Opinion: Crushing medical debt is turning Americans against their doctors
by Noam Levey - LA Times - July 16, 2023
For Emily Boller, it was a $5,000 hospital bill for a simple case of pink eye that took four years to pay off. For Mary Curley, it was the threatening collection letters from a lab that arrived more than two years later, just as her husband lost his job and the family was fighting to save their home.
For Cory Day, it was a $1,000 fee he was charged at an emergency room outside Los Angeles, even though he only checked in and then left before being seen. “I feel like the hospital is a predator,” Day said. “This is a place that’s supposed to be looking after you.”
The experience offered a stark lesson, he said: “Don’t trust the system.”
Reporting on medical debt over the past two years, I’ve spent hundreds of hours on the telephone, in the living rooms and at the kitchen tables of patients like Boller, Curley and Day. They are among the 100 million people in America who have been driven into debt by medical and dental bills.
Many of my conversations with patients have revealed a deep and disturbing disillusionment with our healthcare system.
Medical providers ignore this at their peril — and at a high risk to Americans’ health.
Doctors and hospitals have long held an exalted position in American life, retaining public confidence even as the public has steadily lost trust in other institutions such as government, law enforcement and the media. Growing up, I shared this faith. My father was a physician who never hesitated to get up in the middle of the night and drive to the hospital to operate on a sick child in his care. But as a journalist covering healthcare the past 15 years, I’ve seen patients’ faith shaken.
They’re tired of shocking medical bills they didn’t expect and can’t afford. And they’re disgusted by the collection notices, the threatening phone calls and appointments they can’t get because they owe money.
Many Americans say they simply no longer trust their medical providers. This is borne out by a nationwide poll conducted by KFF as part of an investigation of medical debt. Just 15% of people with healthcare debt said they have a lot of trust that providers have patients’ best interests in mind. That’s about half the rate as among people without such debt.
Many caring people who work in healthcare understand this. I’ve met countless compassionate physicians, nurses and others who see firsthand the toll that debt is taking on their patients.
But I’ve seen a lot more denial and finger-pointing by healthcare leaders. Hospitals and doctors blame the government for underpaying them and blame insurers for selling plans with unaffordable deductibles. Insurers blame providers for obscene prices. Everyone blames drug companies.
And so, the suffering of patients deepens.
In a project on medical debt with NPR, KFF Health News documented cancer patients forced to hold off debt collectors while fighting off nausea and other toxic side effects of chemotherapy; older workers whose retirement savings were obliterated; 30-somethings unable to buy a home because their credit was ruined by healthcare debt; new mothers forced to take on extra work; parents unable to buy Christmas gifts for their children; and seniors who cut back on food because of medical debt.
That our healthcare system would do this to people should be reason enough for hospital executives, insurance CEOs and senior physicians to stop the blame game and look in the mirror.
If nothing else, this should be a flashing red light: the simmering resentment of growing numbers of patients who feel victimized by this system.
We got a hint of the dangers of this during the COVID-19 pandemic, as Americans who distrusted the medical system proved easy prey for misinformation about vaccines and other public health measures, with sometimes fatal consequences.
Other systemic risks are lurking. I was once a political reporter and saw up close what an erosion of trust can do to a system, and how much more difficult it becomes to get things done when the public loses faith in its institutions.
And as the political turmoil of recent years shows, public anger and disillusionment can produce unpredictable, even dangerous results.
Healthcare leaders — and physician leaders in particular — could alleviate patients’ financial suffering.
Physician groups and hospital systems, many of which are led by doctors, could look more closely at the bills they send patients and the collection tactics they use. Health insurers, whose leadership ranks also often include physicians, could reconsider the high-deductible plans they sell and ask whether they truly protect their customers. And physicians everywhere could speak up about the financial travails of patients in their care.
Absent action, patients’ trust is sure to erode further. And without the trust of the people it serves, this American healthcare system cannot long endure.
Noam N. Levey is a senior correspondent at KFF Health News.
https://www.latimes.com/opinion/story/2023-07-16/medical-debt-healthcare-doctors
We’re Already Paying for Universal Health Care. Why Don’t We Have It?
Liran Einav and
There is no shortage of proposals for health insurance reform, and they all miss the point. They invariably focus on the nearly 30 million Americans who lack insurance at any given time. But the coverage for the many more Americans who are fortunate enough to have insurance is deeply flawed.
