, and substance abuse then referring 
as needed.
    HRSA-supported Community Health Centers serve more than 3 million 
women of childbearing age and provide primary care services, including 
prenatal, delivery, and postpartum care, for low-income women who are 
likely to lack access to health insurance or other sources of care. 
Funding for Community Health Centers has been increased substantially 
under a five-year expansion plan initiated by President Bush.
    I hope this brief overview highlighting just some of the 
initiatives this Administration has implemented and supported provides 
a more comprehensive view of our commitment to improving the health of 
low-income women and children. I believe that while undertaking a 
balanced dialogue and delving into the substance of both the problems 
that result when women and children lack access to health care and 
current and proposed solutions, we should never lose sight of our 
shared goal. On behalf of HHS, I hope that we can work together with 
the many organizations that share our vision of a healthier beginning 
for children to encourage states to expand coverage under SCHIP to 
unborn children and their mothers.
    There is still work to be done to meet our universal goal of giving 
children a healthy start in life, and we look forward to continued 
collaboration with Congress.
                  Prepared Statement of Lisa Bernstein
    Mr. Chairman, members of the committee, I am honored to come before 
you today to urge passage of S.724, the ``Mothers and Newborns Health 
Insurance Act of 2001.''
    First, I would like to tell you how I have come to be here and a 
bit about why The What To Expect Foundation was formed.
    The What To Expect Foundation takes its name from the bestselling 
What To Expect pregnancy and parenting series that was written by the 
Foundation's president, Heidi Murkoff and her mother, the late Arlene 
Eisenberg.
    This series of books has helped over 20 million families from 
pregnancy through their child's toddler years. What To Expect When 
You're Expecting is often referred to as ``America's Pregnancy Bible.'' 
According to a USA TODAY poll it is read by 93% of all mothers that buy 
a pregnancy guide the What To Expect series of books are not only the 
three bestselling parenting books in the country--they are among the 
bestselling books in the country on any topic This week What To Expect 
When You're Expecting is #3 on the New York Times bestseller list.
    But I'm sorry to say, as many parents as the What To Expect books 
have helped, they've missed many more. As you know, our nation's infant 
mortality rate is higher than 28 other countries; we're right behind 
Cuba. And even if a mother could afford to buy a prenatal guide she 
might not be able to read it. The literacy rate in the United States is 
a continuing problem. Today 21% to 23% of adults--or some 40 to 44 
million people across the country read at less than a fifth grade 
level.
    Thus the birth of The What To Expect Foundation a non-profit 
organization dedicated to helping mothers in-need receive prenatal 
health and literacy education so they too can expect healthy 
pregnancies, safe deliveries and--can read to their babies.
    The BABY BASICS program provides prenatal education that takes into 
account the special health, economic, social and cultural needs of low-
income women and gives prenatal providers culturally appropriate health 
literacy tools and support.
    By 2003 we will have provided over 200,000 women with the BABY 
BASICS program in English and Spanish we are now building model BABY 
BASICS health literacy sites at clinics across the country.
    While researching the BABY BASICS book and program I had the 
opportunity to speak to hundreds of pregnant, low-income women, and the 
doctors, midwives, nurses, outreach workers, educators and social 
workers that care for them.
    From across the country I heard the pregnancy stories of our 
country's poorest women some were stories about swollen feet, 
indigestion, back pain. Others were about hopes and fears that cut 
across income and education--will I be a good mother, will I know how 
to hold a child? Will I be able to provide for my baby?
    But too many of these stories broke my heart. Teens who were 
pregnant because they wanted someone to love and to love them, women, 
pregnant with no health insurance, who work long days for little 
income, and had to take off unpaid time to sit in a hard chair for 
hours waiting for an unscheduled 5 minute free appointment at a crowded 
clinic. Women who saw a doctor for the first time the day their water 
broke- because they could not afford care.
