Racism and lack of social services: The status of women's health care in the US

A recent publication from the Commonwealth Fund is the 2024 State Scorecard on Women’s Health and Reproductive Care in which they rank all the states (plus DC) for how well that care is provided and the health status of women that results. The map below gives an overall sense (darker is worse), and the entire ranked list can be found in an interactive table in the document. 

The first thing that we see is that there are no real surprises. Massachusetts is at the top and Mississippi is at the bottom. The other top and bottom states are the usual suspects for almost anything that is beneficial to people, with the Northeast doing best and the old Confederacy doing the worst. There are always some minor shifts within those groups, and in this ranking we see that Louisiana* and South Carolina are only “worse than average” not in the “bottom performing states”, while disappointing to me, Arizona and New Mexico are in the lowest group. The reasons are a little different in different states; the Arizona legislature is (narrowly; we hope to flip it this year) controlled by Republicans who are as mean and nasty as those in the deep south. New Mexico is controlled by Democrats, but it is very poor. Poor is a big component of health status, and its fingerprints are all over this data on women’s health.  ‘Despite a small rebound in women’s life expectancy in 2022, it remains at its lowest since 2006,’ says the report.

Abortion care – access to it and the quality of it – has dominated the national political discussion. I don’t want to minimize it; it is incredibly important that women can have abortions, it is a privacy issue, and it will hopefully have major negative repercussions for the party whose agenda is to limit it. That the greatest restrictions on abortion are in the same states that have the worst women’s health status is neither a coincidence nor a surprise; the people who control these states and are anti-abortion are also racists and are unwilling to provide funds to improve the health standards of people who are women, minority, or poor – and especially all three. But it goes far beyond abortion:

For health outcomes, we measured all-cause mortality, maternal and infant mortality, preterm birth rates, syphilis among women of reproductive age, infants born with congenital syphilis, self-reported health status, postpartum depression, breast and cervical cancer deaths, poor mental health, and intimate partner violence.

Abortion is not the major component of poor reproductive health status. Maternal mortality rates are shockingly high in the southeast, and worst in the Mississippi Delta. The US overall does not do very well in this area, especially as it is the richest country in the world. Data from the CIA (!) shows that in 2020, the US maternal mortality rate overall was 21/100,000, tied with Lebanon, Grenada, and Malaysia and just slightly worse than the West Bank or (pre-war) Gaza Strip. This was (and remains) much higher than Canada (11), UK (10), and most of Europe, including eastern Europe at 5 or less! (Note, showing the same dramatic racist differences as in the US, Israel is at 3). Of course, this overall rate in the US is driven by the states with the highest rates, with the worst states having a range of 34.1-51.7! While this is largely the result of excessively high rates in minority women, it is worth noting that the maternal mortality rate for white women in the US is over 19!

 

This is a good time to discuss the segmentation of results for maternal mortality (and all-cause mortality, and really most things) by race or ethnicity. In the bizarre, perverted, and of course racist excuse provided by many (racists) for why the US’ maternal mortality is so high compared to civilized countries, it is often said “it’s the minorities that drive the rate up”. In addition to ignoring the excessively high rate for US whites (19) it is scarcely an excuse; indeed, it is an indictment. It is not only that the US, unlike civilized countries, does not provide health care for everyone, essentially free of charge at the time of service (that is, paid for by tax revenues, as well as costing a lot less because of the elimination of the incredible profits extracted by middlemen such as insurance companies in the US). It also provides lousy social services of all kinds, not ensuring, as civilized countries do, housing, food, and education for everyone. These (the “social determinants of health”) are even more important than medical care in creating improved health status. And, while other countries do spend much more money than we do on providing them, the total cost per capita is probably less than what the US spends on health care alone! Of course, much of the spending (particularly on social services and health care for the poor, like Medicaid) is on a state basis; that is why there are such differences between the Massachusetts’ and Mississippi’s in this Commonwealth Fund study. And what are the practices that work? Again, no surprise:

In our scorecard, states with the lowest rates of maternal mortality had:

·       more maternity care providers (Vermont #2, Connecticut #3)

·       fewer women with no prenatal care (Vermont #1, California #3, Connecticut #5)

·       fewer women with no postpartum checkups (Vermont #1)

·       fewer uninsured women ages 19–64 (Vermont #3)

 

