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Prenatal Care Expansion a No Brainer for Undocumented Patients

CAWEM-Plus program has cost benefits for state, community and patients
October 8, 2013


October 8, 2013 -- The expansion of the Citizen-Alien Waived Emergency Medical (CAWEM) benefit package to include prenatal services on Oct. 1 comes at a time healthcare advocates are getting on the same page as those who want to reign in costs.

CAWEM-Plus is the name of the new benefits package administered by the Oregon Health Authority, which will expand an existing pilot program from 16 Oregon counties to the entire state.

Under the backdrop of Oregon’s healthcare transformation, coordinated care organizations and providers are pushing for more preventative care, said Rep. Alissa Keny-Guyer (D-Portland), who spearheaded efforts to remove prenatal care from the immigration debate and make it an issue of public health.

“Hospitals didn’t have a lot of incentive to promote prenatal care because their bills were paid,” Keny-Guyer said. “Now, they have that incentive. The new business model is driving these healthcare providers to do a new model of care.”

Under the old system, undocumented women qualified only for state and federally funded prenatal care if they lived in one of the 16 Oregon counties that offered CAWEM-Plus.

Otherwise, they received federally funded CAWEM emergency services, which are limited, but include labor and delivery.

Most notably, Marion and Yamhill counties, which each have significant Hispanic populations, were not on the list, said John Hummel, state and federal policy director for the Oregon Primary Care Association.

The association was a driving force behind the expansion of CAWEM-Plus because many of its community health center members served undocumented persons, Hummel said.

“We don’t turn people away – we provide services,” he said. “The problem (was) that the services we could provide uncompensated weren’t as robust as if it was being compensated.”

As a result, undocumented women were starting their prenatal care much later in their pregnancy – sometimes at six months, or when they were going into labor, Hummel said.

“The results are often low functioning adolescents and adults who are more likely to be on a food-stamp program and underemployed,” said Hummel, who is running for Deschutes County District Attorney. “They are more likely to need support for the rest of their lives.”

Hummel credited Keny-Guyer for her advocacy and Dr. Bruce Goldberg, director of the Oregon Health Authority, for “crunching the numbers.” Alberto Moreno at the Oregon Latino Health Coalition also played an instrumental role as an advocate during the last decade, Hummel said.

“There were so many reasons to support this program, that’s why this coalition was able to succeed,” Hummel said.

Ultimately, no legislative action was needed. Cost savings expected from rolling prenatal care into patient care meant the Oregon Health Authority could work the prenatal care expansion into its existing budget without additional funding, Hummel said.

The expansion of prenatal care to all counties throughout Oregon was a huge relief to Gady Rodriguez.

The 34-year old undocumented immigrant, who went for her first appointment under the new CAWEM-Plus program last week, has four children and is 32 weeks pregnant. The first three births went without any complications, but her most recent one was “complicated,” she said through Rosa Cortez Banuelos, an Oregon Health Plan patient benefits coordinator at Salud Medical Center in Woodburn.

Rodriguez is getting early contractions with her current pregnancy, Cortez Banuelos said.

She has wracked up $1,700 in out-of-pocket medical expenses and was having serious pains over the weekend before CAWEM-Plus took effect.

“She couldn’t take the pain anymore, so she called Salud,” Cortez Banuelos said. “We advised her to go to (Silverton Hospital) for emergency treatment, but she didn’t want to go because she owed too much money.”

At her appointment Tuesday, CAWEM-Plus covered the cost of medications for her infection, the cost of an appointment and allowed her to have her baby’s heartbeat checked.

“She feels very happy,” Cortez Banuelos said. “She has been waiting for this day for a long time. She was scared before because she felt she wouldn’t qualify. She has always had to pay out of pocket.”

Rodriguez’s case has been all too common.

Prior to the expansion of prenatal health benefits, undocumented immigrants only qualified for emergency care, which included labor and delivery. That coverage gap resulted in pregnant mothers paying for prenatal services out of pocket or showing up in the emergency room at delivery without having seen a medical professional, Keny-Guyer said.

“If a baby comes in premature, the costs could be as high as $500,000 to spend two weeks in a neo-natal intensive care unit,” she said. “That comes out of the budget. A (provider) could have a blown budget by one birth.”

Delivering prenatal services, including medical, dental, eye exams and some surgeries, costs an additional $3,760 per patient, according to the Oregon Health Authority. Before taking CAWEM-Plus statewide, the monthly caseload was 1,169 clients. That average monthly caseload is projected to roughly double to 2,209 clients under the expansion.

The increased caseload will be offset in cost savings by a 10 percent increase in compensation from the federal government for offering prenatal care as part of its CAWEM package.

The government, which funds 60 percent of the state’s CAWEM, or emergency care, ups its contributions to 70 percent if the state offers prenatal care.

As a result of the federal funding, expanding the $7 million CAWEM-Plus program statewide is projected to cost the state $1.8 million for one year, according to the Oregon Health Authority.

The expanded coverage is likely to help at the state’s 31 community health centers and their partner sites. At these health centers, patients who often have no insurance are not denied care, but often receive fewer services because they would have to pay out-of-pocket.

“We have a lot of patients who decline services because of costs,” said Kevin Heidrick, regional medical director at Salud in Woodburn, Lancaster Family Health Center in Salem and Rosewood Family Health Center in Portland.

“Now that they’re not going to be intimidated by costs, that should translate into better outcomes,” Heidrick said.

At Salud and Lancaster clinics in Marion County, the expansion of CAWEM-Plus also could result in 10 to 15 scheduled prenatal visits over the course of the pregnancy, which will be reimbursed under the new program.

Roughly two-thirds of the estimated 528 annual pregnancies handled at the two clinics were uninsured, Heidrick said.

“Before, we would write these off or patients would have to pay out-of-pocket,” he said. “It’s going to have a huge impact for us.”

Of course, the biggest beneficiaries will be the children who are born healthy, said Alberto Moreno, director of the Oregon Latino Health Coalition, which had advocated for expansion of prenatal care for the better part of a decade.

Its expansion will strengthen the safety net, Moreno said.

“We hope the impact will be one where women and their children will have healthier birth outcomes,” Moreno said. “Keep in mind that when these children are born, they are going to be U.S. citizens. With effective prenatal care, they can have a healthy start in life.”