    Secretary Thompson did an important thing and is to be 
congratulated when he realized that many pregnant women could not 
afford prenatal care. One look at the infant mortality rate, and he 
looked for ways to fix it. He also realized that SCHP a dramatically 
successful program for families had the funds and the ability to reach 
out to help in our constant battle against infant and maternal 
mortality. And I applaud him for finding a stop-gap measure that was 
within his domain to help states provide pre-natal care quickly and 
efficiently by extending the care to the fetus with an implicit 
understanding that this was a quick-fix, one that would be remedied by 
legislation.
    Now, frankly, I'm confused. In his recent letters to you, Senators, 
he seems to have changed his mind, saying such legislation is no longer 
needed. His quick fix is enough.
    But the quick fix put forward by the administration is not really a 
fix at all. Because now we've created even more problems after we're 
spent so much time and money promoting pre-natal care we've gone and 
created an entirely new funded medical program--called ``fetal care''.
    Because ``fetal care'' and ``prenatal care'' are not the same 
thing. Please, let me tell you why.
    Pre-natal care is about dignity. Fetal care is about shame.
    This September, Secretary Thompson, Senator Kennedy, and Senator 
Hatch, along with our Foundation's president, Heidi Murkoff, spoke at 
Robert Wood Johnson's Covering Kids celebration, that honored SCHP's 
5th anniversary. Mothers and fathers explained how Child Health Plus 
helped their family. These were working families, with two jobs, 
working double-shifts to keep their families afloat.
    One family, suddenly unemployed, had no idea how they were going to 
pay for their daughter's continuing diabetes care until they found 
SCHP. Another hard working mother spoke about SCHP paying for surgery 
that saved her boy's life.
    These parents were heroes to their children, and to the audience. 
With the help of SCHP they had provided for their families. Because 
SCHP has been carefully crafted, marketed and promoted as help for 
working families and children these parents were able to retain their 
dignity, and were proud of their ability, as parents, to provide the 
health care their child needed, when they needed it.
    Just as offering pre-natal care to a woman can help her afford to 
do the best for her unborn child. Its friendly help, that is offered 
with dignity and can be accepted with pride.
    Offering ``fetal care'' is a slap in the face. This new regulation 
makes clear that fetal care is about the fetus first. ``Extras'' like 
epidurals and pain medication will only be available if a case can be 
made that they are for the health of the fetus. Fetal care offers the 
mother no dignity, devaluing her life which she risks by sharing her 
body with the unborn child.
    Pre-natal care acknowledges that there are two things that grow 
when a woman becomes pregnant. First, of course, there's the fetus, 
growing to become a healthy baby. And second, and no less importantly, 
there's the woman who also must grow she must grow to think of herself 
as a mother a parent, a provider. Inextricably linked in a dance as old 
as creation mother and child grow together--both nurtured with love and 
care.
    ``Fetal care'' unbinds those ties--breaks those bonds. It's about 
the government choosing fetuses over women, providing the fetus will 
all of its health care needs while saying to the woman we can't help 
you.
    Pre-natal care provides a woman with the comprehensive health 
coverage she needs to have a baby. It cares for her body and her 
health. It helps her stay strong so she can be strong as a mother. It 
provides for her needs before and after the delivery, and gives her the 
chance to recover so she has the strength and the health to nurse her 
precious new bundle.
    ``Fetal care'' tells mothers that once they've had the baby they're 
on their own. Like Cinderella after the ball, once the baby is 
delivered, no more fairy godmother. Suddenly her health care is gone. 
No glass slipper. Even her 48 hours guaranteed hospital stay is out of 
the picture.
    Pre-natal care is about family values. It helps create parents. It 
does what Early Head Start, Head Start, Healthy Start and Even Start do 
so well it gives parents the strong shoulders they need to make sure no 
child is left behind. It fosters optimism.
    ``Fetal care'' throws the parent out with the bathwater. It fosters 
pessimism, and an early pervading sense of failure. From the start it 
fails to acknowledge that a parent is a child's first and best teacher. 