Health insurance is supposed to provide financial protection against the medical costs of poor health. Yet many insured people still face the risk of enormous medical bills for their “covered” care. A team of researchers estimated that as of mid-2020, collections agencies held $140 billion in unpaid medical bills, reflecting care delivered before the Covid-19 pandemic. To put that number in perspective, that’s more than the amount held by collection agencies for all other consumer debt from nonmedical sources combined. As economists who study health insurance, what we found really shocking was our calculation that three-fifths of that debt was incurred by households with health insurance.
What’s more, in any given month, about 11 percent of Americans younger than 65 are uninsured. But more than twice that number — one in four — will be uninsured for at least some time over a two-year period. Many more face the constant danger of losing their coverage. Perversely, health insurance — the very purpose of which is to provide a measure of stability in an uncertain world — is itself highly uncertain. And while the Affordable Care Act substantially reduced the share of Americans who are uninsured at a given time, we found that it did little to reduce the risk of insurance loss among the currently insured.
It’s tempting to think that incremental reforms could address these problems. For example, extend coverage to those who lack formal insurance. Make sure all insurance plans meet some minimum standards. Change the laws so that people don’t face the risk of losing their health insurance coverage when they get sick, when they get well (yes, that can happen) or when they change jobs, give birth or move.
But those incremental reforms won’t work. Over a half-century of such well-intentioned, piecemeal policies has made clear that continuing this approach represents the triumph of hope over experience, to borrow a description of second marriages commonly attributed to Oscar Wilde.
The risk of losing coverage is an inevitable consequence of a lack of universal coverage. Whenever there are varied pathways to eligibility, there will be many people who fail to find their path.
About six in 10 uninsured Americans are eligible for free or heavily discounted insurance coverage. Yet they remain uninsured. Lack of information about which of the array of programs they are eligible for, along with the difficulties of applying and demonstrating eligibility, mean that the coverage programs are destined to deliver less than they could.
The only solution is universal coverage that is automatic, free and basic.
Automatic because when we require people to sign up, not all of them do. The experience with the health insurance mandate under the Affordable Care Act makes that clear.
Coverage needs to be free at the point of care — no co-pays or deductibles — because leaving patients on the hook for large medical costs is contrary to the purpose of insurance. A natural rejoinder is to go for small co-pays — a $5 co-pay for prescription drugs or $20 for a doctor visit — so that patients make more judicious choices about when to see a health care professional. Economists have preached the virtues of this approach for generations.
But it turns out there’s an important practical wrinkle with asking patients to pay even a very small amount for some of their universally covered care: There will always be people who can’t manage even modest co-pays. Britain, for example, introduced co-pays for prescription drugs but then also created programs to cover those co-pays for most patients — the elderly, young, students, veterans and those who are pregnant, low-income or suffering from certain diseases. All told, about 90 percent of prescriptions are exempted from the co-pays and dispensed free. The net result has been to add hassles for patients and administrative costs for the government, with little impact on the patients’ share of total health care costs or total national health care spending.
Finally, coverage must be basic because we are bound by the social contract to provide essential medical care, not a high-end experience. Those who can afford and want to can purchase supplemental coverage in a well-functioning market.
Here, an analogy to airline travel may be useful. The main function of an airplane is to move its passengers from point A to point B. Almost everyone would prefer more legroom, unlimited checked bags, free food and high-speed internet. Those who have the money and want to do so can upgrade to business class. But if our social contract were to make sure everyone could fly from A to B, a budget airline would suffice. Anyone who’s traveled on one of the low-cost airlines that have transformed airline markets in Europe knows it is not a wonderful experience. But they do get you to your destination.
Keeping universal coverage basic will keep the cost to the taxpayer down as well. It’s true that as a share of its economy, the United States spends about twice as much on health care as other high-income countries. But in most other wealthy countries, this care is primarily financed by taxes, whereas only about half of U.S. health care spending is financed by taxes. For those of you following the math, half of twice as much is … well, the same amount of taxpayer-financed spending on health care as a share of the economy. In other words, U.S. taxes are already paying for the cost of universal basic coverage. Americans are just not getting it. They could be.
We arrived at this proposal by using the approach that comes naturally to us from our economics training. We first defined the objective, namely the problem we are trying but failing to solve with our current U.S. health policy. Then we considered how best to achieve that goal.
