Increasing Consumer Participation in the Policy Process

Undoubtedly there are people far better equipped than I to address strategies to increase consumer participation in the policy process. After all, it is very difficult to know where to begin when we learn more people vote for the American Idol winner than do in a US Presidential election – 132 million votes in American Idol verses 129 million in the 2012 election. 1 Of those who did not vote in the 2012 Presidential election, 20% said they were just too busy. 2 Of course there are other factors to consider – those under 18 can vote in Idol and can vote multiple times, etc. But the numbers are nonetheless significant.

But why are we so disengaged? Kraft and Furlong (2015) describe a disassociation between government policies and ordinary peoples lives, and a sense of powerless by people to affect political change.3 Hassner (2012) writes that, “passions and interests” win out over politics, the greatest influences coming from the media and money.4“The classic figures of the great lawmaker and the statesman are disappearing, eclipsed by political actors who try to maneuver from day to day between electoral cycles and unexpected events”. 5

As an illustration of this, several weeks ago, I watched a segment of Last Week Tonight hosted by John Oliver who devoted much of his show to an examination of the tobacco industry’s fight to prevent negative advertising in countries where smoking rates are still significant. 6 Attempts to add disturbing images and warning labels on packs have been met with threats of high dollar lawsuits in international courts. This has included countries such as Australia, Uruguay, Namibia and Togo. Uruguay has had to seek help to pay their legal fees. Togo, one of the poorest countries in the world, has a GDP of $4.8 billion. 7 Phillip Morris has earnings estimates of $80 billion. Powerless seems an appropriate adjective. And yet the same John Oliver has been credited with influencing the 2014 debate on net neutrality by encouraging people to comment on the FCC’s website leading to an overload of the system. 8

Rather than think about strategies, which appear not to be working, it might be helpful to examine groups or individuals who have successfully increased consumer participation in policy. A group that I have been particularly impressed with is the California Nurses Association/National Nurses United (CNA/NNU). 10 (Note: what I am not saying is that I support unions. My feelings regarding unions are fairly neutral!) For a short 6-month period, I worked as an RN in California in a union hospital. Even still, I periodically get glossy brochures from the CNA with pictures of nurses participating in marches, rallies, demonstrations and pickets not only for better working conditions for nurses, but advocating for patient safety. They have inserted themselves in California politics taking on Arnold Schwarzenegger, Meg Whitman, advocated against Wall Street and EBOLA preparedness to name a few. After a merger with two other unions, they are still only 190,000 members strong – a little union by all accounts. 11 It is worth mentioning that if you work in a union hospital, you essentially don’t have a choice but to join the union, but these nurses could hardly be described as apathetic. If anything, they seem energized, passionate, believing in their ability to shape policy, and have enjoyed more than a few political victories.

Direct-entry midwives, as a group, are fairly involved in the policy process because they have to be. They are a small group (64 in Arizona) with plenty of detractors. Once they stop being involved, they may find themselves without the ability to practice, or practice in a home setting. In this state they have been known to hold marches and rallies at the capital and lobby in the legislative arena. Consumer participation has also played a significant role. This is related to several factors. Deciding to give birth at home with a midwife is not a decision that one arrives at easily. Those who do chose homebirth face a multitude of barriers including criticism and fear mongering. So if you decide to give birth at home it has to be something you believe in, something you would advocate for, and something that might compel you to participate in a policy affecting homebirth as a choice.

  1. Federal Election 2012. Retrieved from
  1. United States Census Bureau. (2014). Voting and Registration.
  1. Kraft, M. E., & Furlong, S. R. (2010). Public policy: Politics, analysis, and alternatives. Washington, D.C: CQ Press.
  1. (Hassner, 2012, p. 152)

Hassner, P. (2012). Politics in crisis? Journal of Democracy, 23(4), 150-154. doi: 10.1353/jod.2012.0065. 

  1. (Hassner, 2012, p. 152)

Hassner, P. (2012). Politics in crisis? Journal of Democracy, 23(4), 150-154. doi: 10.1353/jod.2012.0065

  1. Central Intelligence Agency. (n.d.). The world factbook. Retrieved from
  1. National Nurse United. (2015). Retrieved from
  1. California Nurses Association/National Nurses Organizing Committee. (n.d.). In Wikipedia. Retrieved from

Sustaining Innovative Environments

Historically, innovation in the corporate world has been tied to the economy. In strong economies, funds have been directed towards creativity, new ideas, and technologies. In leaner times, innovation becomes less of a priority. Hardly a plan for sustainment! Health care, in the past, has been largely unaffected by this same innovation cycle.  In fact, in many ways, innovation (not simply change) in healthcare seemed largely unsuccessful. The passage of the Affordable Care Act (ACA) in 2010 ushered in a new focus on innovation in health care – but unlike corporate innovation, this new health care innovation involves less funding to both bring about and sustain innovation. But the ACA is only part of the solution and removing more barriers to innovation can only come about through legislation.