To me, ``fetal care'' fosters foster-care.
    Pre-natal care fills hospital wards with healthy babies.
    Fetal care fills hospitals with wards of the state.
    Senators, so many good things can happen when a women gets proper, 
comprehensive pre-natal care. As you've heard, The What To Expect 
Foundation links prenatal care to literacy training. So women learn how 
to read, and learn how to read to their babies. Healthy Start and other 
programs across the country are linking prenatal care to all kinds of 
positive, self-esteem building social programs. Parenting skills, job 
training, long-term housing planning, financial planning.
    We have trouble getting women into pre-natal care why would we ever 
want to put up any barriers to pre-natal care? Secretary Thompson has 
done an honorable thing by opening the door to pre-natal care for 
thousands of women each year. But imaginary barriers, liberal barriers, 
conservative barriers, unintended barriers? No matter what we want to 
call these barriers regardless of their politics or their intent, they 
are unnecessary barriers to care. I'm here to tell you that hundreds of 
providers, practically every doctor, midwife and nurse across the 
country agrees that this fetal care quick-fix must not stand as a 
barrier. And every mother including this mother and the mothers who 
have told millions of mothers across the country What To Expect agree--
Our job is to knock down the barriers. Passing S724 will remove those 
barriers.
    And then we can roll up our sleeves and get back to work. Because 
only a healthy parent can provide a healthy future for a healthy child.
                  Prepared Statement of Kate Michelman
    NARAL applauds the Committee for holding this hearing to highlight 
the current lack of adequate health-care coverage for pregnant women 
and children, and explore potential solutions.
    NARAL's mission is to guarantee every woman the right to make 
personal decisions regarding the full range of reproductive choices, 
including preventing unintended pregnancy, bearing healthy children, 
and choosing legal abortion. NARAL has 26 affiliates nationwide and 
nearly 300,000 members and supporters. On behalf of our membership and 
pro-choice Americans, NARAL submits this testimony to: (1) illuminate 
what is at stake for reproductive rights by making embryos, not women, 
beneficiaries of governmental health care programs and provide context 
illustrating the dangers inherent in the Administration's chosen 
course; and (2) advocate for greater coverage of pregnant women under 
SCHIP's existing framework or new legislation such as that sponsored by 
Senator Bingaman.
    The Stakes and The Context. A woman's right to choose is in peril, 
jeopardized by a fragile consensus on the part of the Supreme Court in 
favor of legal abortion and an Administration determined to make use of 
every power at its disposal to roll back women's reproductive freedom.
    Up to now, the Bush Administration has been pursuing an incremental 
campaign to denigrate and restrict a woman's right to choose. We have 
seen the nomination of anti-choice judges for the federal district and 
appellate courts, support for anti-choice legislation such as the Child 
Custody Protection Act and the Unborn Victims of Violence Act, 
Executive Orders attacking the reproductive rights of women around the 
world, appointment of anti-choice officials to key cabinet and sub-
cabinet positions, statements of support for groups seeking the 
overturn of Roe v. Wade, and the filing of a legal brief supporting 
restrictions on a woman's freedom to choose. Dr. W. David Hager, 
strongly credentialed in anti-choice activism, is the rumored favorite 
to head the Food and Drug Administration's Reproductive Health Drugs 
Advisory Committee. Health agencies from the Centers for Disease 
Control and Prevention to the National Institutes of Health have begun 
censoring their websites for material offensive to the ideology of the 
hard right that is, material disproving anti-choice propaganda about 
abortion, sex education, sexually transmitted diseases, and HIV 
prevention.
    Against this backdrop, this month the Administration took a 
significant step towards its ultimate goal of making abortion illegal. 
On October 3, 2002, the Bush Administration published a final rule that 
would actually designate embryos and fetuses as ``children'' eligible 
for medical benefits independent of the pregnant woman under the State 
Children's Health Insurance Program (SCHIP) (42 C.F.R. 457 (2002)). 