It cannot be stated too strongly that public funds should support a public social safety net, not bloat the profits of private companies as they do here in the US! This is most well-documented for the piggish pharmaceutical industry and the entirely unnecessary (indeed, far worse than unnecessary, destructive and evil) for-profit health insurance industry, which I have discussed many times. But it is also the other parts of the health care industry, particularly delivery systems (e.g., hospitals). Yes, the for-profits, hospitals and nursing homes and other facilities, especially those run by corporations. But it is also the ostensible “non-profits”, which do their best to emulate for-profits by doing everything possible to exclude patients without insurance or with Medicaid, pay their CEOs (and other C-suite executives) exorbitant salaries, and channel huge earnings into subsidiaries that actually own or invest in for-profit enterprises! This is documented in Why many nonprofit (wink, wink) hospitals are rolling in money by Elisabeth Rosenthal (Washington Post, July 29, 2024) and discussed by Don McCanne in Health Justice Monitor ‘Not-for-profit care begets profits’. Dr. McCanne cites a study by KFF showing even a program providing “street medicine”, healthcare for the homeless, in California is making money by getting huge amounts of Medicaid funds. Providing health care to homeless people is a good thing, something we need more of. If I had my druthers, I would rather see them making money than huge “non-profit” hospital systems (or of course straight for-profits, although those at least pay taxes), but they shouldn’t be either.

In health care, and in all social service, all the public money should go to providing direct care (OK, maybe with a 2% overhead, like Medicare – but NOT Medicare (Dis)Advantage – has). Zero dollars should go to profits (or “excess” income that can be invested for profit), bloated salaries, and the like.

We have too many people, women and others, dying because of the lack of such care.

 

*Louisiana just put the two drugs used for medication abortion, mifepristone and misoprostol, on its state’s controlled dangerous substances list, like narcotics. So look for LA’s ranking to drop!

Who should we take in medical school? What should be the criteria? Who will be a good doctor?

There are many serious inequities in our society, and they tend to build upon one another. People with more advantages have more opportunities to do well themselves, and those with fewer have less. Those advantages (or, conversely, disadvantages) include wealth, white race, male  gender, suburban or urban (but not poor areas) location, and education. All these feed one another. For example, coming from a well-to-do family and being white dramatically increase the odds of success in a chosen field. Even if there were no discrimination against people based on race and color (and this is a long way from being true), there is still the fact that people of color are grossly over-represented in low-income communities and families. This is a clear example of structural racism, so that effective discrimination based on class disproportionately falls on people of color.

An important manifestation of this exists in healthcare, and in particular the production of healthcare professionals (but also in other professional fields). In medicine specifically, we have a physician workforce that does not reflect the population of the US in terms of class (or family income), race, gender (although this is the area in which the greatest progress has been and continues to be made), geographic location (rural vs. urban), and specialty choice. Our doctors overwhelmingly are from upper-middle-class backgrounds, are white, are from suburban (or well-to-do urban) communities, and largely male. They practice in urban and suburban areas in even greater proportion than they come from them, in part because they also practice in specialties and subspecialties that cannot survive in smaller communities, rather than in family medicine and other primary care specialties that are in shortage. This exacerbates the other inequities by making healthcare something that is less accessible to many Americans based on geography (where are the doctors located?) and culture, as well as because of cost, the absence of a universal affordable healthcare system being an almost uniquely American phenomenon.

Not having a medical workforce that looks like America, or practicing in the areas and specialties where there is most need, goes beyond the admissions process to medical school. It is impacted by the curriculum (both formal and informal, or “hidden”) in medical school, by role models and mentors, and very much by the potential income from practice. The systemic characteristics of society greatly influence who is considered a “good” candidate for medical school, and even who applies. These are considerations addressed in a recent blog post on LinkedIn®, a professional networking site, by Dr. Heidi Chumley, dean of the Ross University School of Medicine (RUSM). Dr. Chumley focuses on the challenges faced by students from backgrounds underrepresented in medicine (URiM), and in particular on the emphasis on performance on the Medical College Admission Test (MCAT) for deciding who gets into medical school, since URiM students perform less well on that test. She notes that what seems like a small difference in scores makes a significant difference in admission: “There remains an unexplained gap in average MCAT scores between White (503.1), Black (494.9), and LatinX (497.1) test-takers. This gap matters as 29% of applicants with a score of 502-505 are accepted compared to 10% with a score of 494-49.”

