New Florida law allowing C-sections outside hospitals could be national model

by Anna Claire Vollers, Alabama Reflector
January 29, 2025

This story originally appeared on Stateline.

A recently enacted Florida law that allows doctors to deliver babies via cesarean section in clinics outside of hospitals could be a blueprint for other states, even as critics point to the role that a private equity-backed physicians group played in its passage.

The United States has poor maternal health outcomes compared with peer nations, and hospital labor and delivery units are shuttering around the country because of financial strain. Supporters say the Florida law could increase access to maternity care and lower costs for expecting patients.

But critics, including some physician, hospital and midwife groups, warn it’s an untested model that could put the health of mothers and babies at risk. They also note that private equity firms that have made other forays into health care have attracted state scrutiny for allegedly valuing profits over patient safety.

Alex Borsa, a researcher at Columbia University whose published work focuses on private equity’s impact on health care, said he’s not surprised that Florida has become the testing ground for such clinics.

“In addition to Florida being the Wild West in a number of policy directions, it has one of the highest concentrations of private equity-backed health care operators, including OB-GYN and fertility,” Borsa said.

Traditional birth centers are typically staffed by midwives who provide maternity care for low-risk pregnancies and births. Twenty-nine such centers operate in Florida, and about 400 are licensed around the country. The focus in these centers is on natural childbirth in a homelike setting, where women labor without anesthesia and deliver babies vaginally.

Florida’s law creates a new designation, called an “advanced birth center,” that allows physicians to offer labor and delivery services at a freestanding clinic, including delivery by cesarean section. There currently are no such centers. A C-section is a surgical procedure performed with anesthesia in which a baby is delivered through an incision in the patient’s abdomen and uterus. C-sections are generally reserved for situations in which a doctor believes a vaginal birth could be risky for the mother or baby.

Prior to the law’s passage last spring, C-sections could only be performed in hospitals, which have the staffing and equipment designed for surgery and potential complications.

But a private equity-owned physician group called Women’s Care Enterprises in recent years lobbied Florida legislators for the new designation. The group, owned by London-based investment firm BC Partners, operates about 100 clinics across Florida and a dozen more in Arizona, California and Kentucky.

The new designation was tucked inside a larger health policy bill and became law despite opposition from medical and midwifery groups.

“Both mom and baby deserve access to the best possible care, which is why we believe that C-sections should be performed exclusively in the hospital setting where doctors, multidisciplinary teams, sophisticated equipment, and other critical resources are immediately available in the event complications arise,” Florida Hospital Association President and CEO Mary Mayhew told Stateline in a statement.

But the association didn’t fight the bill, which among other things increased Medicaid payments to hospitals for maternity care. Other groups did oppose it.

“We’re primarily opposed to it because you’re calling a lion a tiger,” said Kate Bauer, executive director of the American Association of Birth Centers, a nonprofit that sets national standards for birth centers.

She noted that while advanced birth centers would offer maternity care outside a hospital setting, they are not the same as traditional midwifery-based birth centers. Midwife-attended births are for people with low-risk pregnancies and tend to focus on low-intervention care and emphasize natural birthing techniques. Physician-attended births tend to rely on more advanced medical interventions, like epidurals and labor-inducing medication.

Private equity jumps in

Florida lawmakers supporting the new advanced birth center designation have said it has the potential to increase access to maternity care in underserved areas and reduce costs. Just two of Florida’s 22 rural hospitals have labor and delivery services.

The staff of Florida state Sen. Gayle Harrell, the Republican who sponsored the bill, told Stateline she was unavailable to comment on it. But in previous committee hearings, Republican legislators heralded the centers as an innovative solution for obstetrical care.

“I think what we are hearing from our medical community is the desire for options,” state Sen. Colleen Burton, a Republican, said at a December 2023 committee hearing on the bill. “And what we’re particularly hearing from are patients, from Floridians, [who want] options. And potentially this could provide a lower-cost option.”

But critics question whether OB-GYNs, already in short supply in Florida, are likely to open advanced birth centers in low-income and rural communities where a larger share of patients have Medicaid. The government-sponsored insurance reimburses doctors significantly less for maternity care compared with private insurance.

