HJNO Jul/Aug 2026

areas, less good quality outcomes than we do in urban areas, so there’s a couple things that go on. One is not every community has pediatricians and OBs available to do the proper amount of prenatal care, so prenatal care could be quite a distance away. We often don’t, on the Medicaid side — and keep in mind that around 60% of all the babies born in our state are born on the Medicaid program — so when we think about a focus in Medicaid on birth outcomes, it’s the majority of babies that are born in the state, but even some of the same problems that we look at solving in Medicaid is also the same case in our private health insurance plans like Blue Cross Blue Shield Louisiana, for example. All right, we recognize the problem, we’ve been measuring it for a while. The state for the last maybe 13, 14 years, has underper- formed on the March of Dimes birth out- comes report card. And so as I mentioned in the discussion on quality, we have put prenatal care and birth outcomes solidly in our incentive quality programs so that we are further incenting health plans and our health systems to invest in prenatal care, making providers more available, both in terms of scheduling as well as in communities. We’ve been working with rural health clinics as well as rural hospitals, even those that don’t offer labor and delivery. We would like to see them provide more prenatal care even if they go to a larger hospital to have their baby. So we continue to explore a vari- ety of options, but this is an area that the state again has . . . It’s been on our needs improvement list. It’s right in the middle, and we’re hoping that over the next two or three years we should see the results of all the investments that we’re making right now. Editor If you were designing Louisiana’s healthcare system from scratch today, what would you build differently? Greenstein That is a very good question. I’ll start out by saying we rarely get to redesign something that makes up over a fifth of our state’s economy because it becomes so endemic to each of our communities, each of our systems of care, and the economics around having them operate. I think what I would do though, we’ll take this a couple different ways. I think that we’re not seeing the kind of preparation for healthy people down to our school level and this means exercise in school, the food served in school, and the education of healthy lifestyles and practices at that level. I think that we have underinvested in pri- mary care, often at the expense of specialty care around the state, and that maldistribu- tion could be addressed if one was designing a system. I think we would have a greater production of healthcare professionals in our universities, more nurses, NPs, PAs, and physicians. That would be helpful because we have quite a shortage right now. I would create a much greater empha- sis on value-based contracting rather than modified fee-for-service reimbursement. I would reward significantly even beyond what we’re doing right now for quality health outcomes. And I think those changes right there would lead to an enormous dif- ference in how the system is prepared to take care of the people of our state— Editor From your mouth to God’s ears, as they say, Bruce. Greenstein Yeah, no kidding. Good question though. Editor Well, you know that we’re a journal. We get to sit back and think and go “If we could change the world,” and I believe that’s part of the frustration is that a lot of the healthcare leaders are so entrenched in bailing out the water and keeping things afloat and making sure everything’s running and everything, they don’t get to sit back and look and go, “Okay, what could we do differently?”I mean, the lack of physicians are by design, and you start looking at the money associated with a lot of the stuff and we can do so much better, and I totally agree with you on our schools. I mean, we’re feeding most of the children in the state two of their meals. Greenstein Yeah, that’s right. Editor And we’re in charge of them for the amount of time that they should be active and playing, and I mean, what is the old adage? A good puppy’s a tired puppy. I mean, we should be making sure that these guys are exercising and doing all this, and I think we’re failing our children. Greenstein Yeah. When I was here last time in the legislative sessions of 2010, ’11, and ’12, we fought desperately for . . . The state was proposing to eliminate PE as a mandatory subject, and you know me and the Department of, it was called Health and Hospitals, then we would testify in these hearings all the time that this is necessary. We need to keep it and it’s one of our few lines of defense, and after I left, the bill had “We have put prenatal care and birth outcomes solidly in our incentive quality programs so that we are further incenting health plans and our health systems to invest in prenatal care, making providers more available, both in terms of scheduling as well as in communities.”