Amos Grünebaum: The AMA Chose Grants and Definitions Over Payment Reform
Amos Grünebaum, Professor of Obstetrics and Gynecology at Donald and Barbara Zucker School of Medicine, shared a post on LinkedIn:
“The AMA’s Immediate Past President restates the familiar figures — 19 maternal deaths per 100,000 live births in 2023, 50.3 among Black women, more than 80% preventable — and attributes them to social determinants, maternity care deserts, and workforce shortages. The proposed remedies are $1 million in micro grants (20 awards of $50,000), 14,000 Medicare-funded GME slots pending in Congress, standardized morbidity definitions, and legislation to reimburse remote monitoring devices. Medicaid, which finances roughly 41% of all births in this country, appears exactly once in the entire piece — as a payer for telehealth hardware.
Call it what it is: a statement about maternal mortality that never names the mechanism.
Medicaid financed 41% of U.S. births in 2023 — 40% in metro areas, 47% in nonmetro, and nearly half of rural births. Commercial insurance pays, on average, $8,732 more per delivery than fee-for-service Medicaid — $11,084 more for cesarean, $7,461 more for vaginal birth — and that gap was present in all 38 states with reliable data. The consequence is documented, not theoretical: lower Medicaid rates mean a higher probability of being turned away by physicians. The 2023 Medicaid shortfall to hospitals was $27.5 billion.
Maternity units do not close because of housing instability. They close because the payer mix cannot sustain them. The counties the AMA calls “maternity care deserts” are, with striking regularity, the counties where Medicaid finances most of the births. Two-tier payment produces two-tier access, and two-tier access produces two-tier outcomes.
–> Naming social determinants while leaving the payment differential unnamed is not a diagnosis — it is a way of avoiding one.
–> $1 million in micro grants, against roughly 3.6 million births a year, is about 28 cents per birth.
The AMA has real leverage on CMS rate-setting. It chose to spend this essay on grants and definitions.”
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