CHICAGO — Medicaid coverage for undocumented pregnant women, as well as those up to 12 months’ postpartum, garnered intense debate at a Sunday reference committee hearing during the virtual American Medical Association (AMA) special meeting of its House of Delegates.
The debate came during a discussion of a resolution from the Medical Student Section asking the AMA to support extended Medicaid coverage to pregnant women up to 12 months’ postpartum, and to “work with relevant stakeholders to expand Medicaid eligibility for pregnant and postpartum non-citizen immigrants.” Don Cinotti, MD, an alternate delegate from the American Academy of Ophthalmology who was speaking for the Section Council on Ophthalmology and the Surgical Caucus, said the group objected to the way the resolution was written.
The resolution is “adding the words ‘non-citizen immigrant,’ which includes a large group of illegal aliens,” he said. “And I don’t think that the AMA should be in the position of condoning illegal activity, nor rewarding people who do break the law.” However, he added, “they’re here. They do need healthcare, and someone’s going to pay for it … We just don’t believe that Medicaid, which is almost bankrupt, is the place to do this. It should be federal money only; it should not involve the states and it should not harm any citizen that is already under Medicaid.”
Alan Klitzke, MD, a delegate from the American College of Nuclear Medicine who was chairing the reference committee, asked Cinotti whether his group was offering an amendment or just speaking in opposition; Cinotti said it was the latter. “It’s somebody else’s business to offer an amendment if they wish,” he said.
Dennis Galinsky, MD, who was speaking for the American College of Radiation Oncology, argued for referring the resolution to the AMA Board of Trustees. “These issues are very important,” he said. “We have citizens in the minority communities that are getting inadequate care in this area, and I think they do have to have priority. The issues of legal versus illegal, Green Card versus nothing — all of these things are so complex that I don’t think we can wordsmith this either here or in the House [of Delegates]. And I think that this should be referred, so that this can be looked at by the appropriate people.”
Sophia Spadafore, MD, a delegate from the Resident and Fellow Section who was speaking for the delegation, disagreed. “No human is illegal,” she said. “Growing up in Arizona, I had many friends, neighbors, and classmates who were immigrants” — some documented and others not. “We have to stop looking at this as an ‘us versus them,'” she added. “I strongly recommend that we adopt this resolution as written. Pregnancy and the postpartum period are not the time to take someone’s healthcare away, or to expect them to travel or leave. Our morbidity and mortality of maternal health in this country is abysmal; it shows that the system is broken. We have a chance to fix it. Let’s do our part.”
Kieran McAvoy, MD, a delegate from the American Geriatrics Society and chair-elect of the Resident and Fellow Section, spoke on behalf of the section in support of the resolution, noting that she herself was 17 weeks’ pregnant. “AMA policy 60.906 opposes the separation of migrant children from their families. Resolution 701 is essentially no different,” she said. “By not providing postpartum healthcare coverage to all of our patients, including those ineligible for Medicaid, we are essentially separating newborns from one of their parents … Let’s take an upstream approach to this issue. Let’s practice some compassionate healthcare. And let’s ensure that every single postpartum patient is covered.”
Dave Cundiff, MD, a delegate from the American Association of Public Health Physicians who was speaking for himself, said he learned a long time ago that “there’s no such thing as a baby; there’s only a mother-and-baby unit. And you can’t optimize the care of a baby — most of whom will be United States citizens — without also optimizing the care of the mother.”
Cundiff noted that in rural Washington state, where he lives, many immigrants, whether documented or undocumented, avoid healthcare because they’re afraid of immigration enforcement. “This is not about whether people will get care — it’s about whether the physicians who provide care for those in need will get paid or not.” Cundiff’s voice broke as he quoted the Bible: “The alien who resides with you shall be to you as the citizen among you. You shall love the alien as yourself, for you were aliens in the land of Egypt.”
Cinotti spoke again, this time in favor of referral; he noted that everyone agreed that these mothers and children should get healthcare. “The disagreement is who should pay for it,” he said. “In New Jersey, we are the highest-taxed state in the country, and yet, we are 49th in reimbursement and payment to the physicians. So adding more people to the Medicaid program does not help the physician … The reason I think this should be referred is that we should make a recommendation on what is the best way to pay for these patients. We have to have a system that’s fair.”
Delegates also discussed a report by the Council on Medical Service that recommended that the AMA support increased federal funding to promote access to and greater use of home- and community-based services. Several delegates told personal stories about their own experiences with home care. “My mother became demented in her late 80s,” said Galinsky. After putting her in a nursing home for 2 weeks, his family discovered she had an insurance policy that would cover home care. “We were able to keep her at home … She was able to still go out to lunch once in a while, and shop, and she had a totally different life because of that. I think that we should all support this.”