A Survey of State Medicaid Policies for Coverage of Abortion and Prenatal Diagnostic Procedures JANET WEINER, MPH,
AND
Abstract: In the summer of 1988, we surveyed all states to evaluate access to Medicaid funding for abortion after the diagnosis of an anomalous fetus. All state Medicaid programs covered amniocentesis, and most had expanded coverage to include newer prenatal diagnostic procedures for eligible women. In 29 states, however, abortion coverage was limited to instances when continuation of abortion threatens the life of the mother. Only 13 states paid for a woman on Medicaid to obtain an abortion after diagnosis of an
anomalous fetus. (Am J Public Health 1990; 80:717-720.)
Introduction
Medicaid is a joint state- and federally-funded program, enacted in 1965, to provide health care coverage for many indigent and disabled citizens. Within broad federal guidelines, each state has latitude in deciding which medical and ancillary services are to be covered by its Medicaid program. In 1973, the US Supreme Court decision in Roe v. Wade prohibited states from interfering with a woman's right to abortion except to protect maternal health or a viable (third trimester) fetus. By 1974, three-fourths of the states covered most abortions under their Medicaid programs.' In 1977, Congress passed the Hyde Amendment, which limited federal reimbursement of abortions to situations that threatened the life or physical health of the mother, and to victims of rape and/or incest. Current federal policy reimburses states only for abortions performed to save the life of the mother. Abortions for other reasons, which constitute over 99 percent of all abortions, must be paid for by non-federal or, in most cases, state funding.2 At present, increasingly sophisticated techniques such as amniocentesis, chorionic villus sampling (CVS), ultrasound, and biochemical assays are permitting earlier and broader detection of fetal abnormalities. Malpractice fears impel physicians to identify patients at risk for producing children with prenatally-diagnosable defects and offer them appropriate testing.3 At least one state requires that maternal serum alpha-fetoprotein (MSAFP) screening be offered to pregnant women.4 Ethical practice dictates that when tests show a fetal anomaly exists, the woman be offered the option of pregnancy termination, within the guidelines of each state's law regulating abortion.5 Information has been unavailable nationally on coverage of prenatal diagnostic services by Medicaid programs and on utilization of these procedures by pregnant Medicaid recipients. From the Division of Medical Genetics, Johns Hopkins School of Medicine (Weiner) and the Department of Women's Services and Pediatrics, Sinai Hospital, Baltimore, MD (Bernhardt). Address reprint requests to Janet Weiner, MPH, Department of Scientific Policy, American College of Physicians, 6th Street at Race, Philadelphia, PA 19106-1572. This paper, submitted to the Journal June 29, 1989, was revised and accepted for publication October 12, 1989.
o 1990 American Journal of Public Health 0090-0036/90$1.50
AJPH June 1990, Vol. 80, No. 6
BARBARA A. BERNHARDT, MS The survey reported here delineates state-by-state Medicaid guidelines for coverage of prenatal diagnostic procedures and abortion. Methods We developed a questionnaire that asked about Medicaid coverage of seven prenatal services: amniocentesis, ultrasound to rule out fetal anomalies, CVS, MSAFP testing, fetal DNA analysis, chromosome analysis on cultured amniotic fluid cells, and genetic counseling. We included the standard Current Procedural Terminology Codes for each procedure (when available). Respondents were asked to check either "covered", "not covered", "covered on a case-by-case-basis", or "unknown" for each procedure. We asked about Medicaid coverage of abortion for seven indications, broad enough to encompass the variation in state policies, using the legal terminology of indications for abortion as reported in the Medicare and Medicaid guide.6 We mailed the questionnaire to the director of the Medicaid program in each state and the District of Columbia. After follow-up, including telephone calls, the final response rate was 100 percent. We did not attempt to verify how completely these guidelines were followed in each state. The responses reflect Medicaid regulations as of summer 1988.