Under the joint federal/state SCHIP program, states provide health care 
to low-income children who are not covered by the Medicaid program. The 
Administration took this unorthodox course, notwithstanding the fact 
that both SCHIP and Medicaid law allow states to cover more pregnant 
women than would otherwise be eligible under the state's income limits 
to ensure quality prenatal care.
    Although the rule on its face does not change the status of legal 
abortion, any challenge to Roe v. Wade that reaches the Supreme Court 
will surely contend that an evolving legal trend recognizes fetuses as 
persons. In support of this contention, opponents of Roe will point to 
state legislation recognizing embryos and fetuses as persons in a 
variety of circumstances, and this new SCHIP rule will be an essential 
piece of evidence for their argument. The Administration's interim 
strategy to prepare the way for a challenge to Roe is underway. To 
protect the foundation of Roe v. Wade, NARAL thus opposes this rule 
that distinguishes the embryo's or fetus' interests from those of the 
pregnant woman.
    In a more immediate sense, the new rule could actually do harm to 
women by pitting them against the program's ``patients'' the embryos. 
Under this regulation, would a pregnant woman with cancer be able to 
access potentially life-saving radiation treatment or chemotherapy, 
since such treatment could harm the embryo? The effects of many 
prescription drugs on pregnancies have not been studied; under this 
rule, a woman's treatment for any variety of medical conditions might 
be denied, in favor of the embryo or fetus. If a woman were carrying an 
embryo or fetus covered under this new proposal and she had a 
miscarriage, there would no longer be a ``beneficiary'' for the SCHIP 
program. Would the government then refuse to pay for her follow-up 
care?
    It is commonly understood as a matter of public health that healthy 
women tend to have healthier babies, and as a legal matter that the 
woman should make all decisions relating to her pregnancy. The rule 
imposes a new paradigm separating the woman from her pregnancy, and 
allowing a government health care program to work on behalf of the 
fetus, without any reference to the woman herself. That is, the new 
rule would not provide care for the woman only care for the fetus. A 
woman's pre-existing conditions, such as diabetes or asthma, could 
apparently only be treated if and to the extent that such treatment 
would benefit the fetus. Doctors might well face confusion about basic 
preventive or maintenance care for the woman would her medical 
conditions only be covered when they worsened so as to jeopardize the 
pregnancy? As a practical matter, then, this rule is either unworkable 
or unethical, in setting up potential conflicts between the woman's 
interests and fetal interests.
    In an unexpected move, the Administration's rule also allows the 
embryos and fetuses of immigrant pregnant women to be covered under 
SCHIP. This creates a strange dichotomy because under current law, 
legal immigrants cannot receive Medicaid or SCHIP benefits until they 
have been in the country for five years. (Illegal immigrants do not 
qualify at all.) As a legal matter, the regulation treats immigrant 
pregnant women as if their embryos and fetuses were already born here 
as citizens and were thus entitled to the full benefits of citizenry. 
As a practical effect of this expanded concept of citizenship, the 
three year-old daughter of a recently immigrated pregnant woman cannot 
receive publicly funded health care, but the woman's fetus can. This 
illustrates that the true nature of this rule is not to deliver health 
care to children who need it for the three year old surely needs care 
but to grant fetuses special legal rights.
    In sum, the Administration's failure to address the many practical 
problems with implementing this rule problems NARAL identified in our 
comments opposing the proposed rule indicates that its SCHIP regulation 
is not serious health-care policy; instead, it is a political statement 
and a legal stratagem.
    An alternative vision. NARAL has long supported initiatives to 
provide prenatal care for pregnant women; indeed, the millions of 
uninsured deserve comprehensive health care. Women planning pregnancy 
and the children they bear benefit immensely from high-quality care, 
and conversely, the chronic lack of access to a continuum of services 
for low-income women jeopardizes the promise of healthy pregnancies and 
healthy childbearing.
