Iowa’s reliance on the safety net is likely to grow amid growing health care policy gaps

“It was so dark that I remember thinking if I don’t pay careful attention, I won’t know which direction to go to get back to my car if I am in the wrong place.” Caitlin Hainley, a Doctorate level educated Certified Nurse Midwife described the night she tramped through a dark, muddy field for half an hour. She was trying to deliver a baby in the middle of the night to a rural family in Southern Iowa. Hainley attended the labor with no electricity, headlamp strapped to her head, and peacefully delivered a healthy baby. She returned the next day to check on the family “They were so happy that they got the birth they wanted, and that the care provided was meaningful, relational and kind.”

Not only did Hainley provide safe and high-quality care, but she helped her patient sign up for Medicaid. “At one of the prenatal appts in my office we talked to them about Medicaid, printed out information, and at subsequent appointments, checked in on them in the process.”

Hainley is one of many dedicated health care providers that Iowa is fortunate to have. But these providers face too many barriers to provide care to Iowans, and this year these barriers grew substantially in number and scope.

The past session we endured a flurry of state level actions that have resulted in Iowans losing access to health care. Senate File 494, signed into law earlier this year, is anticipated to be a barrier to Iowans specifically in regards to SNAP benefits, but it also will have a large impact on Medicaid recipients. In a state with increasingly higher maternal death rates, we had an opportunity to expand Medicaid coverage to those who give birth from sixty days to twelve months in an amendment to HF732. While this life saving coverage was extended in Missouri and Nebraska, it was shot down in our legislature. But this is only part of this torturous equation. “Even if we extend Medicaid 12 months postpartum, women still can't access care because of maternity deserts and the fact that the CON (Certificate of Need) keeps the number of free-standing birth centers low. And it's hard to make it work financially to provide maternity care in the first place because of low reimbursement.” Iowa not only is unattractive due to low reimbursement rates and a lack of places to practice. HF732 limits access to care, but it also will have additional collateral damage with its impact on the pipeline of providers choosing to train, practice and live in Iowa.

“Not only have all of these issues converged to create maternity health deserts across much of this state but a study by IDPH (now HHS) found that in counties where the only birthing unit closed, there were higher rates of inadequate prenatal care and severely inadequate prenatal care.”

More recently, Iowa was one of 30 states called out by CMS in a letter outlining eligibility systems issues, issues that resulted in thousands of Iowans losing health care coverage. The termination of continuous Medicaid enrollment, otherwise known as Medicaid unwinding, has been on state and federal radars for months since the announcement of the public health emergency expiration.

Jon Rosmann, CEO of SafeNetRx says his organization is seeing a lot of patient demand with Medicaid unwinding. “We have a flat contract to take care of the population — it doesn’t matter if we are contributing $5 million or $25 million in donated medicine, we get the same amount of program revenue. It’s hard to respond.”

Yet Rosmann’s staff do respond. Over 10,000 Iowans who accessed their program last year saved an average of $200 on every 30-day prescription filled with donated medicine. Prior to COVID, the program also was essential in decreasing recidivism rates to Iowa’s correctional facilities simply by providing necessary medications. Charitable medication programs like SafeNetRx not only help individuals, they help local economies and communities by decreasing cost to health systems and reducing inpatient stays at hospitals. “The health care safety net plays a critical role in maintaining a healthy workforce. Businesses that do not support their workforce with adequate health coverage or a living wage place significant stress on the safety net system. My hope is that key decision-makers and funders will start to recognize safety net health services for what they are — an economic development resource that is vital to maintaining a healthy workforce and community.”

With his service work in rural Iowa, he sees the impact of inadequate health care across Iowa. “Many of the rural communities are in decline and as the foundation of these communities decline, [they] continue to need to rely on other things. Economic development, workforce capacity, and health care — all are inextricably linked and often not thought of together, but they need to be.”

Clarissa is one of the thousands who have received services from SafeNetRx. She was housebound and socially isolated except for her animals. She is excited to have a new worker accompany her on walks that she can now take thanks to the medications that helped improve her daily life. “I can’t thank [SafeNetRx] enough for being there when I needed them. They saved my life.”

If we continue to limit coverage and access, Iowa will need to better fund safety net programs that provide health care to those who are uninsured and underinsured. Dr. Andy McGuire stressed the need for a bipartisan solution “Healthcare should not be partisan — you can fall this afternoon and need care. I think (all) want to do something about it. This is the number one thing that comes up with constituents everywhere they go.” With the announcement of tax cuts that will mostly benefit the wealthy and pose a hardship for programs that serve Iowans, this needed funding increase seems unlikely.

Chris Espersen is a Gazette editorial fellow. chris.espersen@thegazette.com