Results Each state's coverage of prenatal diagnostic procedures is shown in Table 1. The majority of states cover all procedures listed, and almost all have developed guidelines for coverage, as indicated by the low numbers of "caseby-case" or "unknown" responses. All states and the District of Columbia cover amniocentesis, and all but one cover MSAFP testing. Two-thirds cover CVS and three-fourths cover DNA analysis, both of which are newer technologies for the detection of fetal abnormalities. Table 2 lists each state's coverage for abortion. At the time of the survey, seven states and the District of Columbia paid for abortion on demand. All states cover abortions that save the life of the mother, the only ones for which federal reimbursement is available. In 29 states, this is the only indication for which Medicaid will cover an abortion. Eleven states will pay for abortion when the indication is a known or suspected fetal anomaly, and two other states evaluate coverage on a case-by-case basis. Just over one-fourth of the states will pay for "medically necessary" abortions, usually as certified by an attending physician. Likewise, victims of rape and/or incest are covered for abortion in one-fourth of the states. This indication has been hotly debated on a federal level, as President George Bush recently vetoed a congressional package that would have reinstated federal reimbursement for abortion in cases of rape and incest. Discussion A combination of Medicaid regulations has led to the incongruous policy in many states of covering prenatal diagnostic services but not the selective abortion in cases of a diagnosed fetal abnormality. We believe that these policies 717
PUBLIC HEALTH BRIEFS TABLE 1-Medicald Coverage of Prenatal Diagnostic Procedures by States and District of Columbia as of Septeber 1988
States Alabama Alaska Arizona Arkansas Califomia Colorado Connecticut Delaware District of Columbia Florida
Georgia Hawaii Idaho Illinois Indiana
Iowa Kansas Kentucky Louisiana Maine
Maryland Massachusetts Michigan Minnesota Missouri
Mississippi Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York Norih Carolina North Dakota Ohio Oklahoma
Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia
Washington
West Virginia Wisconsin
Wyoming Totals Covered Not Covered
Case-by-case Unknown
CVS
MSAFP
DNA Analysis
Karyotyping
Genetic Counseling
x x x x x
x x c x 0 ?
x x x x x
x x x x x
X X
x x x c 0 0 ?
X 0
x
x
x
x
X ?
x
X O X O
C X X C
X X X X
0 X X X
X X X X
X ? ? X
O O
x O
Amniocentesis
Fetal Ultrasound
x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x
x x x x x
51 0 0 0
x
x x x x
x x x x
x ? X x
0 X X C
X X
X
x x x
x x x
x
x
x x
x x x
0 x x
x x
C 0
C 0
X X X X
X X C X
X X X X
X X X X
x
x
x
x
x
x
x
x
X
X
X
x
?
0
X
X
X
C
X
C
X
C
X
C
x
x
x
x
0
X
O
x x x x
x
O
x x x x
x
x x x x
x
x x x x
X
X
x x x x X
x
C
X
0
0
X
X
X
x x x x
X
X
X 0
x
x
x
C
x
x
x
C
0
0
0
0
0 X X
x
x
x
X
x
x
x
x
x
0 X
0 C
X X
X C
X C
x x x
x x x
x x x
x x x
x x x
X 0
x x x
x
0
x x x x x x x
x x x x x x x
x x x x x x x
x x x x x x x
x x x x x x x
x x x 0 x x x
43 6 1 1
34 9 7 1
50 1 0 0
38 5 6 2
44 4 3 0
42 6 1 3
X
X
X
X
Symbols
X = covered 0 = not covered C = case-by-case ?= unknown
discriminate against poor women and interfere with ethical medical practice. By covering prenatal diagnostic services in Medicaid programs, each state in this country acknowledges the medical necessity of these services and its commitment to providing access to them. Since abortion is a recognized option for women carrying an anomalous fetus, states that refuse to pay for abortion interfere with women's rights. Once a state has agreed to pay for diagnostic procedures, we 718
do not believe it should influence subsequent medical decisions. In the future, Medicaid guidelines will affect more and more women, as Congress encourages states to expand eligibility criteria for pregnant women. By July 1990, federal Medicaid guidelines mandate that all states cover pregnant women at poverty level, and will give states the option of covering women with incomes up to 185 percent of poverty AJPH June 1990, Vol. 80, No. 6
PUBLIC HEALTH BRIEFS TABLE 2-Medicaid Coverage of Abortion Services by States and the District of Columbia as of September 1988