Nonetheless, once we did this, we were struck — and humbled — to realize that at a high level, the key elements of our proposal are ones that every high-income country (and all but a few Canadian provinces) has embraced: guaranteed basic coverage and the option for people to purchase upgrades.
The lack of universal U.S. health insurance may be exceptional. The fix, it turns out, is not.
Liran Einav is a professor of economics at Stanford. Amy Finkelstein is a professor of economics at M.I.T. They are the authors of the forthcoming book “We’ve Got You Covered: Rebooting American Health Care,” from which this essay was adapted.
https://www.nytimes.com/2023/07/18/opinion/universal-health-care.html
A National Treasure, Tarnished: Can Britain Fix Its Health Service?
As it turns 75, the N.H.S., a proud symbol of Britain’s welfare state, is in the deepest crisis of its history.
by Mark Landler - NYT - July 16, 2023
As it turns 75, the N.H.S., a proud symbol of Britain’s welfare state, is in the deepest crisis of its history.
Fifteen hours after she was taken out of an ambulance at Queen’s Hospital with chest pains and pneumonia, Marian Patten was still in the emergency room, waiting for a bed in a ward. Mrs. Patten, 78, was luckier than others who arrived at this teeming hospital, east of London: She had not yet been wheeled into a hallway.
For months, doctors at Queen’s have been forced to treat people in a corridor because of a lack of space. As the ambulances kept pulling up outside, the doctor supervising the E.R., Darryl Wood, said it was only a matter of time before nurses would begin diverting patients into the overflow space again.
“We’re in that mode every day now because the N.H.S. doesn’t have the capacity to deal with all the patients,” Dr. Wood said.
Despite her ordeal, Mrs. Patten was sympathetic. Decades ago, she said, the National Health Service saved her husband’s life when he had a heart attack. “It’s got to cope with a lot more people,” she said. “You can’t be grumpy about it.”
Her stoicism captures the reverence that Britons have for their cradle-to-grave health system, but also their rueful sense that it is broken.
As it turns 75 this month, the N.H.S., a proud symbol of Britain’s welfare state, is in the deepest crisis of its history: flooded by aging, enfeebled patients; starved of investment in equipment and facilities; and understaffed by doctors and nurses, many of whom are so burned out that they are either joining strikes or leaving for jobs abroad.
Interviews over three months with doctors, nurses, patients, hospital administrators, and medical analysts depict a system so profoundly troubled that some experts warn that the health service is at risk of collapse.
“Doctors and nurses face an endless stream of patients filling beds,” said Matthew Trainer, the chief executive of the N.H.S. trust that runs Queen’s and another nearby hospital, the King George. “For the clinical staff, that removes a sense of hope — that sense that what you’re doing matters.”
More than 7.4 million people in England are waiting for medical procedures, everything from hip replacements to cancer surgery. That is up from 4.1 million before the coronavirus pandemic began in 2020.
Mortality data, exacerbated by long wait times, paints a bleak picture. In 2022, the number of excess deaths rose to one of the highest levels in the last 50 years, and those numbers have kept rising, even as the pandemic has ebbed.
In the first quarter of 2023, more than half of excess deaths — that is, deaths above the five-year average mortality rate, before the pandemic — were caused by something other than Covid-19. Cardiovascular-related fatalities, which can be linked to delays in treatment, were up particularly sharply, according to Stuart McDonald, an expert on mortality data at LCP, a London-based pension and investment advisory firm.
Proliferating labor unrest only adds to the crisis, throwing hospitals that were already barely coping into near paralysis. While Mrs. Patten waited for a bed at Queen’s, doctors were picketing outside, protesting starting wages that are comparable to those earned by baristas working at Pret-a-Manger, a sandwich chain in the hospital’s lobby.
Seeking to solve the problem, Prime Minister Rishi Sunak last month announced a 15-year plan to recruit and train 300,000 nurses and doctors, budgeting 2.4 billion pounds (about $3 billion) for the first five years. But critics point out that the plan does not fund wage increases, the only surefire way to prevent workers from leaving.
The fate of the N.H.S. matters beyond Britain. Spiraling health care costs are bleeding public finances in almost every country, regardless of their political systems. The N.H.S. has always managed to deliver a level of care that justified its giant footprint in British public life, and it is hard to imagine a vibrant Britain if the service is not stabilized.
Politically, however, Britain’s fiscal austerity exacerbated the system’s failings. Covid exposed a legion of problems — including poor management and corroded facilities — that had been incubating inside the service since Conservative-led governments began curbing budget increases in 2010.
