Intended for healthcare professionals


US women asked to pay for epidurals in advance

BMJ 1999; 318 doi: (Published 27 March 1999) Cite this as: BMJ 1999;318:828
  1. James Ciment
  1. New York

    Responding to reports that certain hospitals are requiring women with Medicaid to pay for epidural analgesia for childbirth in cash and in advance, the director of the Center for Medicaid and State Operations—an agency within the US Department of Health and Human Services—issued a letter to state Medicaid directors across the country reminding them of their responsibilities and demanding that action be taken.

    Medicaid—a programme inaugurated in the 1960s—pays for the medical services of impoverished Americans. Last year, more than 1 in 3 childbirths in the country were paid for by Medicaid.

    In epidural analgesia local anaesthetics are delivered into the epidural space. In her 27 January letter, director Sally Richardson wrote, “Treatment of a Medicaid patient in this manner is not just a concern, it is alarming….A hospital which accepts a Medicaid patient for treatment accepts the responsibility for making sure that the patient receives all medically necessary services.”

    The incidents that sparked the warning letter occurred in New York, although the national Medicaid office acknowledged that they have heard similar stories from California as well. One case cited in the letter concerned a woman in New York city whose obstetrician had ordered the epidural analgesia in advance.

    But while in labour the woman was refused the service because she had not prepaid in cash, despite the fact that she offered a cheque, a Western Union money telegram, and a credit card to pay for the analgesia.

    Mary Kahn, a spokeswoman for Medicaid, thinks that these incidents hint at a much larger problem. “It worries us that this is going on all over the place, but that the patients are not reporting it. And if they are not reporting it, we don't know it is happening.”

    Referring to the Medicaid patients generally, she added: “We hope that these stories will stir up people to let us know.”

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    Medicaid patients have been asked to pay in advance for epidurals

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