State Alabama Alaska Arizona Arkansas
Califomia Colorado* Connecticut Delaware District of Columbia* Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan* Minnesota Missouri Mississippi Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota
Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Totals Covered Not Covered
Case-by-case
On Demand O
Ufethreatening x
Physical Health Damage
0
Mental Health Damage
0
Fetal Anomaly
0
Medical Necessity
0
Rape/ Incest
0
x
x
x
x
x
x
x
O O
x x
0 0
0 0
0 0
0 0
0 0
x
x
x
x
x
x
x
O O O
X X x
C C 0
C C 0
C C 0
C X 0
0 C 0
O O
x x
x
0 0
x
0 0
x
0 0
x
0 0
x
0 0
x
O O O O O O O O O
x x
X x x x x x x X x
x x
C 0 0 0 0 0 0 C x
C 0 0 0 0 0 0 C x
x x
0 0 0 X 0 0 0 0 x
x x
C 0 0 0 0 0 0 C 0
x x
0 0 0 X 0 0 0 0 X
x x
O O O O O O O
x x x x x x x
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
X 0 0 0 0 0 0
X 0 0 0 0 0 0
x x
x
x
x x
x
x
x
x
x
x
x
x
x
x
x
O O O O O O O O O O O O O O O O
x x X x x x x x x x x x x x x x
0 x 0 0 0 0 x 0 0 0 0 0 0 0 0 x
0 x C 0 0 0 x 0 0 0 0 0 0 0 0 x
x
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
x
0 X 0 0 0 0 X 0 0 0 0 0 0 0 0 X
x
0 0 0 0 0 0 0 X 0 0 0 0 0 0 0 0
x
O O O
x x x
x x 0
x 0 0
x 0 0
x 0 0
x X 0
8 43 0
51 0 0
14 33 4
13 33 5
11 38 2
14 34 3
14 36 1
x
x
x
Symbols X = covered 0 = not covered C = case-by-case *Since the fall of 1988, Michigan and Colorado, by voter referenda, and the District of Columbia, by legislative action, aftered their regulations to pay only for life-threatening abortions.
level.7 Therefore, the public health implications of Medicaid policies on abortion will become even greater. As budgetary pressures force state and federal agencies
to cut costs, the economic burden of restrictive abortion funding will loom larger. The financial cost of the Hyde Amendment was estimated conservatively to be $95 million in 1986. For every dollar spent on a desired abortion through Medicaid, four dollars are saved in medical and social welfare AJPH June 1990, Vol. 80, No. 6
costs in just two years.8 The medical and emotional costs of bearing children that are either not wanted or have major anomalies may be far greater. Health care costs of infants and children with genetic disorders and chronic illnesses are at least three times higher than those of other children.9 Those born to low-income families pose an even greater challenge to an already over-
burdened household. Children with disabilities require addi719
PUBLIC HEALTH BRIEFS
tional health care services including occupational and physical therapy, psychosocial support, home health care, respite and day care. On a state level, Medicaid policies on abortion have been heavily influenced by political pressure from right-to-life groups. Since our survey, two states (Colorado and Michigan) have altered their regulations because of referenda placed on the ballot in the November 1988 elections, and the District of Columbia has withdrawn funding entirely. Regardless of one's views on abortion, we believe the Medicaid program should not be used to force the poorest women among us to bear children with severe congenital anomalies. ACKNOWLEDGMENTS This study was presented at the annual meeting of the American Society of Human Genetics in October 1988.
REFERENCES 1. Torres A, Donovan P, Dittes N, Forrest J: Public benefits and cost of government funding for abortion. Fam Plann Perspect 1986; 18:111-118. 2. Gold RB, Guardado S: Public funding of family planning, sterilization and abortion services, 1987. Fam Plann Perspect 1988; 20:228-233. 3. Rhodes AM: Legal aspects of prenatal diagnosis. Clin Obstet Gynecol 1988; 31:233-252. 4. Steinbrook R: In California, voluntary mass prenatal screening. Hastings Cent Rep 1986; 16:5-7. 5. Powledge TM, Fletcher J: Guidelines for the ethical, social and legal issues in prenatal diagnosis. N Engl J Med 1979; 300:168-172. 6. Medicare and Medicaid Guide, Vol. 3. Chicago: Commerce Clearing House, Inc. 1 15,500-15,660. 7. P.L. 100-360, Sec. 302. 8. Kenney A, Torres A, Dittes N, Macias J: Medicaid expenditures for maternity and newborn care in America. Fam Plann Perspect 1986; 18:103-109. 9. Newacheck PA, McManus MA: Financing health care for disabled children. Pediatrics 1988; 81:385-394.
