Sizing Up the Sentinel Measure of How Well America Promotes the Health of Women and Children –

Key Provisions of the Affordable Care Act Addressing Infant Mortality

By Brent Ewig, MHS
Director of Public Policy & Government Affairs, Association of Maternal & Child Health Programs

Infant mortality is one of the sentinel measures of how well any society is protecting and promoting the health of its women, children and families.  Accordingly, it is fair to ask: How are we doing and how might health reform make a difference?  Taking a long term view, the United States has made tremendous progress in reducing infant mortality rates. In fact, in 1999 the CDC included "healthier mothers and babies" among the 10 greatest public health achievements of the 20th century, noting that from 1915 through 1997, the infant mortality rate declined greater than 90 percent and the maternal mortality rate declined almost 99 percent.

Today however we are painfully aware that this progress has essentially stalled. Moreover, significant disparities by race and ethnicity persist with the African American rate double and in some areas triple the rate for whites.  At this historic turning point in the Americanhealth system there are key provisions in the Affordable Care Act related to coverage, benefits and prevention investments that offer tremendous opportunities for us to reinvigorate and accelerate progress on this sentinel measure.

First, the law will extend affordable health insurance to the estimated one in five women of childbearing age who are currently uninsured. That means roughly 12 million women will have a much better opportunity to receive regular preventive services and early access to prenatal care if they were to become pregnant.

Second, reform provisions ensure that benefits packages have to include certain clinical preventive services with no cost-sharing; maternity and well child care services have to be included in any basic benefits package; and the practice of gender rating insurance premiums is prohibited. An additional provision calls for the development of Bright Futures preventive services guidelines for women. The Department of Health and Human Services recently contracted with the prestigious Institute of Medicine to begin formulating these recommendations. AMCHP has nominated two members to serve on this panel and in our view this is a key opportunity to assure that women are guaranteed access - with no cost sharing - to essential clinical preventive services.

But one thing we know from public health science is that health insurance – while fundamental and essential – is insufficient to improve population health outcomes. The preconception care movement also tells us that focusing on prenatal care alone might simply be too late. As one wise state Maternal and Child Health Director taught me, "We are realizing that seven or eight months of world class prenatal care simply cannot reverse a lifetime of unhealthy behaviors and environmental exposures that contribute to poor birth outcomes.”

Accordingly, throughout the health reform debate, AMCHP has advocated that our best opportunities to improve birth outcomes and prevent infant mortality likely come from focusing on upstream interventions across the lifespan that prevent or mitigate the chronic disease and other risk factors that might cause poor health and poor birth outcomes. In other words – and in what has become an AMCHP advocacy mantra on Capitol Hill – healthy kids start with healthy moms, healthy families, and healthy communities.

Fortunately, the Affordable Care Act includes several key provisions that could move preconception health recommendations into practice and have an impact on reducing infant mortality. Here are the highlights:

The creation of a National Prevention and Wellness Strategy and the Public Health Investment Fund will help reorient our healthsystem toward prevention of disease and injuries. 

• National Prevention and Wellness Strategy: The federal government does not currently have any mechanisms or plans that coordinate health policy across government to assess our public health status, establish national priorities, and identify health goals and objectives. The law calls for creation of a national strategy to accomplish these goals. AMCHP will advocate that improving our nation’s current ranking of 30 in the industrialized world in infant mortality rates has to be a national priority.
• The Public Health Investment Fund: Is a dedicated funding stream for public health and prevention that is needed to meet the many health threats we must face, including infant mortality and its contributing factors. The Fund will build upon what we know already works and to test new approaches. It will prioritize prevention and health, not just treatment. It will supportcore public health infrastructure to help state, local and tribal health departments meet their responsibilities and ensure adequate levels of accountability. The Fund also boosts public health research and will provide public health practitioners and policymakers with the information we need to make the best decisions about preventive health.

Finally, the creation of the new $1.5 billion Maternal, Infant and Early Childhood Home Visiting Program offers states and communities the most direct opportunity to provide at-risk communities with the services and systems needed to move the needle on maternal and infant health indicators. For additional background information, see our June 2010 Pulse issue on home visiting.

None of these provisions are a silver bullet solution to the persistent and complex problem of infant mortality, but taken together they will go a long way to providing the commitment, leadership and resources we need to accelerate progress.