JEFFERSON CITY — Missouri Supreme Court judges questioned Wednesday whether lawmakers stretched the constitution beyond its bounds by legalizing certified midwives through a health insurance bill.
The state’s highest court heard an appeal of an August ruling striking down the midwives provision, partly on grounds that it was unrelated to the bill’s titled subject of health insurance.
An attorney for midwives supporters argued Wednesday that there was a link and the law should be reinstated. Legalizing trained midwives was a means by which mothers can gain health insurance coverage for home births, said attorney Thomas Rynard, representing the Friends of Missouri Midwives.
But some Supreme Court judges seemed skeptical of that connection.
Judge Stephen Limbaugh Jr. said while questioning Rynard that the bill’s title — “relating to health insurance” — seems “underinclusive.”
“Health insurance doesn’t necessarily cover all health care issues,” Limbaugh said. According to the Missouri Constitution, “the title has to have an umbrella sufficient to cover all of the matters in the bill,” he added.
Following the reasoning of midwives supporters, said Chief Justice Laura Denvir Stith, virtually any topic could have been inserted in the legislation as long as it was insurable.
According to the North American Registry of Midwives, Missouri is one of 10 states and the District of Columbia that prohibit “direct-entry midwives” — those who enter the profession directly without medical or nursing degrees.
Missouri already has a network of unlicensed midwives who deliver babies, despite a law that can subject them to as much as seven years in prison.
Sen. John Loudon, R-Ballwin, used an obscure Greek term and a lengthy numerical reference to federal codes to mask the legalization of certified midwives when he tucked the provision into the health insurance bill near the end of the 2007 legislative session. Only after the Senate and House each passed the bill with little discussion did most lawmakers realize what Loudon had done.
Loudon said after watching Wednesday’s court arguments that he believed the crux of the legislation was about making health care available and affordable to more people.
“If we’re going to establish the narrow view that the title of the bill has to be so strictly connected that every jot and title — every paragraph — has to include the word ‘insurance,’ you’re really going to hamstring the legislature,” Loudon said. “‘Relating to health insurance,’ at its core, was helping people afford health care.”
The midwifery provision was challenged by several physician associations. Their attorney, Robert Hess, argued Wednesday that Loudon had failed to provide a direct link to health insurance in his midwives provision. For example, the bill contained nothing requiring insurers to cover certified midwives as a result of legalizing their services, he said.
“You cannot use indirect, chain reasoning arguments to establish the legal connection necessary,” Hess said.
Limbaugh and Stith pressed attorneys for the state and midwives groups on whether there was any evidence in the court record that trained midwives cannot currently get insurance and would be able to do so as a result of legalizing their services. Although no witnesses testified about that during trial, there is a legal basis to believe the change would allow insurance coverage, said Assistant Attorney General John McManus.
Although not the subject of the Supreme Court arguments, the merits of the midwives provision also have proved contentious.
Doctors groups claim allowing unlicensed midwives to practice medicine could jeopardize patients and put physicians who cooperate with them at risk of professional discipline. Midwives insist their supervised home births can be just as safe as ones in hospitals.