    For many months, the Administration tried to play expanded health 
care coverage both ways: it said it supported legislation expanding 
SCHIP eligibility, while at the same time issuing the proposed (now 
final) rule making embryos and fetuses federal health care 
beneficiaries. The other shoe has now dropped. The Administration's 
recent reversal, announcing that it no longer supports legislation 
expanding SCHIP to cover pregnant women, must be met with determined 
Congressional opposition. The Administration's about-face reveals that 
its real goal is a legal and political one endowing fetuses with legal 
rights and shoring up its ideological base rather than a substantive 
policy goal. Moreover, as a matter of separation of powers and the 
proper allocation of governmental responsibilities, the regulation is a 
significant policy change, one that should be overridden by Congress.
    NARAL urges Congress to enact legislation allowing states to expand 
their SCHIP programs to pregnant women, which would effectively nullify 
the regulation. The best way to assure healthy pregnancies and healthy 
childbearing is to provide dependable, quality care for pregnant women, 
and NARAL commends Senator Bingaman and others for their efforts in 
this connection and continues to urge Congress' passage of legislation 
that does so.
    Congress must set the legal and political record straight: pregnant 
women deserve health care coverage. Governmental agencies entrusted to 
protect the public health cannot be misused as vehicles for advancing 
an anti-choice political agenda to the detriment of Americans' health.
                 Prepared Statement of Priscilla Smith
    The Center for Reproductive Law and Policy (CRLP) commends the 
Committee for underscoring the rights of pregnant women to safe 
pregnancy through this hearing and through the ``Mothers and Newborns 
Health Insurance Act'' (S. 724). CRLP is a non-profit legal advocacy 
organization dedicated to protecting and defending women's reproductive 
rights, including the rights of pregnant women to safe pregnancy. CRLP 
submits this testimony to support efforts to expand access to 
pregnancy-related care through legislation such as the ``Mothers and 
Newborns Health Insurance Act.'' This bill not only addresses a 
significant gap in our nation's healthcare system, but also mitigates 
the negative effects of misguided amendments to the State Children's 
Health Insurance Program (SCHIP) recently adopted by the Department of 
Health and Human Services.
     i. ``mothers and newborns health insurance act'' addresses a 
                       significant healthcare gap
    Currently, the United States ranks twenty-first in the world in 
rates of maternal mortality and twenty-eighth in the world in rates of 
infant mortality. It is estimated that every week, 8,500 children in 
the United States are born to mothers who lack access to prenatal care. 
Furthermore, it is likely that half of all maternal deaths in the 
United States could be prevented through early diagnosis and 
appropriate medical treatment of pregnancy complications. This is 
shocking given the availability of unsurpassed medical care and 
technology in the United States and widespread knowledge of the 
importance of early and ongoing prenatal care to help ensure a healthy 
pregnancy and optimal birth outcome.
    A primary barrier to timely prenatal care, and thus to improving 
the health of pregnant women and newborns in the United States, is a 
lack of health insurance coverage. Despite the Medicaid expansions 
implemented in the late 1980s and early 1990s, recently released 
figures from the March of Dimes indicated that nearly one in five women 
of childbearing age (ages 15-44 years) in the United States were still 
uninsured in 1999. See Kenneth E. Thorpe et al., The Distribution of 
Health Insurance Coverage Among Pregnant Women, 1999, prepared for the 
March of Dimes (Apr. 2001), available at http://www.modimes.org/files/
2001FinalThorpeReport.pdf (last visited Apr. 16, 2002). Thus, further 
expansions are necessary to reach the uninsured.
    Moreover, as this Committee and the Administration have recognized, 
there is a troubling disparity in access to prenatal care between white 
women and minority women. Rates of maternal mortality and morbidity and 
infant mortality which are highest among non-white populations reflect 
this disparity. While research suggests that racial and ethnic 
inequalities in medical treatment would persist in some measure even if 
access to health insurance were equalized, see Key Facts: Race, 
Ethnicity, and Medical Care, The Henry J. Kaiser Family Foundation 
(October 1999), it also appears that increased access to health 
insurance coverage would reduce these disparities based on race and 
ethnicity. Id.
