Nearly a decade ago, Maureen Sweeney worked at a Cleveland-area hospital during nursing school, completing her labor and delivery rotations. She helped hundreds of women deliver their children, many of whom were minors in their early teens.

That’s because, in Ohio, the rate of teenage pregnancy is slightly higher than the national average. This year, about 23 in 1,000 teenage girls will become pregnant.

One patient in particular from those nursing school days sticks out in Sweeney’s mind.

“It was a 15-year-old woman who was coming in, in labor, to the emergency room,” Sweeney remembers.

The teen was scared. She didn’t talk much and didn’t trust any of the doctors. She told Sweeney she had no family and that she was a runaway.

“She was by herself and she was living on the streets or between friends’ houses,” Sweeney says.

In that moment, Sweeney became the young woman’s only support system to help her through the delivery of her baby.

“So as it progressed and it got more and more painful, she did request an epidural,” Sweeney says.

An epidural is a common type of regional anesthesia that eases the pain of labor. As she had done many times before, Sweeney followed hospital protocol and called the anesthesia department. But to her shock, they told her they could not help her young patient.

“They said that without parental consent, … she would not be able to sign for her own epidural,” Sweeney says.

In Ohio, people under 18 who are in labor cannot consent to their own health care. They can receive emergency services, but nothing considered to be elective. For the many Ohio minors who become pregnant, it’s a painful gap in coverage.

It’s also complicated by the fact that in Ohio, there is no legal process for emancipation: A minor’s parents must be deceased, or the minor must be married or enlisted in the armed forces to be granted independent legal status.

When the hospital wouldn’t authorize an epidural, Sweeney called the office of Cuyahoga County Children and Family Services; oftentimes an agent from children’s services can sign for medical consent in these cases. But it was 3 a.m. The young woman was in active labor and an agent couldn’t make it to the hospital until 9 a.m.

Sweeney remembers how hard to was to tell her patient the news.

“I had to go in, sit down with her and talk about the fact that she wasn’t going to be able to get an epidural, and she was going to have to do this naturally,” Sweeney says.

That’s when the young woman broke down, Sweeney says, and folded in on herself in tears.

Throughout the U.S., minors are generally required to have permission from their parents or legal guardian before they can receive most medical treatment. However, each state has established a number of exceptions.

According to the Guttmacher Institute, 26 states allow minors 12 and older to get prescription methods of contraception without a parent’s or guardian’s consent, and just two allow minors to consent, on their own, to an abortion. Ohio is one of 13 states that has no explicit policy allowing a minor to consent to prenatal and pregnancy-related care.

Diana Thu-Thao Rhodes directs public policy for Advocates for Youth, an advocacy organization that focuses on, among other things, the rights of minors to get access to health care. She says in the last few years, minor-consent laws in some places around the country have become increasingly restrictive.

“We can legislate minors’ decision-making much easier because of the fact that they are minors,” says Thu-Thao Rhodes.

Dr. Michael Cackovic, an obstetrician at The Ohio State University Wexner Medical Center, says every couple of months he sees a teenage mom who, under Ohio law, is unable to receive elective treatment, like an epidural. He says it’s frustrating to see patients in unnecessary pain.

“First of all, from a labor and delivery standpoint, you don’t like to see anybody uncomfortable,” Cackovic says.

Both Cackovic and Sweeney report that, just as frequently, they’ve had cases where the mothers intentionally denied their teenage daughters an epidural – as a sort of punishment for getting pregnant.

All Cackovic can do is try to talk them out of it.

“To take the mom aside,” he says, “and say, ‘You know, this isn’t some life lesson here. This is basically pain — and there’s no reason for somebody to go through that.’ “

This gap in Ohio law bars a young mother from choosing a C-section. And she can’t consent for a procedure to test for chromosomal abnormalities in the fetus.

Cackovic says he thinks that’s pretty backward: After she gives birth, the teenage mother can consent to the care of her baby, but she can’t consent to the prenatal procedure that would help pinpoint a diagnosis.

There is no way to know for sure how many teens across the country are denied these elective procedures. Thu-Thao Rhodes says in states like Ohio these young patients have been overlooked by lawmakers because they’re not in a position to advocate for themselves.

“The priority for a lot of these young people is to just get the basic health care and services they need,” Thu-Thao Rhodes says, “not spending unnecessary, and often unavailable, time and resources navigating complicated healthcare and legal systems.”

Two Ohio lawmakers, Reps. Nickie Antonio and Kristin Boggs, are currently working to fix this oversight with a state bill, HB 302, that’s progressing through the Ohio House and would allow pregnant minors to consent to health care from the prenatal stage through delivery.