Borsa, of Columbia University, co-authored a 2020 study that found private equity-owned OB-GYN offices were more likely to be located in urban areas with median household incomes above the national average.

Private equity firms use pooled money from investors to buy controlling stakes in companies. They typically focus on boosting the value of a company before selling it within a few years, ideally at a profit. In the past decade, private equity investors have spent $1 trillion acquiring health care companies.

Borsa said he and his colleagues have found strong evidence that private equity involvement in health care “pretty consistently increases costs to patients and payers.”

“There’s a fantasy that Wall Street investors are somehow going to increase access in some of the most rural and poor parts of the country, but we haven’t seen evidence of that,” he said.

In recent years, private equity’s involvement in the health care industry has drawn public ire and legislative scrutiny. Earlier this month, for example, the U.S. Senate Budget Committee released a report detailing how private equity firms wrung hundreds of millions from struggling hospitals.

Dr. Helen Kuroki, the chief medical officer for Women’s Care Enterprises, declined to comment on its support of the new law and on when it might open an advanced birth center. Representatives have previously said they’re looking at opening a center in Tampa or Orlando.

Labor and delivery services tend to be financial losers for hospitals, thanks to low reimbursement rates, particularly from Medicaid. In rural areas, where Medicaid covers as many as half of all births, reimbursement doesn’t cover the full cost of providing obstetrical services.

If patients covered by better-paying private insurance flock to freestanding birth centers that can perform C-sections, that would leave hospitals with a higher proportion of Medicaid patients. And owning the surgical space would allow physicians groups such as Women’s Care Enterprises to keep more of the reimbursement dollars that would normally go to a hospital.

Like surgical centers — sort of

Supporters have compared Florida’s new birth center model to outpatient surgery centers, where patients undergo surgical procedures that don’t require overnight hospital stays. Patients who undergo C-sections would be able to stay overnight at the new birth centers.

But critics argue a C-section is inherently different from, say, cataract surgery or a tonsillectomy.

“We’ve seen outpatient surgery centers can be a successful health care delivery model,” said Bauer, of the birth centers association. “For me, the primary difference is that surgical birth is the only surgery where, when you’re done, you have an extra person. And it’s an extra person whose health may be compromised.”

Some Florida lawmakers expressed concern that the new centers wouldn’t be required to have pediatric specialists on hand to care for a baby if there’s a problem after the birth. The centers are required to have a written agreement with a local hospital for transferring patients with complications. And they also must follow most safety standards for outpatient surgical centers.

So far, Florida remains an outlier. Legislators in other states have yet to introduce similar bills.

But as private equity firms deepen their involvement in women’s health and other health care sectors, Borsa expects them to ratchet up their lobbying of state legislators to win favorable policy changes.

“We could see more health care lobbying, and specifically around this issue in other parts of the country,” he said. “I don’t think this is a one-off, especially if they find they can derive profits.”

Stateline is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Stateline maintains editorial independence. Contact Editor Scott S. Greenberger for questions: info@stateline.org.

Alabama Reflector is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Alabama Reflector maintains editorial independence. Contact Editor Brian Lyman for questions: info@alabamareflector.com.

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Alabama House Democrats, Republicans unveil legislative priorities for 2025 session

by Ralph Chapoco, Alabama Reflector
January 29, 2025

Members of the two parties in the Alabama House this week released their legislative agendas for the 2025 session, which starts on Tuesday.

Alabama Democrats presented Forward for Freedom, the theme for their platform during a news conference Tuesday that touched on an array of issues, from expanding affordable health care and promoting gun safety to making investments in education and voting rights.

“We understand how the law can sometimes be a double-edged sword,” said House Minority Leader Anthony Daniels, D-Huntsville during the news conference. “It can either be a seemingly immovable obstacle to your inalienable right to life, liberty and pursuit of happiness, or it can be the key to unlocking the door to the American Dream.”

Daniels then said that the goal is to expand freedom and “to stand staunchly opposed to any efforts to diminish it, particularly when those efforts are purposely discriminatory.”

Members of the House Republican Conference, who hold a supermajority in the chamber, released their agenda, titled “Alabama Values,” on Monday.