An example of innovation in health care that has been sustained (and continues to grow) is the so-called ‘minute clinics’ or walk-in medical clinics. The business model was launched by CVS in 2000 and is now available in 28 states that CVS operates in.1 Most are staffed by NPs (fitting well with the recommendations of the IOM Future of Nursing report), offer basic health care that is more affordable and easier to use that was what was previously available. The clinics are designed to fit the needs of consumers by taking into account both time and money. Noteworthy challenges that this model helps address are improving access to healthcare, lower costs with greater efficiency and changing the way consumers interact with healthcare as a service. Studies found that there was no impact on return visit rates by patients using a retail NP clinic as opposed to standard office care. 2, 3 For the most part, there has been little opposition from physicians and other providers, which in turn has made working with insurance plans easier, most of whom contract with them. 3

Innovation that disrupts the established approach to the health care service of childbirth has been slow and challenging. A new approach that includes home as a birth setting using direct-entry midwives has yet to gain real acceptance in most states. However, in the current model consumers are not empowered, care is expensive and complex, and power is held by medical providers such as OB physicians who view midwives and home birth as a competitive threat and birth as a medical process – all barriers to innovation. Additionally laws and insurance providers often restrict midwives scope of practice. An optimistic outlook is that innovation will occur, and sooner than later. Woman and childbirth cannot be that only aspect of health care that is immune to healthcare reform, the pursuit of quality and efficient care, and the creation of innovative environments that are sustained.


  1. Wikipedia (2015). MinuteClinic. Retrieved from
  1. Rohrer, J. E., Angstman, K. B., & Furst, J. W. (2010). Early return visits by primary care patients: A retail nurse-practitioner clinic versus a medical office walk-in clinic. Primary Health Care Research and Development, 11(1), 87-92. doi:10.1017/S1463423609990387
  1. Rohrer, J. E., Garrison, G. M., & Angstman, K. B. (2012). Early return visits by pediatric primary care patients with otitis media: A retail nurse practitioner clinic versus standard medical office care. Quality Management in Health Care, 21(1), 44-47. doi:10.1097/QMH.0b013e3182418157
  1. Herzlinger, R. (2006). Why innovation in health care is so hard. Harvard Business Review. Retrieved from

Healthcare Financing

The American health care system is unique among other industrialized countries in many ways. One of these ways is the absence of a universal health system (which the Affordable Care Act seeks to address), another is the role that the market plays in the delivery of healthcare. Most other countries have agreed that it is perhaps not the best idea to allow the market to determine who has access to medical care. But it would not be accurate to describe the healthcare in the U.S. as a free market system either. Healthcare in the U.S. comes from three primary sources – individuals (28%), employers (21%) and the government (26%). 1 About 18 percent of the GDP is spent on health care and federal, states and local governments pay for almost half of total health care spending.2 Healthcare accounts for 24 percent of state and local spending, and 35 percent of their tax revenue. 3 The government plays an important and ever-growing role in healthcare regulation since the introduction of Medicare and Medicaid in 1965.

There are arguments both for and against a market system. Theoretically, a market system allows freedom and choice in healthcare and prevents the inappropriate use of services based on the knowledge that some else is paying for it. A government system might be inefficient, slow and lack incentive to advance and innovate. However, the United States system is truly more a hybrid of the two. One might therefore be inclined to think that it is perhaps better that one or the other. Yet this does not seem to be the case. The most expensive healthcare system in the world (the United States) has not demonstrated itself to be the best.

Interestingly enough, home birth attended by a direct-entry midwife remains one of the purest forms of market-based medical services. Not necessarily because this is how midwives intended it, but because they are generally not reimbursed by any other means. Home birth is offered in the “market”, and when someone needs it, they buy it through direct payment for the service. Additionally home birth cost a fraction of the cost of a hospital delivery. An Internet search estimates cost to range from $1,500 to $5,000, though many midwives will with work with their clients if the cost is still too prohibitive. A 2014 study by UC San Francisco found that hospital charges for vaginal deliveries ranged from just over $3000 to $37,000 depending on location. 4

  1. CMS. gov (nd). NHE Fact Sheet. Retrieved from Reports/NationalHealthExpendData/NHE-Fact-Sheet.html
  2. Executive office of the president council on economic advisers (2009) The economic case for healthcare reform executive summary. Retrieved from
  3. Boyd, D. (2014). The potential impact of alternative health care spending scenarios on future state and local government budgets. Retrieved from
  4. Hsia, R. Y., Antwi, Y. A., & Weber, E. (2014). Analysis of variation in charges and prices paid for vaginal and caesarean section births: a cross-sectional study. BMJ open, 4(1), e004017.

