A Healthy Life for Infants

FOR years, the problem of infant mortality in America has been a case study of the failure of our health care system.

We spend and spend and spend for health care--$550 billion in 1988, comprising 11.5 percent of our GNP. Yet America's infant mortality rate ranks 18th among industrialized nations. The rate of Black infant mortality is twice that of whites and is comparable to rates in many Third World nations.

THIS disparity between high costs and low benefits partly exists because of a profound bias towards institutional health care in this country. Expensive neonatal hospital units which miraculously save the lives of low birthweight babies are rewarded with glamorous news stories and bigger budgets. In contrast, less popular residential clinics which deliver prevention-oriented prenatal care are massively underfunded.

A recent study by the Office of Technology Assessment (OTA) indicated that an investment in prenatal care for those who cannot afford it would save hundreds of infant lives, prevent hundreds more from being born with low birthweight, and avoid thousands of dollars in neonatal care expenditures. Prenatal care pays for itself four times over.

POLICYMAKERS are trying to counteract the health system's bias towards institutional care. President Bush recently proposed increasing Medicaid coverage to 130 percent of the poverty line for pregnant women and infants. And Representative Mickey Leland (D-Tx.) and Senator Bill Bradley (D-N.J.) have introduced legislation which would expand this ceiling to 185% of the poverty line.

Unfortunately, these efforts threaten to replace a case study in the failure of the health care system with a case study in the failure of the political system. Expanding prenatal care through the means-tested Medicaid program would reinforce a second-class health care system for the poor--one which may often fail to deliver needed services.

AN expansion of Medicaid would immediately expand financial access to prenatal care for many American mothers-to-be. But financial access is only one component of actual access to care. Pregnant women must first weave through a maze of Medicaid regulations to become covered by the program. OTA called this process "a formidable barrier to the receipt of timely care." But with the first few months of pregnancy being crucial to the health of the baby, pregnant women can scarcely afford to wait while overworked welfare bureaucrats process their applications.

Once mothers do find their way onto the Medicaid rolls, they must locate physicians willing to deliver care to Medicaid patients. But partly because of huge medical school debts and tremendous malpractice premiums, more than half of American obstetricians cannot afford to provide prenatal care at Medicaid rates. As a result, one-third of low-income women who received inadequate prenatal care last year attributed this failure to their inability to locate a health care provider, according to a study done by the General Accounting Office.

THE problem with Medicaid as a health care program for the poor is that it is a health care program for the poor. Recipients are stigmatized and often embarrassed to participate in the system. Doctors, receiving lower rates of payment, often provide a lower quality of care. And the federal government has a ready-made whipping boy should the budget deficit need a trim. Very few speak out for Medicaid on Capitol Hill.

Why tie the fortunes of pregnant women and infants to a program with little political clout? Why force women to suffer through complicated enrollment procedures and to spend hours searching for a doctor? A Medicaid explosion would further advance the isolation of the poor in the American health care system and society.

But there are alternatives. The same funding which Bush, Leland and Bradley want to commit to a Medicaid expansion could be channeled to government operated Community Health Centers (CHCs). Many of these residential clinics already provide prenatal care to low-income groups, but need more physicians. Most importantly, CHCs serve an entire community, rich and poor. Because they unite rather than isolate, they can serve as a model for a more equitable health care system.

Bush and Congressional leaders should not correct a flaw in the health care system by deepening a flaw in the political system. They should create a prenatal care program which can have a long and healthy life.