State Legislation Update
Momentum continues to build as more states include the US MERA agreements and principles in bills to license Certified Professional Midwives, helping to overcome opposition to the regulation of CPMs that has stymied efforts, often for years and at times even decades. In addition to legislation to license CPMs, midwives and consumer advocates are stepping up in other states to address threats, and to rise to challenges as well as to emerging opportunities. As we share our experiences with legislation and regulation, state to state, we build our common body of expertise to promote and protect the practice of certified professional midwifery. We are pleased to provide you with these updates and look forward to keeping you abreast of further developments in these and other states in the months to come.
The Illinois Council of CPMs – a Chapter of NACPM – and the Illinois Friends of Midwives have introduced the Home Birth Safety Act in both the House of Representatives (HB 677) and the Senate (SB 1754), the same legislation that these groups collaborated on last year with ACOG. With over 1000 babies being born out-of-hospital a year in the state, Illinois ACOG and the midwives believe passage of this bill is a matter of safety for mothers and babies choosing home birth. Aligned with the US MERA agreements, the bill passed out of the Senate Committee of License Activity and Pensions on a 9-2 vote this session, with a promise by the midwives to committee members to further engage with the Illinois State Medical Society who have opposed the bill. A meeting of the parties took place in March, with the Illinois Medical Society agreeing to take the information the midwives provided to them on CPMs and MEAC-accredited education back to their board for discussion. The primary Senate sponsor of SB 1754 has committed to keeping the bill alive and to bringing this legislation to the floor for a vote of that chamber, as soon as next week.
Two identical bills to license CPMs in Kentucky have been introduced, one in the House (HB 148) and one in the Senate (SB 105). HB 148 was heard in the House Committee on Licensing and Occupation, but received no votes this session. Although the bill last year had more hearings and got further in the legislative process, more progress was made in activating the grassroots and building strength for this effort this year than last. CPMs held seven regional meetings around the state this year, effectively engaging people from every corner of the state. The CPMs in Kentucky are rightly proud of this outreach, which took much hard work and organizing, that allowed many more voices to be heard and engaged in the process. Another victory this year was that the midwives were able to effectively stop an oppositional amendment to the bill sponsored by a house member with significant political clout, demonstrating the growing strength of the midwives and the grassroots and the support that is building in the legislature for this effort. Advocates for this US MERA-aligned legislation are busy now preparing for the interim hearing period that begins in June.
There are currently three bills in play in Alabama. Advocates have brought forward HB 316 to license CPMs, a bill that aligns with US MERA agreements, and HB 315 that would exempt a midwife holding a current certification from NARM from the crime of practicing midwifery without a license – sometimes referred to as a decriminalization bill, a ‘back-up’ in the case the licensing bill does not pass. A third bill, proposing to regulate the practice of ‘lay midwifery’ brought forward by the Medical Association of the State of Alabama (MASA), would effectively outlaw all direct-entry midwives except Certified Midwives, and does not have the backing of advocates for CPMs. After years of rejection of any bills to license CPMs, HB 315 recently passed through the Judiciary Committee and HB 316 passed through the Committee on Boards, Agencies and Commissions; both bills are headed now to the floor in the House of Representatives. Although there may still be much work ahead to secure passage of these bills, advocates are encouraged by the support they have found in these committees.
Early this year, Oklahoma CPMs were unexpectedly challenged by the introduction of hostile legislation that would have effectively eliminated their ability to practice in the state. By organizing quickly, engaging midwives and consumers and raising funds to hire an effective lobbying firm, they were able to push back this threat. The newly-formed Oklahoma Chapter of NACPM was chosen by the CPMs in the state to act as the joint legislative arm for the two long-established state midwife associations, with the presidents of each organization serving on the board of the chapter, effectively bridging midwives around the state.
In February, NACPM Executive Director Mary Lawlor, attended the official launch meeting for the Chapter. Midwives came from all over the state to share their concerns and challenges about regulation for midwives, and to learn together about the national picture that is emerging for certified professional midwifery. They discussed the US MERA agreements and Principles for Model U.S. Midwifery Regulation and Legislation, and how alignment with these tools in other states is successfully building momentum. The Chapter board then participated in a work session with Mary, using the NACPM Regulatory Assessment Tool from the NACPM Legislative and Advocacy Took Kit to explore how the US MERA agreements and principles might be applied in Oklahoma to build a strategy for protecting autonomous practice in the state.