Characteristics of innovators and change agents in healthcare

Innovation is perhaps one of the greatest challenges faced by healthcare today. The Triple Aim, a term coined by the Institute for Health Improvement (IHI) emerged from efforts to reform healthcare in the United States. 1 The three components of this framework are: 1. Improving the patient experience of care 2. Improving the health of populations 3. Reducing the per capita cost of healthcare. 1 Pursuit of the triple aim (note – not aims) requires a focus on a balance of all three elements in order to achieve optimal reform.

Achieving the Triple Aim requires healthcare systems to commit to a future of innovation and change. Though hardly new, an evidence-based approach, to evaluate what works and incorporate the use of evidence in decision-making is one strategy to drive change. 2 Evidence-Based Practice (EBP) was originally conceived in the field of healthcare and emphasized making clinical decisions using only empirically supported data, in particular Randomized Controlled Trials (RTCs). Ultimately, it has become an approach to clinical decision-making in which the clinician uses the best evidence available, in concert with patient preferences and clinical expertise, to improve quality and outcomes.3

Other approaches include learning to use systems knowledge to adopt innovation in healthcare. This involves a paradigm shift from individual, local practice to a more global, dimensional, worldview of health care with consideration of how healthcare systems behave, interact with and influence the environment. Complex systems such as healthcare 4, might become complex adaptive systems that continually adapt and learn, allow everyone to be involved in the generation of ideas, share knowledge through relationships, while taking into account the uniqueness of that system. 5

If we consider health care reform, in particular the Affordable Care Act, it is clear to see how the Triple Aim has impacted government policy, and aligned with the goals for reform. In many ways the goals of the Triple Aim also align with the goals of the midwifery Model of Care. 6

The Midwives Model of Care 6 is woman centered and focused on that individual woman’s care and childbirth experience, rather than a specific type of provider (improving the patient experience of care). The aim of care is this model is healthy moms and babies experiencing the least amount of intervention and trauma possible (improving the health of populations). Care provided by midwives costs a fraction of that provided through the traditional medical model (reducing the per capita cost of healthcare).

  1. Institute for healthcare improvement. (2015). IHI triple aim initiative. Retrieved from
  2. Liebman, J. (2013). Building on recent advances in evidence-based policymaking. Results for America and The Hamilton Project.
  3. 3. Melnyk, B. M., & Fineout-Overholt, E. (2011). Evidence-based practice in nursing & healthcare: A guide to best practice. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkin.
  4. Institute of Medicine (U.S.), & Committee on Quality of Health Care in America. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, D.C: National Academy Press.
  5. Bennet, A., & Bennet, D. (2004). Organizational survival in the new world: The intelligent complex adaptive system. Burlington, MA: Elsevier.
  6. Midwife Alliance North America. (nd). Midwifery Model. Retrieved from

Change theory

One of my first introductions to Kotter’s work on organizational change was through a book entitled Our Iceberg is Melting. 1 The story is about a colony of emperor penguins in the Antarctica who are forced to change in light of a very real threat to their home and way of life. More than a story, the book is a fable with animals that speak and act much like us, and struggle with fear, resistance, and obstacles to change.


Kotter’s first step in the process of change is creating a sense of urgency. 1 I certainly do not remember a time in health care that we have felt more compelled to change. The Affordable Care Act has spurred this change by emphasizing high-quality, low-cost care. We have many new words in our health care vocabulary like accountable care organizations (ACO), essential health benefits (EHBs), ambulatory intensive care units (A-ICUs), insurance exchanges, interoperable electronic health records (EHRs), Big Data, telemedicine, transprofessional care, personalized medicine, genomic profiles, wellness programs and person-centered care. Regardless of individual political views, this legislation will restructure the way health care is provided. The stage is set. Several years later, perhaps understandably, many of us in health care continue to be unsure about the best strategic response. Health care systems, organizations, and providers may be found at different steps in the difficult process of change.

In my interview with Marinah Farrell about home birth, she mentioned that where things are with respect to change, depended on which level was being discussed. Things may change a lot on the grassroots level, but very little on a national level. Though it might be easy for some to see the need for changes in maternal and infant care, it is a little more difficult to really create that sense of urgency because we are not discussing two mutually exclusive practices. There will always be birth in a hospital (for good reason). The question is how we can shift the focus from the setting to best-care practices in normal birth care.

Kotter, J., & Rathgeber, H. (2005). Our iceberg is melting: Changing and succeeding under any conditions. New York, NY: St. Martin’s Press.