Health care spending rose by an average of less than 2 percent a year from 2010 to 2019, compared with 5.1 percent from 1998 to 2008. Britain spent less a year per person on health care than the wealthiest European Union countries during the decade of austerity, and now has fewer doctors and hospital beds per capita than its European neighbors. Its capital investment lagged the bloc’s average by $41 billion, according to the Health Foundation, which tracks the industry.
That has led to horror stories like doctors in a hospital outside London discovering dirty water from a leaky pipe in the ceiling dripping onto a circuit board that controls high-tech surgical equipment.
“Austerity has made matters a lot worse,” said Nigel Edwards, the chief executive of Nuffield Trust, a health research organization. “There’s been lots of salami-slice savings over the years, which has made the system much more fragile.”
No mainstream politician proposes to privatize the N.H.S.: The specter of the inequitable U.S. health system still horrifies many Britons. And in some ways, the service remains a marvel, one of the world’s most comprehensive, taxpayer-funded health care providers — “free at the point of delivery,” in the words of its utopian motto. It still offers annual physical exams, mammograms, vaccinations and other services at a level that visiting Americans find impressive.
Indeed, jaundiced observers say the N.H.S. is perpetually in crisis. But this time, the problems are of a different order, magnified by Britain’s faltering economy and its convulsive, post-Brexit politics. Experts say its model of universal access has become unsustainable, and there is no clear blueprint to reinvent it.
These problems are compounded by a breakdown in primary care, which has made it all but impossible for many people to get an appointment with their family doctor. With a shortage of general practitioners and nowhere else to turn, the E.R. has become the first stop for millions of sick Britons.
The interconnected nature of the N.H.S.’s problems — financing, staffing, case load, efficiency — makes simple fixes impossible. And because of its hallowed status as a national treasure, any efforts at root-and-branch change quickly run up against political resistance.
“It has become this albatross around our necks,” said Sally Davies, the master of Trinity College at Cambridge University, who served as the chief medical officer of England from 2010 to 2019. “You tinker with it at your peril.”
“The N.H.S. became the nation’s religion,” she added, “but it’s actually a National Sickness Service.”
For Doctors, Fatigue and Frustration
With Dolly Parton’s office-worker anthem “Nine to Five” squawking from a speaker, a group of young doctors rallied next to a traffic circle outside Queen’s Hospital. They brandished banners that said, “£14/hour is not a fair wage for a junior doctor,” and waved at motorists, some of whom honked as they drove past.
It was mid-March, the first three-day walkout of a labor action that shows no sign of being resolved (a five-day strike, their longest yet, began on Thursday). The junior doctors — qualified physicians who are still in clinical training — have been seeking a 35 percent wage hike, which they say is needed to counteract a more than 25 percent cut in real wages since 2008.
In this season of strikes, the junior medics have been joined by senior doctors, nurses and ambulance workers. They all list the same grievances: long hours, relentless pressure and pay that has failed to keep pace with months of double-digit inflation.
With junior doctors striking, Queen’s pressed more experienced physicians to replace them, resulting in quicker diagnoses that briefly reduced E.R. waiting times. Reassigning the doctors came at a cost to other treatment, however. The hospital was forced to cancel 495 surgeries and 4,731 outpatient appointments.
“It looks like we’re coping,” said Mr. Trainer, the chief executive of the hospital trust, “but it’s a bit like the Tube system coping by closing a third of its lines.”
With more than 700 beds, Queen’s serves 800,000 people in three ethnically diverse boroughs that sprawl northeast of London. Though only 17 years old, the hospital, with its four squat circular brick buildings, already looks as tired as its staff.
Beyond the immediate crisis, Mr. Trainer said, the N.H.S. risks losing the next generation of doctors and nurses.
Max Berrill, 32, a trainee in internal medicine, said he and his colleagues routinely pulled 12-hour shifts, answering phones that rang every 10 seconds and treating frustrated patients.
Facing a decade of training in those conditions, some of his friends were abandoning the N.H.S. for jobs in Australia or New Zealand, he said. That exodus is an acute problem for a service that was already plugging a shortage by recruiting doctors from abroad, and it is not limited to the N.H.S.
The number of full-time general practitioners in England has declined steadily in recent years. If current trends continue, there will be a shortfall of about 8,800 family doctors by 2031, according to the Health Foundation.