This story was produced in partnership with WOSU and Side Effects Public Media, a reporting collaborative focused on public health.

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Tightening the screws on pricey imaging exams, health insurer Anthem will no longer allow many patients to get MRI or CT scans at hospital-owned outpatient facilities, requiring them to use independent imaging centers instead. The insurer began phasing in these changes in July and expects to finish by March.

Anthem says the change is aimed at providing high-quality, safe care while reducing medical costs.

But critics say that imposing a blanket rule that gives preference to freestanding imaging centers is at odds with promoting quality and will lead to fragmented care for patients.

“To achieve true value, you have to have high-quality care at a good price,” says Leah Binder, president and CEO of the Leapfrog Group, a nonprofit organization that advocates for improved safety and quality at hospitals.

“Anthem would be better off judging the quality of these [imaging] diagnoses,” regardless of where they’re provided, and setting payment accordingly, she says.

Imaging tests are generally subject to preapproval by Anthem to confirm that they’re medically necessary. Under the new policy, AIM Specialty Health, an Anthem subsidiary, will also evaluate where they should be performed. Doctors who request nonemergency outpatient MRI or CT scans that can be done at an independent imaging center rather than one owned by the hospital will be given a list of centers eligible for patient referrals.

The policy doesn’t apply to mammograms or X-rays.

In rural areas that lack at least two imaging centers that aren’t owned by hospitals, outpatient scans from hospitals will still be approved.

The new policy could save Anthem enrollees hundreds of dollars, says Lori McLaughlin, Anthem’s communications director.

“There are huge cost disparities for imaging services, depending on where members receive their diagnostic tests,” she says. “Members can save close to $1,000 out-of-pocket for some imaging services for those who haven’t met their deductible, and up to $200 for those whose plans require only a copay.”

Hospital imaging is indeed pricier than imaging at freestanding centers. Average prices for MRI and CT scans ranged from 70 percent to 149 percent higher at hospitals, according to an analysis published by the Healthcare Financial Management Association, a membership group for health care finance professionals.

But price isn’t the only important variable, and the perception that all imaging studies conducted by qualified providers generally yield comparable results is wrong, Binder says. A study published last year in The Spine Journal, for example, found that when a “secret shopper” patient with low back pain received MRI at 10 imaging centers over a period of three weeks, each center reported different findings. Some missed a problem they should have found, while others detected nonexistent problems.

The Anthem policy applies to 4.5 million enrollees in individual and group plans in 13 of the 14 states in which Anthem operates, according to McLaughlin. (Self-funded employers that pay their employees’ claims directly are exempted from the policy, but can incorporate it if they wish.) New Hampshire is the only state on that list without an implementation date, McLaughlin says.

This is the second change in coverage from Anthem this year that’s attracted attention. The company has also come under fire for a new policy under which it will no longer pay for emergency department visits that it determines after the fact weren’t emergencies. Some physicians and others worry that policy could discourage people who might need emergency treatment from seeking care.

Patient advocates and health care providers have also expressed concerns about the new imaging rule’s potential impact on patients.

Cancer patients, who often are being treated at cancer centers within hospitals, would feel the effect, notes Dr. J. Leonard Lichtenfeld, deputy chief medical officer for the American Cancer Society.

“They have to go to a new outpatient facility, get the film, get it read and transmitted back to the cancer center,” Lichtenfeld says. If, as often happens, the hospital and the imaging center’s computer systems don’t talk to each other, the patient may have to bring the results back to the doctor on a CD. “For that patient who’s in a lot of stress to begin with, it adds another level of stress,” he says.

Dr. Vijay Rao, chair of the department of radiology at Thomas Jefferson University in Philadelphia, says the Anthem policy will create extra effort for hospital radiologists on a patient’s care team, if they need to review and possibly redo the imaging center’s work. Further, relying on a patient to transport the scan so that it can be put into the hospital’s electronic medical record system “leaves lots of room for error,” she says.

Anthem isn’t the only insurer trying to find a way around hospitals’ steeper costs for outpatient imaging, says Lea Halim, a senior consultant at the Advisory Board, a health care research and consulting company. The Medicare program is taking steps as well, although its approach doesn’t directly influence patient care in the same way.

In recent years, hospitals have been snapping up independent physician practices and outpatient imaging and testing facilities, and then charging Medicare higher hospital outpatient fees for their services. In a bid to equalize payments, in January the Medicare program reduced by 50 percent the amount it pays some hospital-owned outpatient facilities — including imaging centers — that are located away from a hospital’s campus.

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