Obstetrical Pulmonary Embolism Mortality, United States, 1970-85 ADELE L. FRANKS, MD, HANI K. ATRASH, MD, MPH, HERSCHEL W. LAWSON, MD, Abstract: To investigate pulmonary embolism as a cause of obstetrical death, vital records data from 1970 through 1985 were analyzed. Results showed that the number of obstetrical pulmonary embolism deaths per 100,000 live births declined by 50 percent for both Whites and Blacks. However, Black women maintained more than a 2.5-fold higher risk, and women over age 40 had a ten-fold higher risk of embolism mortality. Thus, although the risk of obstetrical pulmonary embolism death has declined, some subgroups of women remain at higher risk. (Am J Public Health 1990; 80:720721.)
Introduction Several studies of maternal mortality have found pulmonary embolism to be the leading cause of maternal death in recent years.'-5 It has been suggested that pulmonary embolism deaths may be becoming more important as a cause of maternal death because deaths due to other causes are declining more rapidly, or because medicolegal concerns favor the diagnosis of causes of death perceived to be nonpreventable. 1,4 Little is known nationally about trends in maternal mortality due to pulmonary embolism. The purpose of the current analysis was to determine the absolute and relative importance of pulmonary embolism as a cause of obstetrical death over time on a national basis, and to describe the demographic risk factors for obstetrical pulmonary embolism (OPE) death.
Methods The total number and characteristics of obstetrical deaths were obtained from multiple cause of death mortality Address reprint requests to Adele L. Franks, MD, Division of Reproductive Health, Pregnancy and Infant Health Branch, Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control, Mailstop C06, Atlanta, GA 30333. Drs. Atrash and Lawson are also with that Branch at CDC; Ms. Colberg is with Statistics and Computer Resources Branch, DRH, CCDPHP, CDC, Atlanta. This paper, submitted to the Journal September 22, 1989, was revised and accepted for publication December 4, 1989.
720
AND
KAREN S. COLBERG, BA
tapes made available by the National Center for Health Statistics (NCHS). Up to 20 diagnoses are recorded from each death certificate and coded according to the International Classification of Diseases (ICD).6,7 Obstetrical deaths were identified as those with any nonabortive pregnancyrelated diagnosis (ectopic pregnancies, spontaneous abortions, induced abortions, and molar pregnancies were excluded). For the years 1970 through 1978 OPE deaths included ICDA-8 codes 634 and 673, while for 1979-85 they included ICD-9-CM code 673. These data do not allow one to separately identify amniotic fluid, thrombotic or air pulmonary embolism; therefore all causes of pulmonary embolism are grouped together. The OPE mortality ratio is defined as the number of obstetrical deaths associated with pulmonary embolism per 100,000 live births during the same time period. The numbers of live births for each year were obtained from national natality computer tapes made available by NCHS. The OPE mortality ratios for both Blacks and Whites over time were standardized to the age distribution of White live births 1970-85. The percent of obstetrical deaths due to embolism is the number of pulmonary embolism-associated obstetrical deaths per 100 obstetrical deaths during the same time period. The analysis is restricted to women over the age of 14 years and younger than 45 years who were classified as either White or Black.