“Nearly everyone loves the part of the job that involves treating patients,” said Dr. Berrill, taking a break from his roadside protest. “But the system has thrown up so many barriers to prevent you from doing that.”
A Quasi-Sacred Institution
During the darkest days of the pandemic, people gathered once a week to cheer and bang metal pots for the N.H.S. Children colored “Thank you N.H.S.” signs that were placed in the windows of 10 Downing Street. Boris Johnson, the former prime minister who was treated for Covid at an N.H.S. hospital, was among those who turned out to clap.
Protecting the health service has become an article of faith for British leaders of all parties. Mr. Sunak, who has made shorter wait times one of the five bedrock goals of his government, regularly reminds Britons that his father was a physician and his mother a pharmacist.
“When I talk about the N.H.S.,” he said in January, “I’m not just talking about a prized public service, I’m talking about my family’s life calling.”
Such devotion was not inevitable. In the service’s early decades, Britons were wary of public health care, fearing it would meddle in their relationships with their family doctors. Those suspicions crested in the 1980s with the free-market revolution of Margaret Thatcher.
Yet rather than being privatized, the N.H.S. survived the Thatcher years. That was partly because its defenders shrewdly contrasted it with health care in the United States, playing up America’s soaring costs, deep inequities and vast number of uninsured.
But more important, the champions of the N.H.S., in research institutes, academia and the news media, developed a multiyear public-relations campaign that transformed the service into a quasi-sacred institution, so revered that its birthday was celebrated with a service at Westminster Abbey.
“They deliberately plugged it into British national identity,” said Andrew Seaton, a historian at Oxford University who has just published a book, “Our N.H.S.: A History of Britain’s Best-Loved Institution.” “It involved this cultural dynamic, making the N.H.S. seem integral to British culture.”
That triumph of marketing has created a predicament for politicians: They feel forced to be cheerleaders for a system that is eroding before their eyes, yet the most obvious solution — throwing piles of money at it — is no longer economically feasible in an era of ballooning budget deficits.
Experts periodically float ideas like privatizing parts of the service or charging fees for some treatments, which might make people less quick to go to the E.R. for minor health issues. Sajid Javid, a Conservative former health secretary, has proposed changing its funding base from taxes to an insurance-based system, like that used in Germany.
But Mr. Edwards of the Nuffield Trust said there was little evidence that the service’s problems stemmed from how it was funded. Other high-income countries have had woes with their health systems.
“I doubt there will be an appetite for changing the funding model or changing the ownership of the hospitals,” Mr. Edwards said. “The risk, then, is they try to play with the train set, which is what incoming governments like to do.”
Experimenting With Solutions
For all of the doom-saying about the N.H.S., there are things that still work, like the physicals and mammograms. And the hospitals themselves are experimenting with new ways to treat patients more efficiently to shorten waiting times.
That kind of adaptation is taking place at Queen’s, where Mr. Trainer pointed to some hard-won gains — or, as he calls them, “green shoots.” The percentage of patients with serious illnesses or injuries who are treated within four hours of being admitted increased from its low point of 30 percent in February to 48 percent in May, its best performance since August 2019.
That is largely thanks to a new same-day emergency care unit in the E.R. Intended for people with less serious issues, it allows the hospital to discharge more patients without having to get them a bed.
At the King George, the smaller sister hospital of Queen’s, Gerald Merritt, a retired bus driver, was patient as doctors prepped him for a knee replacement one morning. He had waited six months for the operation, but that was two months less than he waited to have his other knee replaced in 2018.
“Everybody would love to have it done tomorrow,” said Mr. Merritt, 69, who attributed his failing knees to a lifetime of rock climbing and hill walking. “But you’re prepared to put up with a wait.”
An hour later, Mr. Merritt, under a spinal anesthetic, chatted amiably with a doctor, while on the other side of a curtain an orthopedic surgeon drilled into his knee. He is one of about 500 people who will get knee and hip replacements this year, a high volume that is possible only because the surgery unit is walled off from E.R. patients that clog the operating rooms at Queen’s.
That level of improvement shows that adjustments on the fly can produce a quick fix, but there is usually another problem waiting around the corner. At the King George, doctors cannot discharge patients quickly enough because there is nowhere to send them for longer-term therapy.
That is yet another weak link in the chain — and one that is out of its control. In Britain, local councils, not the National Health Service, are responsible for social care. Years of budget cuts have left them stretched and not up to the task.