“The ‘Alabama Values’ name represents the conservative beliefs and values that most Alabamians embrace, but, at the same time, it also represents the morals and principles that we ‘value’ as a people,” House Majority Leader Scott Stadthagen, R-Hartselle said in a statement. “Our caucus members stand unanimous in support of this agenda, and we look forward to promoting these conservative ideas and beliefs throughout the upcoming session and beyond.”

The priorities mimic that of the national Republican Party, which includes border protection.

“With (President) Donald Trump in the White House, Alabama House Republicans will once again promote policies that discourage illegal immigrants from locating here, and we will work to repair the economic and societal damage resulting from the irresponsible open border policies pushed by those on the left,” the agenda stated.

Both caucuses said they would prioritize public safety in the coming session.

Violence, particularly firearms, has been one of the key problems that the state faces, especially in the state’s urban centers like Birmingham and Mobile. According to data obtained from the Alabama Commission on Re-Entry, most crimes in Alabama have decreased, but homicides have increased by 43%.

In September, four people were killed and another 17 people were injured during a mass shooting incident in Birmingham. In November, a shooting incident near Tuskegee University left one person dead and another 16 injured.

“Alabama House Republicans will work with law enforcement officials on the state and local levels to provide needed resources and supplement efforts to combat crime while preserving the fundamental gun rights that allow our citizens to protect themselves from harm,” the GOP agenda stated.

The Democratic platform calls for measures to address access to weapons, and includes a call for the repeal of permitless concealed carry laws, signed by Gov. Kay Ivey in 2022.

Democrats will also offer HB 26, sponsored by Rep. Phillip Ensler, D-Montgomery, that would make it a state crime to use a “Glock switch” to convert a semi automatic firearm to a fully automatic weapon.

Another bill, HB 23, sponsored by Rep. Kenyatté Hassell, D-Montgomery, would require that a person have a permit to lawfully have an assault weapon. Rep. Barbara Drummond, D-Mobile, also plans to refile a bill require parents to safely secure their firearms so that children do not gain access.

Democrats also plan to push on voting rights.

“Every other right and freedom we enjoy today is predicated on that fundamental right to vote,” Rep. Adline Clarke, D-Mobile said on Tuesday. “Yet, so many of our citizens do not participate, and think that their vote just doesn’t matter.”

Clarke is sponsoring HB 31, which would allow  a voter with a disability to designate someone to deliver an absentee ballot and the absentee ballot application to the election manager.  Clarke has also filed HB 60, which among other provisions would establish no-excuse absentee voting and an Alabama Voting Rights Commission to review actions by the state that could discriminate against protected classes of voters.

House Democrats also want to increase investments in education, hoping to have some input when the state considers a new school funding model.

“We are really excited about that because we have money,” Drummond said. “When federal dollars came to Alabama, we put away some of that money, so we are going to be able to do a hybrid model that we can start funding some of those needed areas and then work our way out of the foundation program.”

The hybrid model would allocate a base amount for each school, but also additional resources for groups of students, such as those with a disability and English Language Learners.

The Alabama Values platform said Republicans would be committed “to funding and expanding public education programs that produce desired results, addressing programs that fall short, and continuing to provide teachers and administrators with the classroom resources they need to do their jobs effectively.”

Alabama Reflector is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Alabama Reflector maintains editorial independence. Contact Editor Brian Lyman for questions: info@alabamareflector.com.

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Trump’s federal funding freeze leads to confusion, concern among Alabama agencies, nonprofits

by Alander Rocha, Alabama Reflector
January 28, 2025

President Donald Trump’s freeze on federal assistance created confusion and concern Tuesday among state agencies and nonprofits that depend on federal money for operations.

A spokeswoman for the Alabama Medicaid Agency said Tuesday that the agency appeared to have been locked out of its federal funding portal, though it was restored later in the day.  The Alabama State Department of Education said that at least some of its discretionary funding had been affected.

In a memo dated Monday, the White House’s Office of Management and Budget (OMB) announced a freeze on all federal financial assistance, including grants and loans. The move affected both state programs and nonprofits that depend on federal funding for programs.