A Note on Privacy

In general, we have all agreed that our blogs should avoid politics, keep a scholarly tone, and steer clear of personal opinion or “I” statements. For the most part I have tried to do that. This week is a little different for me, because recently I have been reflecting a great deal on privacy, including privacy in healthcare. Much of this began while attempting to write a paper on cloud computing in healthcare, a subject in which I quickly found myself way out of my depth. More recently I watched, Citizenfour, a documentary concerning Edward Snowden. Whether one agrees with what he did or not is immaterial. What is hard to ignore is just how very subjective the condition of privacy is, and how that we, as citizens of this country, or even the world, should feel about that.

Ultimately, I have decided that privacy, or at least the notion that we have the power to control information about ourselves, is perhaps an illusion. We can be tracked, detected, seen and discovered in more ways than we can imagine. Technology gives the ability to gather, analyze and disseminate vast amounts of information on individuals – like us. Though law protects privacy, it also has the ability to considerably undermine privacy.

The protection of health information comes about in two primary ways – through legislation (law) and through ethics. Most of us have taken more education modules than we can count on the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy, Security and Breach Notification Rules. Additionally, nursing, similar to other healthcare disciplines, has made a social contract with society that makes nurses morally bound to protect patient’s privacy, through the Code of Ethics for Nurses. In this way, privacy in healthcare relies primarily on the presence of a code or law, rather than the knowledge that health information is truly private.

What has this to do with home birth? Probably more than is apparent. Women may chose to give birth at home because the privacy that this setting affords. At home, women can decide who and how many people can attend their birth. This is not an option in a facility. Likewise, the decision to giving at birth at home is tied to many fundamental human rights including privacy, self-determination and autonomy. Sadly, these rights often don’t seem to be extended to all peoples, all the time, in every instance.

Interview with Marinah Farrell, LM, CPM.

Marinah Farrell is a Licensed and Certified Professional Midwife with a degree in politics from Arizona State University. She is the current President of the Midwives Alliance of North America (MANA). She is a founding board member and midwife with the Phoenix Allies for Community Health, a free clinic for those without medical care.


L: Do you feel like there is a political aspect to (your role in MANA)?

M: Mostly politics. Birth in this country is very political in general because for the most part birth is…it’s a corporate thing in the US. So what happens is that every…even though we have such a maternal health provider shortage…you know we have OBs and they practice like crazy…and we have nurse midwives but can’t get into programs; there’s very limited programs for nurse midwives; and then for CPMs and LMs, it’s even worse because we have even fewer programs, and yet there is this huge need for maternal health care providers; so, what’s happening is that it’s kind of like everything is stunted by lobbyists…and a lot times it is the OB lobbyists that really don’t want or don’t like out-of-hospital births, and then also they have sort of other issues when it comes to even, you know, um, sort of like being a primary care physician for…even in a group practice where there are midwives. It is very, very political. And right now we are trying to work with the nurse midwives, actually…and the CMs, who are sort of in this bridge ground too, like how LMs are. The CMs are, they can only practice in two states. And it’s kind of crazy, you know. And so we’re trying to actually do some legislative work together, but you can imagine it is very challenging. We have very different paradigms because a lot of us that didn’t elect to be nurses, we often don’t get the complexity of what being a nurse is; and those who are nurses often don’t get the complexity of what it means to kind of struggle to be an out-of-hosp…to be a non-nurse midwife in this country. It’s a very hard bridge to cross. We’re always having to struggle with it, and so a lot of politics is going on with it at the national level. And then, you know, every state has its struggle, every single one. Even, for instance, in Arizona right now, the state is really going after midwives, and they’re doing this weird interpretation of the rules, like when they actually want us to give less care than more care. So we’re struggling with that. So to be a midwife in general in this country, I think, to be a medical care provider in this country, is political, all the time.

M: We’re trying to do some bridging. We’re working with the nurse midwives to sort of bridge pieces of our education, so that our education is more accepted. It’s definitely always political. It’s kind of a bummer because it ends up being not so much about birth as it does about liability and money.

L: Yeah, it is, and especially because cost containment is such a big piece of health care moving forward. I’ve read statistically that birth…or at least… labor and delivery and newborn care is the biggest hospital expenditure…and probably the most they get reimbursed for too.

M: Right, I think they say that the physicians that are the highest paid are the anesthesiologist and the OB. They’re like one and two on the list. And I’m like ‘Of course they are because they work together,’ you know? And I think it’s like 70% of income for hospitals is OB, I think. So, we’re looking at a system where a lot of money is made.

L: Do you have lobbyist or is it midwife driven?

M: We work with some…there are some organizations out there for midwives. Usually midwives themselves, for instance, in Arizona, the Arizona Midwives Association just simply can’t afford lobbyists, and even if they could, the amount of money that we could pay a lobbyist is nothing compared to what, like, the OBs pay or even the AMA. The AMA is really who calls all the shots. And so, we have a group called the Big Push. Their whole purpose is to try to get midwives credentialed in states, or licensed in states. They sometimes do have lobbyists that work for them, but I think, I mean, again, they’ve done comparisons…like, if you go to, you can see some of their data there. They do comparisons of how much they pay versus how much that big medicine pays, and it’s almost nothing. So, I would say ‘not really.’ You know, it’s kind of incredible when you look at how many gains midwives have made in the last 30 years without money.