Results From 1970 through 1985 there were a total of 1,417 OPE deaths and 55,096,188 live births, for an overall OPE mortality ratio of 2.6 OPE deaths per 100,000 live births. Over the 16-year interval OPE mortality ratios, standardized by age, declined more than 50 percent for both Whites (from 3.3 to 1.3 per 100,000 live births) and for Blacks (from 9.0 to 4.2 per 100,000 live births) (Figure 1). However, Black women maintained more than a 2.5-fold higher risk of OPE mortality than White women throughout the 16-year interval. This racial disparity did not vary systematically over time or AJPH June 1990, Vol. 80, No. 6
AND
Abstract: In the summer of 1988, we surveyed all states to evaluate access to Medicaid funding for abortion after the diagnosis of an anomalous fetus. All state Medicaid programs covered amniocentesis, and most had expanded coverage to include newer prenatal diagnostic procedures for eligible women. In 29 states, however, abortion coverage was limited to instances when continuation of abortion threatens the life of the mother. Only 13 states paid for a woman on Medicaid to obtain an abortion after diagnosis of an
anomalous fetus. (Am J Public Health 1990; 80:717-720.)
Introduction
Medicaid is a joint state- and federally-funded program, enacted in 1965, to provide health care coverage for many indigent and disabled citizens. Within broad federal guidelines, each state has latitude in deciding which medical and ancillary services are to be covered by its Medicaid program. In 1973, the US Supreme Court decision in Roe v. Wade prohibited states from interfering with a woman's right to abortion except to protect maternal health or a viable (third trimester) fetus. By 1974, three-fourths of the states covered most abortions under their Medicaid programs.' In 1977, Congress passed the Hyde Amendment, which limited federal reimbursement of abortions to situations that threatened the life or physical health of the mother, and to victims of rape and/or incest. Current federal policy reimburses states only for abortions performed to save the life of the mother. Abortions for other reasons, which constitute over 99 percent of all abortions, must be paid for by non-federal or, in most cases, state funding.2 At present, increasingly sophisticated techniques such as amniocentesis, chorionic villus sampling (CVS), ultrasound, and biochemical assays are permitting earlier and broader detection of fetal abnormalities. Malpractice fears impel physicians to identify patients at risk for producing children with prenatally-diagnosable defects and offer them appropriate testing.3 At least one state requires that maternal serum alpha-fetoprotein (MSAFP) screening be offered to pregnant women.4 Ethical practice dictates that when tests show a fetal anomaly exists, the woman be offered the option of pregnancy termination, within the guidelines of each state's law regulating abortion.5 Information has been unavailable nationally on coverage of prenatal diagnostic services by Medicaid programs and on utilization of these procedures by pregnant Medicaid recipients. From the Division of Medical Genetics, Johns Hopkins School of Medicine (Weiner) and the Department of Women's Services and Pediatrics, Sinai Hospital, Baltimore, MD (Bernhardt). Address reprint requests to Janet Weiner, MPH, Department of Scientific Policy, American College of Physicians, 6th Street at Race, Philadelphia, PA 19106-1572. This paper, submitted to the Journal June 29, 1989, was revised and accepted for publication October 12, 1989.
o 1990 American Journal of Public Health 0090-0036/90$1.50
AJPH June 1990, Vol. 80, No. 6
BARBARA A. BERNHARDT, MS The survey reported here delineates state-by-state Medicaid guidelines for coverage of prenatal diagnostic procedures and abortion. Methods We developed a questionnaire that asked about Medicaid coverage of seven prenatal services: amniocentesis, ultrasound to rule out fetal anomalies, CVS, MSAFP testing, fetal DNA analysis, chromosome analysis on cultured amniotic fluid cells, and genetic counseling. We included the standard Current Procedural Terminology Codes for each procedure (when available). Respondents were asked to check either "covered", "not covered", "covered on a case-by-case-basis", or "unknown" for each procedure. We asked about Medicaid coverage of abortion for seven indications, broad enough to encompass the variation in state policies, using the legal terminology of indications for abortion as reported in the Medicare and Medicaid guide.6 We mailed the questionnaire to the director of the Medicaid program in each state and the District of Columbia. After follow-up, including telephone calls, the final response rate was 100 percent. We did not attempt to verify how completely these guidelines were followed in each state. The responses reflect Medicaid regulations as of summer 1988.