    Therefore, increasing access to health insurance coverage for 
pregnant women is vital for two reasons. First, insuring access to 
early and ongoing pregnancy-related care for women in all ethnic and 
racial groups must be the first step in any efforts to reduce overall 
rates of maternal mortality and morbidity, and to erase the disparity 
between the quality of care received by women of color and white women. 
Second, increased access to prenatal care will improve the health of 
newborns throughout the country and similarly work to erase disparities 
in infant mortality rates between racial and ethnic groups.
    The ``Mothers and Newborns Health Insurance Act'' serves these 
goals by increasing access to insurance coverage. The legislation 
provides insurance coverage for prenatal care, delivery and post-partum 
care to targeted, low-income pregnant women. The legislation also 
provides coverage for newborns for their first year of life. Through 
these provisions, S. 724 ensures better birth outcomes and healthier 
mothers and children.
 ii. the ``mothers and newborns health insurance act'' is far superior 
                to the new schip regulation amendments.
    Unlike S. 724, the recent amendments to the State Children's Health 
Insurance Program (SCHIP), promulgated by the Department of Health and 
Human Services (HHS), fail to adequately address the overwhelming need 
for healthcare coverage for pregnant women. Instead of extending 
benefits to pregnant women, the new regulation classifies the fetus as 
an ``unborn child'' and expands coverage to ``an individual in the 
period between conception and birth up to age 19.'' 67 FR 61956-01 
(Oct. 2, 2002). It is greatly disturbing that HHS has promoted 
amendments to the SCHIP regulations to extend the plan to cover 
fetuses, while patently ignoring the health needs of pregnant women. 
This new policy is fraught with legal and practical problems:
    The regulation could place the health of pregnant women at risk and 
threatens a woman's integral right to control her own healthcare.
    By defining a fetus as a ``child'' from the moment of conception 
for purposes of SCHIP, the regulation is in clear tension with 
fundamental principles of constitutional law.
    Low-income pregnant women deserve actual, not merely incidental, 
health insurance coverage that covers all of their pregnancy-related 
needs.
    There are superior means of ensuring prenatal care for women whose 
incomes fall within the SCHIP-eligibility criteria in their state, such 
as the ``Mothers and Newborns Health Insurance Act.''
    CRLP has significant concerns with the new amendments, as outlined 
below. CRLP urges Congress to enact the ``Mothers and Newborns Health 
Insurance Act'' to address and remedy the significant gaps left by the 
SCHIP program.
A. By Covering the Zygote, Embryo or Fetus and Not the Woman Herself, 
        the Regulation Could Place the Health of Pregnant Women at 
        Risk.
    Although the Administration claims that the goal of the new 
regulation is to provide for comprehensive prenatal care in order to 
improve the pregnant woman's health, the mechanism chosen could 
actually place the woman herself at risk. The regulation does not 
provide any insurance coverage for pregnant women in the post-partum 
period, nor does it provide for comprehensive care for pregnant women 
during either pregnancy, or labor and delivery.
    First, the standard of care for pregnant women requires continuity 
of medical treatment from prenatal care through post-partum care. The 
American College of Obstetricians and Gynecologists (ACOG) and the 
American Academy of Pediatrics (AAP) recommend that the physical and 
psychosocial status of the mother be assessed on an ongoing basis 
following hospital discharge. They further recommend that four to six 
weeks after delivery the mother should receive a post-partum review and 
examination. American Academy of Pediatrics & American College of 
Obstetricians and Gynecologists, Guidelines for Perinatal Care (4th ed. 
1997).