M: There are a lot more consumer groups popping up, and they can do it. They can stand up to them, which is really good.

L: There was a consumer group that helped with SB 1157, right?

M: Exactly. If it wasn’t for the consumers, who knows what would have happened. And you’re seeing that in a lot of states. You’re seeing where consumers groups are really the power, which is really interesting. So it’s really moms and families asking for changes.

L: So, was it mostly, uh, people who have had home births and used midwives? Is that who the consumer group was mostly made up of…?

M: I think so. I mean yeah. I think it is. Although, we also now have the birth bar rights association…or the birth bar association, which is just attorneys for birth. It’s definitely expanding. I think that in the last decade, I have seen so many more supporters coming out for midwives than ever before.

L: Yeah, that’s great. So, what happened to SB 1157? It passed out of the health and human services committee, and then it just dropped?.

M: Well, what happened was, um,…what I think happened is I think that the…uh…I’m not going to remember her name…but the main chair of that committee is an MD, and what happened was during the hearing they had…it was very interesting how they did it, because the had an OB and a nurse midwife speak to the work of licensed midwives. They didn’t have any licensed midwives speak, and then we had our time to speak but it was very short. They only would gives 2 minutes or, you know. But, at one point, the doctor who was the chair (and I can’t remember her name) brought up abortion, and she basically said something like, “I believe in women’s rights, but I’m antiabortion, and I also worry about that you all are hurting babies or that babies are dying.” She said something to that effect. And that created a huge ripple…that we actually went to the national organizations and said, “Hey, this is what she said.” And there was a ton of moms in that audience who were very conservative, who also were pro-life, but they’re home birthers, and they were furious. They were like, ‘How dare she assume that we’re not pro-life because we’re home birthers?’ And it got a little bit hairy. And, I swear, I really think that she, that she just dropped it. I think they didn’t want the controversy. I think it was a really big political maneuver that happened.

L: I think her name is Ward. I watched so it afterward online. [Lisa paraphrases what Ward said.]

M: There is a big knowledge gap. But, you know what happened was that we knew that after about the first 10 minutes of it that it had already been decided.

M: She [Ward] kind of shot herself in the foot doing that, because I really believe that she thought home birth were completely unpolitical, were completely crazy radical, not realizing that in this state that people who have advanced our causes more than anybody have been republicans because republicans are home schoolers, and they’re home birthers, and they’re Mormons, and they’re all these things that they love midwives. And so, um, that was fortunate in that…because I think it could have gone a different way and not a good way for us. I think it could have actually gotten very constrained. I think that is what she wanted. So even thought it didn’t go the way we wanted to go, it didn’t go the way we didn’t want it to go.

L: Do you think the passage of the Affordable Care Act has helped midwives or has been neutral for midwifes? Because it’s hard to get on provider panels to begin with – do you have any thoughts on that?

M: I will be really honest and say we don’t really know. We thought it would be, and some of the wording and legislation of the act gives us a little more power as providers, but I don’t really think it’s made a whole lot of difference. I guess time will tell but it doesn’t seem like it. And I hate to say that because it hasn’t all played out, but it sure doesn’t seem like it.

M: And what scares me, or one of the things that scares me, is that midwifes can’t get it together to be one powerful force and what’s scary about that is that who is starting to do births are PAs who have two years of education. I oversee PAs at the free clinic and I am not kidding you, Lisa, they do one semester of women’s health. And that’s it. They do one semester, and the only hands on thing they do, they do a vaginal exam on a woman, not even a pap, that everyone does a vaginal exam on – someone they’ve hired to do the exam on. And they literally graduate…I just had a PA student who just graduated directly into an OB office and a week after she graduated, she caught a baby. She had never even been to a birth and she was catching babies. And moms don’t know this and I often wonder did that mom know. I love NPs. I say, let there be more NPs. In other countries they call them OB nurses. They don’t do that here…but advanced practice nurses make great midwives. But instead not even nurses are being able to catch babies. But nurses are actually the professionals here. They know how to catch babies, not a resident or a PA that happens to be here because the physician is not here or whatever. So less expensive options, but also less skilled options are replacing us.

L: That is very similar to other NP and PAs. Physicians prefer PAs because they’re practicing under their license and are taught under the same medical model, which is obviously different than the nursing model.

M: It’s amazing how many PAs are graduating out of two-year programs and replacing nurse midwives and nurses in a big way. It’s just something to kind of think about, when thinking about the legislative thing and workforce. That picture is a really important picture too.

