Legislating Quality Of Care Will Not Work

July 01, 1997

Public Health Reports, the journal of the U.S. Public Health Service, uses drive-by deliveries to explore the validity of legislating of health care. Legislative decisions do not result in the best quality of care for patients. Three separate pieces make the case: the results of research into the influences on the state legislators who introduced bills to curb drive-by deliveries; a viewpoint by Ruth Watson Lubic--former director of the Maternity Center Association--who writes that an important opportunity was missed; and a commentary by Senator James M. Jeffords (R-VT) who speaks of constituent pressures.

Comprehensive survey of state legislators finds concern for infant health, desire to limit the role of insurers and HMOs in medical decision-making, and anecdotal evidence very influential.

A survey of the 99 state legislators in 40 states who introduced legislation to assure insurance coverage for a post-partum hospital stay of at least 48 hours revealed that legislators were most influenced by concern for infant health, the desire to maintain physician and patient authority in decision-making regarding appropriate hospital length of stay, and a desire to limit the role of insurers and HMOs in length-of-stay decisions. Legislators were also influenced by constituents--parents and individual physicians--who contacted them, and by their own personal experiences of childbirth, and those of friends, relatives, and colleagues. To a lesser degree, legislators were also influenced by the opinions of the professional associations such as American Academy of Pediatrics and the America n College of Obstetricians and Gynecologists. As a percentage of the total number of state legislators, women legislators were over three times as likely to introduce this legislation as their male counterparts and Democrats were almost twice as likely to sponsor bills as legislators of other political parties.


Background

Shortening the average length of stay for deliveries--the most common reason for hospital admission in the United States--can result in significant cost savings for third-party payers. In 1970, the average length of stay for all hospital deliveries was 4.1 days. In 1992, the average had fallen to 2.6 days. Asserting that research supported the safety of a 24-hour discharge and that decisions to limit hospital coverage were justified, insurers were increasingly refusing to pay for stays beyond 24 hours for normal, uncomplicated vaginal deliveries.

Professional health-related associations and concerned individuals rallied in opposition, claiming that 24-hour postpartum hospital discharge should be curtailed, at least for the time being, for three reasons: (a) the practice was being driven by financial decisions and third party payers, rather than by physicians and patients; (b) health-related criteria and guidelines should be the driving force behind the discharge of mothers and newborns; and (c) the data provided little insight into whether early hospital discharge was safe, and if so, for whom and under what conditions.

The objections expressed by parents, health care providers, and professional medical associations were heard. Legislative initiatives formulated to curb the practice of "drive-by deliveries" were introduced in 40 states during the 1995-1996 legislative sessions. As of November 1996, laws or administrative regulations had been passed in 30 states: Alabama, Alaska, Connecticut, Florida, Georgia, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Maine, Maryland, Massachusetts, Minnesota, Missouri, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Virginia, and Washington.

Following the introduction of state-level legislative initiatives, state officials pressured for a Federal bill and the Newborns' and Mothers' Health Protection Act of 1996 was passed to take effect January 1, 1998. The law requires that a health plan or an employee health benefit plan offering maternity and childbirth benefits provide coverage for a minimum 48-hour hospital stay for normal vaginal delivery and 96-hour hospital stay for cesarean deliveries following delivery. In addition, the law provides for timely post-delivery care when the mother and infant are discharged before the minimum hospital length of stay has expired.

The Federal legislation applies to a resident of a state who is not protected by the state's laws, because he or she (a) receives health care in a state without pertinent legislation; (b) is covered by a health insurance company headquartered in another state; or (c) works for a self-insured employer. Because 82% of large companies self-insure and 65% of all companies do so, state-mandated health benefits do not pertain to a large portion of a state's population.

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NOTE: This memo to reporters is from the journal staff and is not an official release of the US Public Health Service; nor does it reflect USPHS policy.
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Public Health Reports

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