March 2018Volume 23Number 4PDF icon PDF version (for best printing)

Lowering costs of healthcare by increasing access to midwives and nurse practitioners

The cost of healthcare in the United States is expensive and cited as a reason for needing healthcare reform.1 The average American will spend $10,000 on healthcare in a year. This is especially hard for the youngest generation of adults, Millennials, as 70 percent have only about $1,000 in savings and 30 percent have no savings at all.2 However, it is not just Millennials who have little or no savings—57 percent of Americans have only $1,000 in savings.3 A medical expense can cause many problems for those who have little savings. This is especially concerning for women who plan on having children because the cost of childbirth in the hospital will be unknown until the bill comes in.

In Illinois, the average cost for a vaginal delivery is $7,5264— ours is among the states with the highest costs of childbirth.5 The national average is closer to $30,000 charged by the hospital and about $15,000 covered by insurance with a $2,000 out-of-pocket cost for patients.6 If your out-of-pocket costs are more than $1,000, chances are you could be one of the 60 percent of Americans who could not cover that expense when the bill comes.

Medical debts like those associated with childbirth are a leading cause of foreclosure and bankruptcy. According to one study, medical bills account for 23 percent of hardships leading to foreclosure.7 According to that same study, a medical cause led to 57% of foreclosures.8 According to different studies, medical causes account for between 26 percent9 to 62.1 percent10 of bankruptcy cases. It makes sense that a medical cause would lead to foreclosure and bankruptcy because an illness would often require time off and possibly job loss. This is especially the case with childbirth because the United States does not mandate paid leave, so families could lose income when they add a child. It is clear that medical debts and expensive healthcare are a public policy problem. One way to decrease the cost of healthcare is to expand access to freestanding birth centers, midwives, and nurse practitioners.

In 2007, Illinois approved licensing freestanding birth centers in a pilot program, but the rules were not finalized until 2011.11 Since then, only two birth centers have been built, one in Chicago and one in Bloomington. Birth centers are less expensive than hospitals and expand access to needed care.12 It is unfortunate that only two have been licensed and built in Illinois thus far.

In nearly every General Assembly session there will be a proposal to expand midwifery in Illinois to those who do not have advanced nursing degrees. They would be called certified professional midwives. There is one pending currently;13 however, it hasn’t passed. Illinois licenses nurse midwives and nurse practitioners as advanced practice registered nurses. Current Illinois law requires that they practice with a collaborative agreement with a physician.14 However, if they have 4,000 hours of clinical experience and 250 hours of continuing education, they may have full practice authority and do not need collaborative agreements with physicians.15 While this is the new law, the rules implementing it are not yet finalized, so no advanced practice nurses have been licensed yet.16 This is a good step for Illinois healthcare consumers—Midwives are proven to be a cheaper option for pregnant women.17 But in Illinois, midwives are not well-integrated into healthcare for women, which means that midwives face regulatory barriers and problems with payor restrictions from insurance.18 Similarly, nurse practitioners are also proven to provide cheaper care.19 The public policy of Illinois should shift to better integrating midwives and nurse practitioners into healthcare and assuring that they are reimbursed and covered by insurance. The new law indicates that the policy is shifting, which is a welcome sign. This will hopefully help decrease the out-of-pocket costs of care for Illinois consumers.

Much of the debate over healthcare reform focuses on insurance. While insurance is an important consideration, an equally important consideration is the cost of medical care and how that interacts with insurance and medical debts. If it is important to reduce the costs of care, then expanding access to cheaper care must be addressed. Allowing midwives and nurse practitioners to practice on their own will hopefully lead to a decrease in costs so Illinoisans are not driven to bankruptcy and foreclosure by medical bills.


Tracy Douglas is a supervising attorney in the Community Preservation Clinic at the University of Illinois College of Law. She is a member of the Standing Committee on Women and the Law and the Administrative Law Section Council.


1. Ester Bloom, “Here’s how much the average American spends on health care,” CNBC, 2017.

2. Id.

3. Cameron Huddleston, “More than half of Americans have less than $1,000 in savings in 2017,” GoBankingRates, 2017,

4. Elizabeth O’Brien and Pratheek Rebala, “Find out how much it costs to give birth in every state,” Time, 2017.

5. Id.

6. Truven Health Analytics, “The cost of having a baby in the United States,” Executive Summary, January 2013.

7. Christopher Tarver Robertson, Richard Egelhof, and Michael Hoke, “Get Sick, Get Out: The Medical Causes for Home Mortgage Foreclosures,” 18 Health Matrix 65.

8. Id.

9. Daniel A. Austin, “Medical Debt as a Cause of Consumer Bankruptcy,” 67 Maine Law Review 2, 21 (2014).

10. David U. Himmelstein, Deborah Thorne, Elizabeth Warren, and Steffie Woolhandler, “Medical Bankruptcy in the United States, 2007: Results of a National Study,” The American Journal of Medicine, Vol. 122, No. 8, 741, 743, 2009.

11. Carla K. Johnson, “Illinois may soon join states with birth center alternative,” St. Louis Post-Dispatch, July 31, 2011.

12. Susan Rutledge Stapleton, Cara Osborne, and Jessica Illuzzi, “Outcomes of Care in Birth Centers: Demonstration of a Durable Model,” 58 Journal of Midwifery & Women’s Health 3, 9 (2013).

13. Home Birth Safety Act, Senate Bill 1754, 100th General Assembly, available at

14. 225 ILCS 65/65-35 (2018).

15. 225 ILCS 65/65-43(b)(2018).

16. Susan Swart, “Update on Nurse Practice Act – APRN Full Practice Authority, Illinois Society for Advanced Practice Nurses,” January 9, 2018, available at

17. Dylan Walters, Archna Gupta, Austin E. Nam, Jennifer Lake, Frank Martino, and Peter C. Coyte, “A cost-effectiveness analysis of low-risk deliveries: A comparison of midwives, family physicians and obstetricians,” 11 Healthcare Policy 61, 69 (2015).

18. Saraswathi Vedam, Kathrin Stoll, Marian MacDorman, Eugene Declercq, Renee Cramer, Melissa Cheyney, Timothy Fisher, and Emma Butt, “Mapping integration of midwives across the United States: Impact on access, equity, and outcomes,” PLOS, 2018, available at

19. Jeffrey C. Bauer, “Nurse practitioners as an underutilized resource for health reform: Evidence-based demonstrations of cost-effectiveness,” 22 Journal of the American Academy of Nurse Practitioners 228, 231 (2010).

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