L: So on my blog the biggest question that always comes up – the people who comment are nurses and they work in hospitals and see bad outcomes – The question that always comes up, is that if the mom really knew all the risks involved maybe she wouldn’t choose a homebirth. How would you reply to that?

M: Hmmm….well, in a way I think it really downplays the importance of women and birth. And I think that’s true for anyone who provides care to women. I think women often don’t receive true information and informed consent. But honestly, when do women truly have informed consent? It’s very rare and so I think there is some truth to that. I think even midwifes can be guilty of not fully informing clients of risk.

Yet, studies have shown even here in the U.S if you are a low-risk mom with a certified professional that has proven her competency, then you are in pretty good hands. Your outcomes are just as good as a hospital birth. It’s a little bit more questionable around the baby and the health of the baby, but I think those studies are really controversial because they’re based on birth certificate data. They include people who never intended to have a homebirth but had their baby at home, or just didn’t make it on time and even people who don’t go to hospital because they can’t afford to, so they just birth, unassisted at home. It can include a wide range of outcomes that have nothing to do with midwifes. It has to do with faults in the system. So if you look at MANA and their division of research studies, they take women who have planned homebirths, the outcomes are great. Even when it comes to things like water births, MANA is coming up with some great research. Overall it’s not totally true to say that.

But there are things that are critically important. Midwives do need to know how to transfer in a manner that is effective and safe. There does need to be more inter-professional care. And there might need to be a little more oversight, especially in states where there is no licensure. So what happens is there are states that don’t licensed midwife’s because they think midwives are unsafe, so what ends up happening is that they truly have midwifes that are unsafe because they don’t license them. Of course, that’s not everyone. I know some amazing midwifes who have been working underground for more than 20 years, but I’ve also known moms who have had terrible outcomes in states where midwifes – God only knows where they got their education, and it reflects badly on all of us. And people say well, “that’s the midwifes! That’s what they’re like!” So for nurses in hospitals that are seeing our transports, it really is a drag, and they think there is no system in place, no education, no oversight. It should be included in their education. But at the same time there is some truth on each side. And I didn’t used to think that, but the more I understand the whole playing field, the more I realize that it’s mostly the system and the system tries to put blame on the midway. I can’t think of a single out-of- hospital midwife who wouldn’t love to have a better system, wouldn’t love to have more time with nurses in the hospital, would love to have more doctors who are willing to do collaborative care. It truly is a desire but what happens is the system doesn’t allow it.

L: So where do you see the issue of midwife practice in the context of policy development? Do you think, in general, it’s more in an early stage?  

M: I think it depends on what level you’re talking. It’s definitely in early-stage as far as policy development at the national level as it relates to ACOG and ACNM. I would say in the last five years we are doing a lot more work with ACNM…. and even AGOG. The homebirth summit is kind of a big deal, providers from maternity care all over the U.S. getting together and talking…. so it is newer. Yet, for instance, the CPM and having our own credentials that started in the early 90s. There is a little bit where at the grass roots level it’s been happening. In Arizona for example it’s been going on since the 70s. It’s kind of been at this grass roots level like a snail… Yet big leaps have been made in 30 years.

What’s interesting is that we’ve had a voice in the international world for a long time – since the 80s actually. So it’s kind of interesting in that we haven’t been recognized, yet we have.

Private Sector Innovation & Policy Advancement

The most apparent examples of the private sector’s engagement in innovation and policy can be seen in relation to global health. In recent years, financial resources, expertise, and partnerships have come from the private sector to address the challenges faced in global health, and to improve health outcomes in developing countries, in particular. The Bill & Melinda Gates Foundation comes to mind, which is estimated to contribute as much each year as the World Health Organization (WHO). Johnson & Johnson, the Clinton Foundation, the Global Fund, Exxon Mobil, PepsiCo, Procter & Gamble, UNICEF, nongovernmental development organizations, for-profit and not-for-profit organizations and even academic institutions, contribute significantly to global health initiatives.

Health care in the United States is largely provided through private health providers. These comprise for-profit healthcare organizations, private practice providers, and not-for profit nongovernmental organizations, including those that are faith-based. Other private sectors of health care consist of insurance companies, professional medical associations and industries such as pharmaceuticals, medical devices, biopharmaceutical, and the like. As mentioned in blog entry 2, in political (health policy-making) markets the connection between cost and benefit is not linear, individuals alone are rarely demanders, and health policies ultimately reflect both public and private sector self-interests. However, the U.S. government, as the nation’s largest healthcare purchaser through financing of Medicare and Medicaid programs, has the ability to impact innovation and policy because of its role in both healthcare regulation and funding. 1 The Affordable Care Act provides a pretty clear example of this.

