Infant Mortality Rises in North Carolina: Black Babies do Better in Botswana

Botswana, a 96% black African nation, has an infant mortality rate of 9.9 per 1000 live births according to the CIA. North Carolina's infant mortality rate rose for the second year in a row in 2012 to 7.4 per 1000 for all babies and 13.9 per 1000 for black infants. Black babies in their first year of life have better prospects for survival in Botswana than North Carolina. Rural counties with high African American populations along the I-95 corridor have extraordinarily high infant mortality rates for a developed nation. Japan's infant mortality rate is 2.2 while the rate in Pasquotank County, NC is 20.4. Yet, Governor McCrory (R) has refused to expand Medicaid to cover the working poor, rejected running a state health insurance exchange under the Affordable Care Act, delayed funding the Women's Infants and Children program, slashed unemployment insurance, and is attempting to privatize a state run Medicaid program that had been a national model before the great recession hit.

“It’s discouraging that the rate worsened, particularly after the past several years, where we were at record lows,” said pediatrician Peter Morris, who heads the legislative Child Fatality Task Force. ...

Morris also noted that the research indicates that the state of a woman’s health before she gets pregnant is a prime predictor of how healthy her babies will be. About 12 percent of births were to women who had fewer than six months between delivery and a subsequent conception.

“If you’re trying to take care of women’s health before they’re pregnant, it’d be a really good idea to have health care coverage for their entire adulthood,” Morris said.

Even though low-income women are eligible for Medicaid when they’re pregnant and for three months after they give birth, about one in five of North Carolina’s adults under the age of 65 is uninsured.

My wife is an obstetrician/gynecologist working in North Carolina so I know the difficulties of delivering health care to pregnant women here. When the great recession hit, the state cut and delayed Medicaid payments, causing financial problems. She closed her practice and found a job in a larger town. Doctors and hospitals delivering care to lower middle class and working class women have been hit hard by the recession, just like their patients. That's why infant mortality is rising. Rural and community hospitals in North Carolina are struggling to survive. Big city hospital systems bring in high revenues from insured patients for specialized procedures. Urban hospital centers put the profits back into improving their facilities and investing in new equipment. Rural and community hospitals are struggling to replace obsolete equipment at present revenue levels. I interviewed the CEO of Onslow Memorial Hospital, Ed Piper, about the need for Medicaid expansion to learn the details.

Ed explained to me that hospitals made a deal with the federal government to accept an end to federal payments for unreimbursed care because the Affordable Care Act would expand Medicaid coverage for the working poor and provide subsidized insurance coverage for lower middle class Americans who weren't covered by employer provided insurance plans. His hospital's revenues are now running barely above costs, a 3.5% margin, barely enough to replace failing old equipment. But, because McCrory is rejecting Medicaid expansion, his hospital will be in trouble next year when the federal reimbursements for unreimbursed care cease. Onslow county has one of the best infant mortality rates in rural eastern North Carolina. Smaller hospitals in poor counties with out military bases will be in deep trouble. And these counties already have third-world-level infant mortality rates as high as 20 deaths per 1000 births.

North Carolina's Rate of Uninsurance by County correlates Directly with Infant Mortality

For 30 years Democrats and Republicans worked together in North Carolina to improve the health care of women and children to cut infant mortality rates. Governor Jim Holshauser, a moderate Republican who died this summer, began efforts in the mid 1970's to improve infant mortality rates by improving rural health care.

He supported creating a statewide kindergarten system. He backed the Coastal Management Act, regarded as national landmark environmental legislation to protect the state’s fragile seacoast. Holshouser helped start the rural health center program to provide more medical care in the countryside. He oversaw a major expansion of the state park system. He appointed several blacks and women to high-visibility posts in state government. And he supported creating black-oriented enterprises such as Soul City, the new town project started in Warren County by former civil rights leader Floyd McKissick.

To date, McCrory and the Republican legislature that took over in 2012 have implemented extreme anti-government policies that have shocked many North Carolinians accustomed to the prudent governance of Jim Holshauser and moderate Republicans. One of my wife's cousins, a longtime Republican, and his wife just declared themselves independents in response to the extreme, inhuman policies of today's North Carolina Republicans. He is not alone. McCrory's popularity is plummeting. The latest PPP poll showed McCrory's approval rating in the low 30s.

Q2 Do you approve or disapprove of Governor Pat
McCrory’s job performance?
Approve .......................................................... 32%
Disapprove ....................................................... 50%
Not sure .......................................................... 19%

Governor McCrory and the Republican legislature can reverse course and expand Medicaid to prevent a disastrous decline in rural health care. At present North Carolina has one and a half million uninsured residents. About half a million of those residents would be eligible for Medicaid expansion. Because the federal government is picking up the full cost of expansion, North Carolina would bring in over a billion federal dollars to hospitals and health care providers across the state at no cost to the state. In many rural counties, community hospitals are the largest employers. Those hospitals, their workers and their communities will be slammed by rejecting Medicaid expansion. Counties will lose millions of federal dollars they desperately need.

About half a million of the uninsured earn less than 100 percent of the poverty level – $11,490 for a single person and $23,500 for a family of four. They are not eligible for insurance subsidies, and therefore are not subject to a penalty for not buying health insurance. That’s because authors of the Affordable Care Act assumed this group would get benefits through the Medicaid expansion.

Mostly these people who earn too little to get subsidies are healthy adults without children. They are “literally too poor to be eligible,” said Madison Hardee, a lawyer with Legal Services of the Southern Piedmont.

Hospitals across North Carolina had embraced Medicaid expansion. It meant they would be reimbursed for treating poor people who are unable to pay hospital bills.

“This was integral to implementation of the Affordable Care Act,” said Joe Piemont, president and chief operating officer of Carolinas HealthCare System in Charlotte.

“These (uninsured) folks are here, and we’re taking care of them now, but it certainly would have been a benefit to have them qualify for the Medicaid expansion.”

The annual cost to North Carolina’s hospitals of not expanding Medicaid is estimated to be as much as $660 million, based on an analysis conducted for the N.C. Institute of Medicine by N.C. Division of Medical Assistance.

What the Republican ideologues and the governor don't understand is that keeping women of child bearing age healthy saves both money and lives. For every baby that dies in the first year there are many more that require long hospital stays. One sick baby of uninsured parents can cost a hospital hundreds of thousands of dollars. It's far cheaper to fund insurance and good nutrition for healthy mothers and babies than it is to pay the cost of caring for prematurely born infants. When women with uncontrolled blood sugar problems come into the office or hospital pregnant the damage to the baby may already be done. High maternal blood sugar levels in early pregnancy can cause heart defects and other fetal anomalies. Pregnancy Medicaid is not sufficient to prevent devastating health problems that will be apparent at birth. Blood sugar levels need to be controlled in the early weeks of pregnancy before women typically show up for care. Women need health care and adequate nutrition before they get pregnant to prevent birth defects and prematurity.

North Carolina's infant mortality rate is shameful. The infant mortality rate for black babies is beyond shameful. How can a state in the nation with the world's largest economy have worse black infant mortality than Botswana?

I am appalled and disgusted that Governor McCrory is promoting policies that will kill even more babies. North Carolina's rural health care is about to collapse under the load of uninsured poor people that could be covered by Medicaid expansion. Governor McCrory needs to change course to save babies and to save North Carolina's community hospitals.

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What Botswana has done right

Despite problems with HIV, Botswana has achieved very good infant mortality rates for Africa by providing health services to everyone according to comments on DailyKos by American expats who have lived in southern Africa.