Given the need to overhaul primary care and social care, some experts argue the best thing the N.H.S. can do is simply run its hospitals better. At Queen’s, even with the recent improvements, patients suffering from mental health issues can be stranded in the emergency room for more than 36 hours.
“Forget about big ideas, like ‘let’s introduce fees,’ and focus on the basics,” Mr. Edwards said. “You can ensure they’ve got functioning computers so they don’t spend 15 minutes logging on.”
In the E.R. at Queen’s, nobody had the luxury to ponder long-term fixes. In one bed, Michelle Scanlan, 54, was waiting to be treated for a gash on her face from falling on a glass coffee table. Next door, Kaushik Bhatt, 67, was waiting for a bed after feeling faint because of low blood sugar.
In the resuscitation unit, which handles the most unstable patients, Dr. Wood, the E.R. doctor, took a break after checking on Tony Eaton, 48, a worker on the London Underground who was recovering from a hypoglycemia attack.
It was a comparatively peaceful moment in a job that rarely has them, and Dr. Wood was in a reflective mood.
“I come from South Africa, where it’s tough and we see a lot of trauma,” he said, after pausing to pick up a ringing phone. “But it doesn’t compare to this. There’s just too much that’s hitting us.”
https://www.nytimes.com/2023/07/16/world/europe/uk-nhs-crisis.html
More Mothers Are Dying. It Doesn’t Have to Be This Way.
Dr. Veronica Gillispie-Bell is an OB-GYN and associate professor for Ochsner Health in New Orleans.
After Tori Bowie, an elite athlete, died in May, the reality of the health risk to Black women posed by childbirth was once again in the spotlight. The maternal mortality rate for Black women in America is, according to the Centers for Disease Control and Prevention, 2.6 times that for white women.
Now a recently published study in the medical journal JAMA has revealed that the U.S. maternal mortality rate — already the highest among peer nations — has increased for all racial and ethnic groups. Maternal outcomes in the United States are a public health crisis, and they are only getting worse. We know the data. We need to focus on the solutions.
As a practicing OB-GYN and medical director of Louisiana’s Maternal Mortality Review Committee, I understand not only the problem, but also the solutions. To ease the U.S. maternal health crisis, we must improve systems of care, improve clinical quality of care and address social determinants of health. In the United States, we have a health care system that does not serve all populations equitably. Black women are more likely to bear the brunt of structural factors that limit access to care in the form of transportation, child care and economic stability. Even when Black women are able to access health care, we are not always provided the same quality of care as our white counterparts. But there are pathways to improvement.
Some of the increase in the rate of maternal deaths can be attributed to changes in data collection. The addition of a “pregnancy check box” to the U.S. Standard Certificate of Death in 2003 led to better detection of maternal deaths that otherwise might have been missed, although it may have also introduced some overcounting, according to a C.D.C. report. But this does not account for the disproportionate maternal deaths experienced by Black, American Indian and Alaska Native mothers.
The United States spends a larger portion of its gross domestic product on health care than any other high-income country, yet our infant and maternal health outcomes are among the worst. We continue to invest in a system that is broken.
Because the United States is the only wealthy country that does not guarantee health coverage, many patients come into pregnancy with chronic medical conditions that have not been diagnosed or managed before pregnancy, including hypertension, diabetes and heart conditions. Among the leading causes of pregnancy-related deaths between 2017 and 2019 were cardiovascular conditions.
In 2021, 41 percent of births in the United States were financed by Medicaid, with rates ranging from 21 percent in Utah to 61 percent in Louisiana. However, in many states, insurance coverage under Medicaid ends 60 days after birth, leaving mothers uninsured and with no access to care. Fifty-three percent of maternal deaths occur between seven days and one year postpartum, demonstrating that the period to intervene to prevent deaths extends at least a year, and maybe longer. Under federal law, states have the option to extend Medicaid to one year postpartum. As of this month, 36 states have enacted the extension. Extension of Medicaid to one year ensures insurance coverage to address those chronic illnesses, such as cardiovascular conditions and diabetes, that increase the risk of maternal death.
Insurance coverage is only one piece of the puzzle. We must also address the physician shortage in the United States, specifically the shortage of OB-GYNs. The Bureau of Health Workforce estimates that by 2030, there will be a demand for 52,660 OB-GYNs but a supply of only 47,490, leaving a deficit of 5,170 physicians, with the impact worst in the West and the South.