On March 29, the Midwives Association of Florida (MAF), consumers, and the Florida Chapter of NACPM celebrated an impressive turnout for Capitol Day in Tallahassee when many constituents met with their legislators in support of Licensed Midwives. Physicians are seeking to require mandatory reporting of adverse incidents for Florida licensed midwives, to include reporting of maternal and fetal deaths, severe maternal hemorrhage, and transfers of mothers and infants to intensive care units. The midwives agree with these requirements. With the support of their lobbyists they are in dialogue with Florida ACOG about this legislation, which may involve opening up their midwifery practice act, a potential turn of events that is causing the midwives to strengthen their organizations and to rally support from around the state to ensure autonomous practice.
On another note, congratulations are in order! The midwives in Florida are celebrating a long-sought victory: as a result of 20 years of advocacy, new rules now provide for licensed midwives to do their own risk screening for new clients coming into birth center care, reversing a long-standing requirement that birth center clients have their initial exam and risk assessment with an MD or a CNM.
With a more than 30-year history of policy and advocacy work, the Midwives Association of Washington State (MAWS), has lobbied this year for two budget provisos: one to maintain the 8-year-old cap on the licensing fee for midwives, and the other to nearly triple the facility fee for birth centers paid by Medicaid. Maintaining the cap on the annual licensing fee, which would otherwise now be triple the current rate of $525, has contributed to a 40% increase in the number of midwives in the state over these last 8 years, now nearly 170. The increased birth center Medicaid reimbursement would not only benefit people having babies in Washington State, but could support efforts to increase the low rates of birth center reimbursement throughout the country, much as the 2007 Department of Health Cost-Benefit Study has helped make the case for Medicaid reimbursement for community birth in other states and to the federal government.
An Oregon Victory for the Harkin Amendment
Just last week NACPM was informed that an insurer, PacificSource in Oregon, has cited the 2015 guidance issued to the states by the U.S. Department of Health and Human Services (HHS) on Section 2706 of the Affordable Care Act (ACA) – commonly known as the Harkin Amendment – as the factor that has led it to finally issue reimbursement for direct entry midwife services provided to an Oregon resident in 2015. Since the ACA passed in March 2010 until now, the implementation of the Harkin Amendment has been a discouraging story.
In agreeing to cover the costs of care for this consumer, the Oregon Insurance Division (OID) stated: “…PacificSource has reviewed the Centers for Medicare and Medicaid Services (CMS) FAQ that provides additional clarification for provider non-discrimination requirements. The insurer has agreed that members who go to in-network Licensed Direct Entry Midwives can receive benefits under their policy. They also have agreed that members who seek out-of-network care by a Licensed Direct Entry Midwife would have their benefits paid at the out-of-network level the member policy permits (in a non-discriminatory manner).”
This victory is celebrated by the Integrative Health Policy Consortium and NACPM. NACPM is an IHPC Partner for Health and has held a board of director’s position for the last decade. This new development in Oregon could portend well for reimbursement of midwife services for people having babies around the country. Dogged persistence on the part of this Oregon consumer who had her baby at home with licensed midwives, along with support from the Oregon Midwifery Council and IHPC, has finally paid off in this unexpected but happy turn of events. Of interest, the OID sent their email on the same day that the American Health Care Act (AHCA) was pulled from the floor of the U.S. House of Representatives, leaving the ACA as the law of the land. Although it is likely that there will be no movement until fall of this year, there is reason to hope that the Oregon Insurance Division now will commit to fully implementing Section 2706 to address the current inconsistencies in coverage for professions in the state, and provide an example to other states on implementation of this important provision of the ACA.
The Integrative Health Policy Consortium was instrumental in working with Senator Harkin and other legislators during the development of the ACA to include Section 2706 to ensure patient access to care. This provision of the law, sometimes known as the non-discrimination clause, requires that insurers include and reimburse licensed healthcare providers in health insurance plans. It states:
(1) A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider’s license or certification under applicable State law.
(2) This section shall not require that a group health plan or health insurance issuer contract with any health care provider willing to abide by the terms and conditions for participation established by the plan or issuer. Nothing in this section shall be construed as preventing a group health plan, a health insurance issuer, or the Secretary from establishing varying reimbursement rates based on quality or performance measures.
Notwithstanding small pockets of progress, implementation of this provision has met roadblock after roadblock since its passage. In 2013, IHPC launched a nation-wide initiative to ensure adequate implementation of Section 2706 called Cover My Care, a national grassroots program of information and patient engagement designed to create public advocacy for access to all healthcare providers who are licensed by states. Cover My Care provides a website, information and FAQs about the law, patient guides,a toolkit for consumers and forums for consumer sharing.
In the coming months, IHPC and NACPM will be closely tracking progress of Section 2706, and providing all possible support for the goal of full implementation of this provision around the country.