Stratification Through Medicaid: Public Prenatal Care in NYC

The Study of access to prenatal care illustrates how healthcare coverage remains unequal after the implementation of ACA. This articles explores how those with coverage through Medicaid received lesser coverage than those with private healthcare plans.

• Medicaid expansion accounted for over HALF of those who gained coverage under ACA
• Looks at the EXPERIENCE OF HEALTH CITIZENSHIP (rather than lack of coverage)
• Single payer system would have incorporated all citizens equally into the healthcare system instead of the patchwork of inequality we now experience.
• negative valuation given to public assistance- less deserving of healthcare
• NY- more than a third of its residents receive healthcare through Medicaid
• offers FREE healthcare to all pregnant women with up to 233% of FPL regardless of status
• created a ZONE ON INCLUSION
• despite this, the experience of these patients is far from equal
• long clinic wait times
• extensive medicaid required prenatal counseling

NYC Study

• long term system of public and municipal hospitals provide care to all NYC residents (pre medicaid)
• legally bound to accept everyone- supported the "medically indigent"

• hospitals and clinics, private teaching hospitals, charitable institutions
• NOT EQUAL- public hospitals served as safety nets for the poor and uninsured
• private hospitals could deny care because of lack of funds, type of illness or "moral failing"
• with the introduction of Medicaid, private hospitals also scrambled to attract medicaid patients but continue to deny access to those without coverage. Public hospitals remained financially strapped.
• Public hospital developed expertise in prenatal care because single mothers were often denied access to public hospitals on moral grounds.
• Bellevue Hospital
• oldest prenatal program in the country and oldest public hospital 1799
• 1911 created first midwife education program- free to immigrant woemn who could not afford nursing school
• 1989 PCAP was passed (Prenatal Care Assistance Program) which provided subsidies for hospitals providing prenatal care for women not covered by medicaid.
• NYC opted to include higher incomes, AND those without legal immigration status
• The stats on prenatal health disparities were recognized by NYC:
• rate of prenatal and maternal mortality correlate with 
• poverty
• minority status
• lack of access to prenatal care
• co-morbidities during pregnancy

 HEALTH INCLUSION VERSUS HEALTH EQUITY

• Moral Deservingness is understood as the flip side of one's rights (Sarah Willen)
• context dependent
• relational
• conditional upon presumed or actual characteristics of the individual
• medicaid recipients had trouble seeing the doctors they wanted without long waits
• " and having doctors treat them with respect
• Prenatal services become a site where pregnant women can receive care but also experience unequal "health citizenship"
• sometimes these judgements are overt -"Wily patient" is imultaneously stupid and is shrewdly working the system to her benefit.
• like the "welfare queen" - racialized
• tend to be voiced by low levl workers rather than providers (front line workers)- because they share the socioeconomic status of these women, comments served as boundaries between themselves  (the working poor) and those that are morally undeserving.
• Mechanisms of Health Inequity
• Waiting
• belief in the disposability of poor people's time
• disciplinary power of having to wait for services
• should wait for services that are free
• socializes the poor into their lower sytus within the community
• opaque reasons for delays
• assigned appointment without concerns for their preexisting schedules
• time becomes an important locus of conflict and acquiescence
• As charity cases they are expected to wait because they wont take their business elsewhere
• Causes:
• unintentional consequence
• huge volume of people served with understaffing and underfunding
• will see all patients even if they come in late (inclusion goal)
• Public Prenatal Care- discipline and nurturance (medicaid)
• Requires that women accept surveillance that comes with public assistance
• subject to social, state, and federal medical oversight
• lengthly pre-certifications
• HIV testing
• psychological screenings
• mandatory education programming
• seen as being a greater medical and social risk than women with private insurance
• Contribute to lengthy visits
• All is done in house because their fear women wont be compliant or will not be able to locate the services
• Rebuffing discipline and restrictions
• women would jump from clinic to clinic if they did not like their care
• women would show up at a private hospital in the advanced stages of labor to have their babies there
• shows they believe medical care is better at private hospitals

Attention to ideologies and practices around pregnancy and birth can shine a bright light on broader social tensions

Women's inclusion, whether equitable or not, is liminal (temporary) in that it only lasts 60 days after childbirth- women and children move in and out of "rights"

Ideology

• pregnancy is constructed as a state of emergency that requires temporary exemptions to the law, but when no longer pregnant, women lose their ability to make claims for healthcare except as emergency care or as mothers (producers) of citizen children
• Is it possible to change our attitudes toward entitlements when we have private health insurance that we must pay for? How would this all change with Universal Coverage?