The United Way of Central Alabama said in a statement Tuesday that it was “carefully evaluating” what the move meant for programs it supports — “whether it’s housing for veterans experiencing homelessness, meals for homebound seniors or support for parents raising children.”

“The federal grants we receive are crucial for services we provide in the community, and without this cash flow for an undetermined amount of time, both we and our network of funded partner agencies could face significant operational risks,” the statement said. “This freeze also jeopardizes the financial security and stability of the families who depend on these much-needed community services.”

The memo also led to widespread confusion about what the freeze meant for Medicaid, a federal program serving poor and low-income Americans. In Alabama, Medicaid covered about 1 million people – nearly 20% of the population – in 2022 and paid for more than half the births in the state. The program, considered critical for health care in Alabama, gets about 73% of its funding from the federal government.

A footnote attached to the OMB memo said it should not be “construed to impact Medicare or Social Security benefits” but did not mention Medicaid.

A separate memo from OMB on Tuesday morning said “In addition to Social Security and Medicare, already explicitly excluded in the guidance, mandatory programs like Medicaid and SNAP will continue without pause.” But White House spokeswoman Karoline Leavitt said Tuesday she was not certain about whether Medicaid was affected, according to ABC News. State Medicaid programs around the country reported difficulties accessing a federal funding portal.

“It is our understanding that access to the portal has been halted temporarily, and we are currently awaiting guidance from CMS,” Melanie Cleveland, a spokesperson for the Alabama Medicaid Agency, said Tuesday morning.

Later that day, Cleveland said “the Centers for Medicare & Medicaid (CMS) Payment Management System is now accessible.”

U.S. Rep. Terri Sewell, D-Birmingham, demanded in a post on X, formerly known as Twitter, that the administration to restore access to the portal on Tuesday afternoon.

“More than 1 million Alabamians rely on Medicaid along with the providers, hospitals, & clinics that serve them. The Trump Administration needs to restore it NOW!” Sewell posted.

Eric Mackey, Alabama’ state schools superintendent, said in a statement Tuesday that they did not believe the OMB memo “affects formula-driven programs like Title I and IDEA.” Title I provides supplemental financial assistance to school districts for children from low-income families. IDEA ensures that students with disabilities receive a free education.

“We are working closely with other state and federal agencies to secure any funds necessary to continue normal daily operations without interruption. Some discretionary grant funds will be affected,” the statement said.

A separate memo from OMB lists off the programs that will be paused temporarily while it reviews which federal spending it deems appropriate, which includes higher education grants and the Pell Grant program. The U.S. Department of Education, however, said that financial aid and student loans would not be impacted, according to CNBC. 

The Appalachian Regional Commission, an economic development partnership between the federal government and states, has also been affected by the order to freeze federal dollars.

“The ARC is complying with the pause order from OMB, and we have been communicating with OMB and working to provide them with the information they need to assess ARC’s programs and grant opportunities,” said Janiene Bohannon, communications director for the Appalachian Regional Commission.

She added that until the organization “is pausing” until it learns more from the Office of Management and Budget about the next steps.The organization operates in 37 counties in Alabama, which comprises the northern part of the state, but goes as far south as Macon County.According to the list provided by OMB, the Appalachia Regional Commission has five programs affected by the order.

Just about all the programs relate to economic development, which include the Appalachian Development Highway System funding program.

Organizations filed a lawsuit in federal court Tuesday ahead of the temporary pause taking effect. Senate Minority Leader Chuck Schumer said Tuesday morning that he’s spoken with New York State Attorney General Letitia James about a legal challenge.

Mackey cautioned against getting distracted amid a “flurry of activity” that makes “some of our educators uneasy.”

“In short, just keep having school. Let’s stay focused on teaching and learning. I assure you that we are staying on top of the situation and will pass along information as we get updates,” Mackey said.

Ralph Chapoco contributed to this report.

This story was updated at 4:37 p.m. to reflect that the federal funding portal for the Alabama Medicaid Agency became accessible late Tuesday afternoon.

Alabama Reflector is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Alabama Reflector maintains editorial independence. Contact Editor Brian Lyman for questions: info@alabamareflector.com.

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