Results Each state's coverage of prenatal diagnostic procedures is shown in Table 1. The majority of states cover all procedures listed, and almost all have developed guidelines for coverage, as indicated by the low numbers of "caseby-case" or "unknown" responses. All states and the District of Columbia cover amniocentesis, and all but one cover MSAFP testing. Two-thirds cover CVS and three-fourths cover DNA analysis, both of which are newer technologies for the detection of fetal abnormalities. Table 2 lists each state's coverage for abortion. At the time of the survey, seven states and the District of Columbia paid for abortion on demand. All states cover abortions that save the life of the mother, the only ones for which federal reimbursement is available. In 29 states, this is the only indication for which Medicaid will cover an abortion. Eleven states will pay for abortion when the indication is a known or suspected fetal anomaly, and two other states evaluate coverage on a case-by-case basis. Just over one-fourth of the states will pay for "medically necessary" abortions, usually as certified by an attending physician. Likewise, victims of rape and/or incest are covered for abortion in one-fourth of the states. This indication has been hotly debated on a federal level, as President George Bush recently vetoed a congressional package that would have reinstated federal reimbursement for abortion in cases of rape and incest. Discussion A combination of Medicaid regulations has led to the incongruous policy in many states of covering prenatal diagnostic services but not the selective abortion in cases of a diagnosed fetal abnormality. We believe that these policies 717
PUBLIC HEALTH BRIEFS TABLE 1-Medicald Coverage of Prenatal Diagnostic Procedures by States and District of Columbia as of Septeber 1988
States Alabama Alaska Arizona Arkansas Califomia Colorado Connecticut Delaware District of Columbia Florida
Georgia Hawaii Idaho Illinois Indiana
Iowa Kansas Kentucky Louisiana Maine
Maryland Massachusetts Michigan Minnesota Missouri
Mississippi Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York Norih Carolina North Dakota Ohio Oklahoma
Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia
Washington
West Virginia Wisconsin
Wyoming Totals Covered Not Covered
Case-by-case Unknown
CVS
MSAFP
DNA Analysis
Karyotyping
Genetic Counseling
x x x x x
x x c x 0 ?
x x x x x
x x x x x
X X
x x x c 0 0 ?
X 0
x
x
x
x
X ?
x
X O X O
C X X C
X X X X
0 X X X
X X X X
X ? ? X
O O
x O
Amniocentesis
Fetal Ultrasound
x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x
x x x x x
51 0 0 0
x
x x x x
x x x x
x ? X x
0 X X C
X X
X
x x x
x x x
x
x
x x
x x x
0 x x
x x
C 0
C 0
X X X X
X X C X
X X X X
X X X X
x
x
x
x
x
x
x
x
X
X
X
x
?
0
X
X
X
C
X
C
X
C
X
C
x
x
x
x
0
X
O
x x x x
x
O
x x x x
x
x x x x
x
x x x x
X
X
x x x x X
x
C
X
0
0
X
X
X
x x x x
X
X
X 0
x
x
x
C
x
x
x
C
0
0
0
0
0 X X
x
x
x
X
x
x
x
x
x
0 X
0 C
X X
X C
X C
x x x
x x x
x x x
x x x
x x x
X 0
x x x
x
0
x x x x x x x
x x x x x x x
x x x x x x x
x x x x x x x
x x x x x x x
x x x 0 x x x
43 6 1 1
34 9 7 1
50 1 0 0
38 5 6 2
44 4 3 0
42 6 1 3
X
X
X
X
Symbols
X = covered 0 = not covered C = case-by-case ?= unknown
discriminate against poor women and interfere with ethical medical practice. By covering prenatal diagnostic services in Medicaid programs, each state in this country acknowledges the medical necessity of these services and its commitment to providing access to them. Since abortion is a recognized option for women carrying an anomalous fetus, states that refuse to pay for abortion interfere with women's rights. Once a state has agreed to pay for diagnostic procedures, we 718
do not believe it should influence subsequent medical decisions. In the future, Medicaid guidelines will affect more and more women, as Congress encourages states to expand eligibility criteria for pregnant women. By July 1990, federal Medicaid guidelines mandate that all states cover pregnant women at poverty level, and will give states the option of covering women with incomes up to 185 percent of poverty AJPH June 1990, Vol. 80, No. 6
PUBLIC HEALTH BRIEFS TABLE 2-Medicaid Coverage of Abortion Services by States and the District of Columbia as of September 1988