Midwives who attend home births exist, almost exclusively, in the private sector. Largely excluded from the formal health sector, innovation and policy advancement can really only come from the private sector. Among the many examples of this include a former talk-show host named Ricki Lake and Midwives Alliance North America (MANA).

In January 2008, The Business of Being Born, a documentary about homebirth and midwifery, was released. 2 In many ways the movie, produced by Lake and filmmaker Abby Epstein, has been described as landmark documentary about homebirth. The documentary raised many important questions about birth in America, examining whether money and fear is driving birthing, resulting in outcomes that may not be beneficial for mothers and babies. The movie includes some of Lake’s experience during the home birth of her second child. Lake has been both vilified, largely by the medical community, and praised, for encouraging women in particular, to consider other birthing options including home birth. Quickly after the release, ACOG issued a statement reiterating its opposition to homebirth and named Lake personally. The statement included the line, “childbirth decisions should not be dictated or influenced by what’s fashionable, trendy, or the latest cause célèbre”. 3 The AMA also adopted the resolution, but Lake’s name was removed from the final version.

MANA is as a professional organization for all types of midwives, that developed the first national certification for direct-entry midwives, defined the core competencies of midwives and collects data on births outside the hospital. 4 MANA later gave rise to the North American Registry of Midwives (NARM), an organization that established the Certified Professional Midwife (CPM) credential. 5 Many states, such as Arizona, use the NARM written examination and CPM credentials as a requirement to obtain a midwifery license.

  1. gov (2014). NHE fact sheet. Centers for Medicare & Medicade Services. Retrieved from
  3. ACOG (2009). ACOG statement on home births.1. Retrieved from
  4. (2008). Certified professional midwives in the United States. Retrieved from
  5. North American Registry of Midwives (NARM). (2014). Retrieved from

Medicare, Medicaid, and the Affordable Care Act

The Patient Protection and Affordable Care Act was good for women.1 As incomprehensible as it seems, prior to 2014, women were routinely discriminated against, based on sex, in both obtaining health insurance and access to healthcare. This included denying coverage based on pre-existing conditions – which, in some cases was a cesarean section, gender rating, or charging higher premiums because the applicant was female, and denying coverage for maternity care. Even the White House summary of women-related provisions of the Affordable Care Act (ACA) acknowledged that a healthy 20-something female could be charged 150 percent higher for health insurance when compared to her male counter-parts. 2

The ACA requires any plan offered through the insurance marketplace to cover 10 basic categories of services known as Essential Health Benefits (EHB). One of these categories is “maternity and newborn care”. The Centers for Medicare and Medicaid Services (CMS), however, left these categories very broad, in other words did not provide great detail as to what services would be included in the EHB. Instead, individual states would choose a plan within their marketplace, and require all other plans to provide equal or similar services.

So will the ACA cover midwives, births in birthing centers or home births?

Probably? Maybe?

Section 2706(a) of the Public Health Services Act (as added by section 1201 of the Affordable Care Act), states that “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.”3 This language clearly implies that midwives cannot be excluded from network participation if appropriately licensed. And that license the provider holds cannot be the determining factor in reimbursement.

None-the-less, most state plans remain very general when describing which type of providers might provide maternity and newborn care and the setting in which care occurs. Therefore, provider network are not required to include services provided certified nurse-midwives (CNMs)/certified midwives (CMs)/certified professional midwives (CPMs). Even if included, they are often times not listed in provider directories, or the plan does not have a category for midwife so are essentially hidden. A survey of insurers conducted by the American College of Nurse-Midwives (ACNM) found that 20% of plans do not contract with CNMs, 24% will not cover a birthing center delivery and 56% will not reimburse for home birth with CNMs.4 65% of the plans did not contract with CPMs, and some plans further restricted their scope of practice beyond state requirements.4

Interestingly, all state Medicaid plans (including ACCCHS) must cover midwifery services, to include birthing centers and home birth (for certain categories of women). Arizona alone is the only state that explicitly allows coverage for birth centers.

Midwives would maintain that they provide an EHB. The ACNM emphasizes that the midwifery model is markedly different to the medical model of childbirth, therefore midwives are providing a different service and cannot be interchangeable with their physician counterparts as providers.4. Midwives provide cost-effective, high quality outcomes with low levels of intervention. Yet, universal recognition and adoption of midwives as healthcare providers has been slow, and concern is now raised of provider discrimination in women’s health.


  1. U.S Department of Health & Human Service. (2015). Read the Law. The affordable care act, section by section. Retrieved from
  2. Whitehouse.Gov/Healthreform. The Affordable Care Act Gives Women Greater Control Over Their Own Health Care. Retrieved from
  3. Patient Protection and Affordable Care Act, 42 U.S.C. § 1201 (2010), p.97.
  4. American College of Nurse-Midwives. (2014). Ensuring Access to High Value Providers ACNM Survey of Marketplace Insurers Regarding Coverage of Midwifery Services. Retrieved from

The pitchforks and efforts to aid the uninsured, disabled, and decrease health disparities.

