Eulalia Raymundo started her prenatal care with a smile and an ultrasound showing the first signs of a baby girl she would call Selina.
Her joy has turned to worry as she learned she is among more than 6,000 pregnant women in Nebraska who suddenly might be without prenatal medical coverage as a result of a change in the state’s Medicaid system.
Like Raymundo, a Guatemala native having her fifth child, about 1,000 are undocumented immigrants.
But an additional 5,000 poor, pregnant women who were born in this country or who are legal residents also are caught up in a revision of state policy that has many health care and immigrant advocates outraged.The revision has some state lawmakers questioning why Gov. Dave Heineman and top Medicaid officials did not propose any answers or seek legislative action.
“Either the governor is not in fact concerned about it, or he has passed the buck to the Legislature,” said State Sen. Danielle Conrad of Lincoln.
The governor’s spokeswoman, Jen Rae Hein, said Friday that Heineman “is reviewing the issue.”
Several state senators have embarked on a frantic search for a solution.
“I think this is the biggest pro-life issue in the Legislature this year,” said Sen. Jeremy Nordquist of Omaha.
Nebraska has long provided Medicaid coverage of prenatal care based on an unborn child’s eligibility, not the pregnant woman’s.
The policy has allowed pregnant women to receive care even if they cannot qualify for Medicaid on their own. That includes undocumented immigrants, such as Raymundo, who are barred from getting federal benefits themselves.
Nebraska has provided them with prenatal care to give their children, who are expected to be born as U.S. citizens, the best start possible.
The policy also affects pregnant women whose incomes are near the cutoff for Medicaid. They qualify only if their unborn child is included as a family member.
But the federal Centers for Medicare and Medicaid Services notified the Nebraska Department of Health and Human Services in early December that the Nebraska policy violates federal rules, which do not allow coverage for an unborn child.
In a letter dated Nov. 30, a regional CMS official offered a couple of options for the state to continue prenatal care for those women.
One would be through the state’s children’s health insurance program.
The Nebraska program, called Kids Connection, now covers children ineligible for Medicaid because their family income is too high. Under federal law, the program also could be used to cover unborn children.
The financial impact of going this route is unclear. The federal government provides a higher match for Kids Connection than for Medicaid, which would help the state’s bottom line.
But the income cutoff for Kids Connection is 200 percent of the federal poverty line. The cutoff for Medicaid prenatal care has been 185 percent.
That means additional women might qualify for coverage, increasing the cost to the state.
A family of two could make as much as $26,955 under the 185 percent cutoff. At 200 percent, a family of two could have an income as high as $29,140.
The second option would be a program funded 100 percent by the state.
So far, state officials have taken neither option.
Kerry Winterer, HHS chief executive officer, told a legislative committee this week that the department cannot act on its own to continue the coverage.
“We’ve looked at this in every way that we can,” he said. “Essentially, it becomes a legislative issue.”
Winterer acknowledged that the department did not offer legislation or seek sponsors.
A letter notifying senators about the issue was not sent until Jan. 15, near the end of the 10-day bill introduction period. The only option mentioned in the letter was a state-funded program.
Some senators said lawmakers share the responsibility for not offering legislation.
“I think it was probably the senators that dropped the ball,” said Sen. Tom Hansen of North Platte.
Some advocacy groups learned of the issue in December but said they did not realize legislation might be needed.
Jim Cunningham of the Nebraska Catholic Conference said he understood that HHS could make an administrative change in Kids Connection to continue the coverage.
Sen. Tim Gay of Papillion, chairman of the Health and Human Services Committee, said a group of senators now is starting to collect information and work toward a solution.
If legislation is needed, lawmakers could suspend the rules to allow introduction of a new bill, or they could amend an existing bill dealing with Medicaid.
“Bills aren’t drafted in a day,” Gay said. “We’re still defining the problem, if you ask me.”
In the meantime, HHS is moving ahead to end coverage.
A notice sent to Medicaid providers Thursday said prenatal coverage for undocumented immigrants is to end immediately.
Medicaid will continue to pay for delivery and birthing services, which are considered emergency care.
HHS workers are reviewing cases of the 5,000 other women to see whether they can qualify for Medicaid through other means. If not, their coverage will end March 1.
Raymundo said she doesn’t know how she’ll cope with the loss of prenatal coverage.
She can get care on a sliding fee schedule at OneWorld Community Health Care Centers, a federally subsidized clinic.
But the sliding fee doesn’t apply to lab tests and services performed elsewhere. She is not sure how she would pay for those, as her husband’s packinghouse income already is stretched paying for four children ages 9 to 2. He has no medical insurance, she said.
“I hope God will help us,” she said.
Dr. Carl Smith of the University of Nebraska Medical Center said the fear is that without coverage, women will choose to forego certain procedures, endangering baby and mother.
At the least, experts say, it could lead to greater costs related to a sick child after delivery.
“It has the potential to make Nebraska look even worse than it looks already in terms of infant mortality and premature delivery rates,” Smith said.
Dr. Kris McVea, chief medical officer at OneWorld, said the clinic estimates that it will lose $650,000 annually if undocumented women are not covered by Medicaid.
Of the estimated 1,000 undocumented women who are likely to be affected, about 600 are treated through OneWorld.
McVea said she cannot understand why state officials and the governor don’t make the administrative change to cover the women affected.
“It is such an easy thing to do,” she said. “It will save lives, prevent birth defects. I can’t imagine why someone would ever oppose this.”
She said the babies are going to be the ones bearing the brunt of the changes.
“They’re American citizens.”