State Alabama Alaska Arizona Arkansas
Califomia Colorado* Connecticut Delaware District of Columbia* Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan* Minnesota Missouri Mississippi Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota
Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Totals Covered Not Covered
Case-by-case
On Demand O
Ufethreatening x
Physical Health Damage
0
Mental Health Damage
0
Fetal Anomaly
0
Medical Necessity
0
Rape/ Incest
0
x
x
x
x
x
x
x
O O
x x
0 0
0 0
0 0
0 0
0 0
x
x
x
x
x
x
x
O O O
X X x
C C 0
C C 0
C C 0
C X 0
0 C 0
O O
x x
x
0 0
x
0 0
x
0 0
x
0 0
x
0 0
x
O O O O O O O O O
x x
X x x x x x x X x
x x
C 0 0 0 0 0 0 C x
C 0 0 0 0 0 0 C x
x x
0 0 0 X 0 0 0 0 x
x x
C 0 0 0 0 0 0 C 0
x x
0 0 0 X 0 0 0 0 X
x x
O O O O O O O
x x x x x x x
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
X 0 0 0 0 0 0
X 0 0 0 0 0 0
x x
x
x
x x
x
x
x
x
x
x
x
x
x
x
x
O O O O O O O O O O O O O O O O
x x X x x x x x x x x x x x x x
0 x 0 0 0 0 x 0 0 0 0 0 0 0 0 x
0 x C 0 0 0 x 0 0 0 0 0 0 0 0 x
x
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
x
0 X 0 0 0 0 X 0 0 0 0 0 0 0 0 X
x
0 0 0 0 0 0 0 X 0 0 0 0 0 0 0 0
x
O O O
x x x
x x 0
x 0 0
x 0 0
x 0 0
x X 0
8 43 0
51 0 0
14 33 4
13 33 5
11 38 2
14 34 3
14 36 1
x
x
x
Symbols X = covered 0 = not covered C = case-by-case *Since the fall of 1988, Michigan and Colorado, by voter referenda, and the District of Columbia, by legislative action, aftered their regulations to pay only for life-threatening abortions.
level.7 Therefore, the public health implications of Medicaid policies on abortion will become even greater. As budgetary pressures force state and federal agencies
to cut costs, the economic burden of restrictive abortion funding will loom larger. The financial cost of the Hyde Amendment was estimated conservatively to be $95 million in 1986. For every dollar spent on a desired abortion through Medicaid, four dollars are saved in medical and social welfare AJPH June 1990, Vol. 80, No. 6
costs in just two years.8 The medical and emotional costs of bearing children that are either not wanted or have major anomalies may be far greater. Health care costs of infants and children with genetic disorders and chronic illnesses are at least three times higher than those of other children.9 Those born to low-income families pose an even greater challenge to an already over-
burdened household. Children with disabilities require addi719
PUBLIC HEALTH BRIEFS
tional health care services including occupational and physical therapy, psychosocial support, home health care, respite and day care. On a state level, Medicaid policies on abortion have been heavily influenced by political pressure from right-to-life groups. Since our survey, two states (Colorado and Michigan) have altered their regulations because of referenda placed on the ballot in the November 1988 elections, and the District of Columbia has withdrawn funding entirely. Regardless of one's views on abortion, we believe the Medicaid program should not be used to force the poorest women among us to bear children with severe congenital anomalies. ACKNOWLEDGMENTS This study was presented at the annual meeting of the American Society of Human Genetics in October 1988.
REFERENCES 1. Torres A, Donovan P, Dittes N, Forrest J: Public benefits and cost of government funding for abortion. Fam Plann Perspect 1986; 18:111-118. 2. Gold RB, Guardado S: Public funding of family planning, sterilization and abortion services, 1987. Fam Plann Perspect 1988; 20:228-233. 3. Rhodes AM: Legal aspects of prenatal diagnosis. Clin Obstet Gynecol 1988; 31:233-252. 4. Steinbrook R: In California, voluntary mass prenatal screening. Hastings Cent Rep 1986; 16:5-7. 5. Powledge TM, Fletcher J: Guidelines for the ethical, social and legal issues in prenatal diagnosis. N Engl J Med 1979; 300:168-172. 6. Medicare and Medicaid Guide, Vol. 3. Chicago: Commerce Clearing House, Inc. 1 15,500-15,660. 7. P.L. 100-360, Sec. 302. 8. Kenney A, Torres A, Dittes N, Macias J: Medicaid expenditures for maternity and newborn care in America. Fam Plann Perspect 1986; 18:103-109. 9. Newacheck PA, McManus MA: Financing health care for disabled children. Pediatrics 1988; 81:385-394.