Those numbers most likely underestimate the decrease; 40 to 75 percent of OB-GYNs report some form of professional burnout from patient load, malpractice litigation and other demands on time. According to the March of Dimes, 2.2 million women of childbearing age live in a maternity care desert — an area with virtually no access to birth centers or obstetric providers.
To address this shortage, we must incorporate midwives into obstetric care. Midwives are trained health care providers equipped to give prenatal care and deliver infants, allowing obstetricians to focus their care on patients who are at higher risk for morbidity and mortality. When midwives are involved in obstetric care, patients have lower C-section rates and decreased rates of preterm birth. However, among high-income countries, the United States has some of the lowest rates of midwives per 1,000 live births.
As an OB-GYN who has been practicing for 15 years, the way I was trained to treat many conditions, including hypertensive disorders of pregnancy, is no longer recommended. Doctors and other providers are not always aware of these changes. Much like the general population, pregnant women and new mothers need medical care that is evidence-based to ensure good health outcomes.
The Alliance for Innovation on Maternal Health, or AIM, is a quality improvement initiative designed to put in place and support best practices to reduce maternal morbidity and mortality. AIM in combination with state-based perinatal quality collaboratives, or P.Q.C.s, use patient safety bundles — evidence-based practices to ensure readiness, response and recognition for some of the leading causes of maternal morbidity and mortality — to ensure hospitals and providers are giving quality care. Through P.Q.C.s, states have seen fewer severe complications from hypertension and hemorrhaging and reduced rates of unnecessary C-sections. As of May, at least 27 states had C.D.C.-funded P.Q.C.s, and all states except Wyoming are enrolled in AIM. The Centers for Medicare and Medicaid Services has created the “birthing friendly” designation for hospitals participating in structured quality improvement programs and establishing patient safety bundles. To improve clinical quality of care, all birthing facilities should work to receive this designation.
Maternal outcomes are not determined by health care alone. What we call social determinants of health — where we live, work and play — also affect health outcomes. Social factors affect about half of health outcomes. When we think about maternal mortality, we should also look to economic stability, education access, health care access, neighborhood and the built environment and community.
Generations of racial residential segregation supported by unfair lending practices for home buying have perpetuated inequities for Black Americans. In minority neighborhoods, there is less access to health care and there are food deserts and environmental factors such as factories that have been linked to various negative health outcomes, including preterm births. Add to this decreased access to transportation, which leaves these mothers and families further removed from care.
Social determinants of health also play a critical role in the year after birth. A report from the Commonwealth Fund comparing maternal care in 11 wealthy countries found that the United States is the only one that does not guarantee home visits in the postpartum period. Ours is also the only high-income country that does not ensure paid maternity leave.
Social determinants of health contribute to the disparities we see, but they are not the only factor. A Black woman with a college degree is 1.6 times as likely to die as a result of pregnancy or childbirth as a white woman with less than a high school diploma. Even when we adjust for socioeconomic factors, Black women still suffer. We know of countless accounts, including my own, of Black women presenting for medical care and being ignored.
Why do we ignore the voices of Black women? Unconsciously, we in the medical field have developed biased beliefs about Black women based on stereotypes. There is a biased belief that Black women are overly loud and demanding and that we can take more pain than our white counterparts. A study has shown that some medical residents believe that Black people have thicker skin, and therefore do not feel pain in the same way as other racial groups. In the same study, participants who endorsed such false beliefs were less likely to prescribe appropriate pain medicine. Such biases create inequities in health care delivery.
We know the problems driving the maternal health crisis, and we know what we could be doing to improve the situation. No mother should ever go into childbirth fearful that the cost of bringing in a life will be the loss of her own.
https://www.nytimes.com/2023/07/16/opinion/reduce-maternal-mortality-strategies.html
Opinion: Let’s refocus on public health care solutions
Opinion: Rather than allow unfair access to care, let’s refocus on public solutions that will actually reduce wait times for all and overcome the challenges facing our health care system.
On April 6, 2023, the Supreme Court of Canada dismissed the Cambie Surgeries Corporation’s appeal, putting an end to a 14-year-long legal saga that threatened to undermine our nation’s public health care system and its core principle: that access to medical care must be based on need, not one’s ability to pay.
https://vancouversun.com/opinion/op-ed/opinion-lets-refocus-on-public-health-care-solutions
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