    Unfortunately, the regulation does not allow states to provide 
SCHIP coverage to pregnant women for any post-partum care. This is 
because under the regulation, SCHIP would cover only the ``child'' in 
utero, not the pregnant woman. While the pregnant woman would 
incidentally receive some covered care as a result of carrying the 
``child'' within her uterus, that covered care would be available only 
during ``the period from conception to birth.'' The moment after the 
birth of her child, a woman who may have been covered for any 
incidental care as a result of having an SCHIP-covered fetus in utero, 
would appear to lose insurance coverage. The woman would therefore not 
be eligible for any covered care during the post-partum period, 
including for the post-delivery hospital stay, care for her incision 
received during a Cesarean section delivery, for an episiotomy or any 
other post-delivery complications. This result flies in the face of 
sound medical and public health policy, not to mention the regulation's 
stated goals.
    In contrast, S. 724 provides coverage to pregnant women for post-
partum care, thus remedying this troubling omission.
    Second, by insuring only the fetus, it is unclear whether the 
regulation authorizes insurance coverage for pregnant women for medical 
treatments that do not have a direct impact on the well-being of the 
fetus. Thus, for example, if an epidural is needed during delivery, 
would that be covered even though it would benefit only the woman, and 
not the fetus? If the woman broke her leg during the pregnancy, would 
treatment be covered? And, since eligibility for benefits only exists 
in relation to a living fetus, it is unclear whether any benefits would 
be available to the mother for complications following a miscarriage 
technically, since the beneficiary is no longer alive, such benefits 
would not be available. While we agree with the statement made by 
Secretary Thompson regarding the importance of prenatal services as ``a 
vital, life-long determinant of health'' for the fetus, HHS to Allow 
States to Provide SCHIP Coverage for Prenatal Care, HHS News Release, 
January 31, 2002, we believe that ensuring meaningful health benefits 
for the pregnant woman is an equally important goal, and one that this 
regulation fails to meet but that S. 724 directly addresses.
    Third, targeting coverage to the fetus also appears to create 
serious conflicts over health care decision making, all of which 
threaten a woman's integral right to control her own healthcare. It is 
unclear under the regulation how the interests of the fetus and the 
pregnant woman should be balanced when their health care needs diverge, 
or where treatments needed by the pregnant woman could actually be 
harmful to the fetus. For example, a woman with mental illness may 
require medications, such as lithium, that are contraindicated for the 
fetus. See, e.g., Jennifer R. Niebyl, M.D., Drugs in Pregnancy and 
Lactation, in Steven G. Gabbe, M.D., Jennifer R. Niebyl, M.D., Joe 
Leigh Simpson, M.D., eds., Obstetrics: Normal and Problem Pregnancies 
at 249, 255 (3d ed. 1996). Similarly, a woman diagnosed with breast 
cancer may not be covered for radiation treatments needed to save her 
life. Would the treatments in these cases be covered? Could the state 
intervene on behalf of the fetus? What would happen if the life-saving 
treatment was for the fetus, but it endangered the mother could the 
mother be compelled to undergo the treatment? Who would decide these 
types of coverage questions the state, the federal government, the 
doctor, or the pregnant woman herself? Could the state or the other 
parent's health care decisions trump the pregnant woman's, even where 
her own health could be adversely affected? These are all troubling 
questions that are raised by the regulation but that would not be 
implicated by S. 724 since the legislation recognizes the pregnant 
woman's right to healthcare.
B. This Regulation Seeks to Chip Away at Fundamental Principles of 
        Constitutional Law.
    By defining a fetus as a ``child'' from the moment of conception 
for purposes of SCHIP, the regulation is in clear tension with 
fundamental principles of constitutional law. The Supreme Court clearly 
stated in Roe v. Wade that ``[T]he word `person,' as used in the 
Fourteenth Amendment, does not include the unborn,'' 410 U.S. 113,158 
(1973). The Administration's impractical attempt to force the 
definition of a child to include a fetus results in bizarre outcomes 
and administrative confusion, revealing the Administration's true goal 
of chipping away at fundamental rights. For instance, under current 
law, states track eligibility for public benefits using Social Security 
numbers, which all Americans receive when they are born. Since fetuses 
are not eligible for Social Security numbers, it is unclear how states 
will track their eligibility for benefits until they are born. Will 
they create a whole new individual identifier just for fetuses? There 
will be further implications for tax rules as well. Generally, an 
American citizen is only counted for taxation purposes after they are 
born. Does the granting of legal personhood under the regulation mean 
that fetuses could be taxed inside the womb? Alternatively, could they 
be claimed as a deduction before they are born? These examples 
demonstrate the irrationality of this policy and the confusing results 
it would generate.