Obstetrical Pulmonary Embolism Mortality, United States, 1970-85 ADELE L. FRANKS, MD, HANI K. ATRASH, MD, MPH, HERSCHEL W. LAWSON, MD, Abstract: To investigate pulmonary embolism as a cause of obstetrical death, vital records data from 1970 through 1985 were analyzed. Results showed that the number of obstetrical pulmonary embolism deaths per 100,000 live births declined by 50 percent for both Whites and Blacks. However, Black women maintained more than a 2.5-fold higher risk, and women over age 40 had a ten-fold higher risk of embolism mortality. Thus, although the risk of obstetrical pulmonary embolism death has declined, some subgroups of women remain at higher risk. (Am J Public Health 1990; 80:720721.)
Introduction Several studies of maternal mortality have found pulmonary embolism to be the leading cause of maternal death in recent years.'-5 It has been suggested that pulmonary embolism deaths may be becoming more important as a cause of maternal death because deaths due to other causes are declining more rapidly, or because medicolegal concerns favor the diagnosis of causes of death perceived to be nonpreventable. 1,4 Little is known nationally about trends in maternal mortality due to pulmonary embolism. The purpose of the current analysis was to determine the absolute and relative importance of pulmonary embolism as a cause of obstetrical death over time on a national basis, and to describe the demographic risk factors for obstetrical pulmonary embolism (OPE) death.
Methods The total number and characteristics of obstetrical deaths were obtained from multiple cause of death mortality Address reprint requests to Adele L. Franks, MD, Division of Reproductive Health, Pregnancy and Infant Health Branch, Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control, Mailstop C06, Atlanta, GA 30333. Drs. Atrash and Lawson are also with that Branch at CDC; Ms. Colberg is with Statistics and Computer Resources Branch, DRH, CCDPHP, CDC, Atlanta. This paper, submitted to the Journal September 22, 1989, was revised and accepted for publication December 4, 1989.
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tapes made available by the National Center for Health Statistics (NCHS). Up to 20 diagnoses are recorded from each death certificate and coded according to the International Classification of Diseases (ICD).6,7 Obstetrical deaths were identified as those with any nonabortive pregnancyrelated diagnosis (ectopic pregnancies, spontaneous abortions, induced abortions, and molar pregnancies were excluded). For the years 1970 through 1978 OPE deaths included ICDA-8 codes 634 and 673, while for 1979-85 they included ICD-9-CM code 673. These data do not allow one to separately identify amniotic fluid, thrombotic or air pulmonary embolism; therefore all causes of pulmonary embolism are grouped together. The OPE mortality ratio is defined as the number of obstetrical deaths associated with pulmonary embolism per 100,000 live births during the same time period. The numbers of live births for each year were obtained from national natality computer tapes made available by NCHS. The OPE mortality ratios for both Blacks and Whites over time were standardized to the age distribution of White live births 1970-85. The percent of obstetrical deaths due to embolism is the number of pulmonary embolism-associated obstetrical deaths per 100 obstetrical deaths during the same time period. The analysis is restricted to women over the age of 14 years and younger than 45 years who were classified as either White or Black.
Results From 1970 through 1985 there were a total of 1,417 OPE deaths and 55,096,188 live births, for an overall OPE mortality ratio of 2.6 OPE deaths per 100,000 live births. Over the 16-year interval OPE mortality ratios, standardized by age, declined more than 50 percent for both Whites (from 3.3 to 1.3 per 100,000 live births) and for Blacks (from 9.0 to 4.2 per 100,000 live births) (Figure 1). However, Black women maintained more than a 2.5-fold higher risk of OPE mortality than White women throughout the 16-year interval. This racial disparity did not vary systematically over time or AJPH June 1990, Vol. 80, No. 6