Nick Hanauer is a self-described .01%er and capitalist. Just one of his über-successful business ventures includes the sale of aQuantive, an Internet advertising company that he founded, to Microsoft for $6.4 billion in cash. 1 I heard him speak on NPR during a TED radio hour episode entitled, “Seven Deadly Sins”. 2 He was specifically addressing greed. I was struck by many things he said and later found an article he wrote echoing the same sentiments to his fellow Zillionaires. The title began, The Pitchforks are Coming

But the problem isn’t that we have inequality. Some inequality is intrinsic to any high-functioning capitalist economy. The problem is that inequality is at historically high levels and getting worse every day… Unless our policies change dramatically, the middle class will disappear, and we will be back to late 18th-century France. Before the revolution… If we don’t do something to fix the glaring inequities in this economy, the pitchforks are going to come for us. No society can sustain this kind of rising inequality. In fact, there is no example in human history where wealth accumulated like this and the pitchforks didn’t eventually come out. You show me a highly unequal society, and I will show you a police state. Or an uprising. There are no counterexamples. None. It’s not if, it’s when. (Hanauer, 2014. p.1) 1

I began to wonder if he was right. Because inequality in this country is not limited to economics, it is equally apparent in health. In fact, strong and complex relationships exist between health and economics, where those in the highest income group can anticipated to outlive their lower income peers by six and a half years, on average. 3 Likewise, the four most common, non-communicable diseases – cardiovascular diseases, cancers, diabetes and chronic lung diseases disproportionally affect lower income persons and countries. 4 Health disparities are not limited to incomes – they include race, education and access-related factors. Addressing health disparities requires us to look beyond just inequality (as increasing numbers of American obtain health insurance) to health equity – the pursuit of which is key to addressing these disparities. Health equity relates to variations in population health, tied to unequal socio-economic conditions that can only be addressed by altering or attempting to alter these underlying conditions (disparities). 5 Healthcare policy is the only route to achieve a healthcare system that is equitable, sustainable and just (and thus avoid the pitchforks)!

The U.S. Government has a history of attempting to address poverty and public health problems such uninsured, underinsured, disabled, and health disparities through the public sector. This includes programs like Social Security, welfare, Medicare, and Medicaid. 6 Depending on who one might ask they have been marginally successful. For more than two decades, 2000 -2020, a primary goal of ‘Healthy People’ has been to reduce and then eliminate healthcare disparities. Yet they persist.

Disparities, in particular racial disparities, are pronounced in maternal and infant health. African-American women die in pregnancy or childbirth three to four times more often than white women, and their babies die 2.4 times the rate of their white counterparts. 7 African-American babies have lower birth weights – the leading cause of infant mortality. 7 Not attending high school impacts prenatal care; women who receive no prenatal care are three to four times more likely to die after giving birth than those who have even one prenatal appointment. 7 Rural women experience poorer health outcomes and have less access to health care than urban women.

Midwives are in an ideal position to help address these health disparities by providing safe, accessible, cost-effective, and quality care. 8


  1. Hanauer, N. (2014). The Pitchfork are coming…for us plutocrats. Polotico Magazine. Retrieved from coming-for-us-plutocrats-108014.html#.VOZq5_nF_UX
  1. Raz, G. (Narrator). (2015, February 6). Seven Deadly Sins [Radio broadcast episode]. In G. Raz (Producer), TED Radio Hour. Washington, DC: National Public Radio.
  1. Unnatural causes: Is inequality making us sick? Smith, L., Adelman, L., California Newsreel (Firm) and Vital Pictures (Firm) (Directors). (2008). [Video/DVD] San Francisco, Calif.: California Newsreel.
  1. World Health Organization (WHO). (2015). Global Health Observatory (GHO) data. NCD mortality and morbidity. Retrieved from
  1. Braveman, P., & Gruskin, S. (2003). Poverty, equity, human rights and health. Bulletin of the World Health Organization, 81(7), 539-545. Retrieved from 10.1590/S0042        96862003000700013.
  1. Kraft, M. E., & Furlong, S. R. (2015). Public Policy: Politics, Analysis, and Alternatives (5th ed.). Thousand Oaks, CA: CQ Press.
  1. Association of State and Territorial Health Officials (ASTHO). (2015). Disparities and inequalities in maternal and infant health outcomes (Issue brief)        Disparities-Issue-Brief/
  1. I am a Midwife 2.0 [iamamidwife]. (2012, May 18). ‪Midwives address health disparities. [Video file]. Retrieved from