    Other Supreme Court cases, such as Planned Parenthood of 
Southeastern Pennsylvania v. Casey, 505 U.S. 833 (1992) and Stenberg v. 
Carhart, 530 U.S. 914 (2000) have emphasized the importance of 
protecting women's health in the face of laws restricting access to 
abortion. Because the regulation elevates the fetus' health to the 
potential detriment of the woman's health, this conflict places the 
regulation in further tension with Supreme Court precedent by 
potentially jeopardizing the woman's health.
    The regulation indicates that the Administration cares more about 
promoting the ``rights'' of a fertilized egg with an eye to building 
the legal foundation to overturn the Supreme Court decision in Roe v. 
Wade, than it does about women's health. The best way to improve 
women's health is to recognize their right and ability to make private, 
medical decisions about their own bodies.
C. The Regulation Denigrates Women Without Achieving Its Purported 
        Goal.
    Low-income pregnant women deserve actual, not merely incidental, 
health insurance coverage that covers all of their pregnancy-related 
needs, including those that extend into the critical post-partum 
period. By providing insurance for the fertilized egg or fetus, but not 
for the woman herself, this regulation denigrates women treating them 
as mere vessels for a fetus, undeserving of health care in their own 
right. Given the superiority of these alternative means of achieving 
improved birth outcomes (see below), the Administration's decision to 
promulgate the regulation--and inexplicably withdraw support for other 
measures--must be seen as a political gambit, unrelated to improved 
pregnancy-related care. It can only be seen as an ideologically-based 
attempt to redefine a fetus as a ``person,'' in conflict with the 
Supreme Court's ruling in Roe v. Wade, 410 U.S. 113 (1973) without 
regard to whether health care coverage is actually increased.
D. There Are Superior Means of Ensuring Prenatal Care for Women Whose 
        Incomes Fall Within the SCHIP-Eligibility Criteria in Their 
        State, Including the ``Mothers and Newborns Health Insurance 
        Act.''
    The regulation is all the more unacceptable because it is not 
necessary to ensure prenatal care for women whose incomes fall within 
the SCHIP-eligibility criteria in their state. There are at least two 
superior means of achieving this goal: 1) the ``Mothers and Newborns 
Health Insurance Act,'' which has been proposed with bipartisan support 
to expand SCHIP to include pregnant women; and, 2) until federal 
legislation is in place, a streamlined process for obtaining Sec. 1115 
waivers to add pregnant women to a state's SCHIP program (as New Jersey 
and Rhode Island have done).
    CRLP supports the regulation's stated goal of expanding access to 
early and regular prenatal care in order to ensure the health of both 
pregnant women and newborns, but questions SCHIPS' approach of allowing 
health insurance coverage for a zygote, embryo and fetus in utero. 
Because there are other less controversial and more effective ways of 
achieving the stated goal, the Administration's choice of this strategy 
is curious at best.
                             v. conclusion
    It now falls to Congress to stand up for the healthcare needs of 
pregnant women through the ``Mothers and Newborns Health Insurance 
Act.'' CRLP urges the Senate to quickly enact this legislation to 
expand healthcare coverage to uninsured pregnant women. Once enacted, 
this legislation would allow states to go beyond the current framework 
of the SCHIP program and provide insurance to pregnant women in 
addition to their children.
    Thank you.

    [Whereupon, at 11:47 a.m., the subcommittee was adjourned.]

                                    

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