Dr. Chumley also address two other critical points. First, that the lower MCAT scores are likely tied to many of the social and educational disadvantages faced by URiM students, thus reflecting, and compounding, the other factors that these students have to overcome. Second, that efforts implemented by many medical schools (and endorsed by the Association of American Medical Colleges, AAMC) to have a more “holistic” admissions process mostly changes the selection of which high-scoring students are admitted. Yes, it is great that students who have a social conscience and have done volunteer work in the US and abroad are selected over those who are selfish and not so involved, but this rubric, as she points out, ignores the fact that many lower-income (and URiM) students need to work at paying jobs to support themselves (and often their families), and devalues such employment in comparison to the voluntarism that is more accessible to those from privileged backgrounds.

Added to this is the financial component of the cost of medical school itself, which, in the US and in the US (and Canadian) serving Caribbean medical schools (of which Ross is one of the largest and most prominent), is staggering. Students typically graduate from medical schools with debt loads of $250,000 or more. In addition to being outrageous to start with, add the fact that compound and accrued interest makes the total to be repaid much higher, and this encourages students to choose higher-paid specialties even when that is not where the greatest need is (you may make, over a lifetime, $7M more practicing as, say, an anesthesiologist compared to a primary care doctor) or even where the student’s personal interest lies.

Dr. Chumley describes some of the efforts to increase access for URiM students at RUSM, and they are indeed impressive. They include “pipeline” relationships with HBCUs (Historically Black Colleges and Universities) and HSIs (Hispanic-Serving Institutions) and  re-thinking what criteria for admission are essential, valuing the life experience (including work experience) of applicants and putting less emphasis on the absolute score students get on the MCATs. As she points out, the MCAT predicts performance on similar multiple-choice tests of knowledge including most “pre-clinical” tests in medical school, and the licensing exam, the USMLE (particularly Part I, which covers basic science). It definitely does not predict performance as a good or excellent clinician. Also, while there are significant differences in the first-time pass rates on USMLE in those who score “over-500” (> 95%) and “just under 500” (> 80%) groups on the MCAT, the medical school curriculum should be addressing those differences.

The two points I would like to emphasize are the criteria for who is likely to become a good doctor (and thus should preferentially be admitted to medical school) and the enormous cost burden on medical students that obviously falls hardest on those with the least wealth. As I have said before (The high cost of medical education: Who should be trained to become doctors?, Dec 10, 2019; Free tuition in medical school is only one step toward producing the doctors America needs, Aug 26, 2018), those who should be given the opportunity to become doctors (ie., be admitted to medical school) should be those most likely to make a positive difference in the health of our population. This includes a sense of community over self, a willingness to serve where needed, and interest in (preferably commitment to) practicing the specialties most in need in the areas most in need of them. Since URiM doctors are more likely to practice with patients from similar backgrounds (and those patients are often more comfortable seeing them), and a comparable correlation exists with those from rural backgrounds, these characteristics should be very important criteria. As should coming from a family with lower than average wealth and income, which requires addressing the second point. Higher income does correlate with better education and higher MCAT scores, and maybe higher scores on basic science tests in medical school (which are very like undergraduate science tests) and USMLE Part I scores, but not (and almost inversely) with practicing the specialties most needed and caring for the people most in need. So this should at best be a neutral, not positive, criterion.

And the money is a big one. You can admit a student from a low-income family who will be a great doctor, but they should not have to go into absolutely crushing debt and certainly not to enter the highest-income specialties to pay it off. This can partially be addressed by medical schools offering scholarships and states and localities offering loan-repayment programs, but it would be most effective if the federal government could subsidize the cost to make it far lower, and in conjunction with requirements that schools (state or private, stateside or Caribbean) to produce the physicians America needs.

Of course, as well, and even more important for all our people, to have a free or very low cost universal health system.

 

Disclosure: Dr. Chumley and I have known each other for many years and previously worked together.

Lower life expectancy in the US: A reflection of racism, classism, and social inequity

One of the things that most fuels self-deception is imagining that we should be living, or maybe even still live, in what we imagine was a better past. Of course, the past was not always better – in fact, it was overall, for most people, worse – but our minds repress the bad and remember the good from when we were children, as I have discussed in my other blog, “Life, the Universe, and a Few Things” (Brooklyn Nostalgia, August 21, 2011). Sometimes there is a conscious effort, a movement if you will, to block out the really bad things that have happened in the past not only from our individual memory but from our history books and schools. Clearly, this is happening now with regard to the primary founding evils in US history, extermination of the indigenous inhabitants (Native Americans, Indians) and slavery. That these were real is incontrovertible. That they were horrific, inexcusable, and must be remembered both to honor the victims and prevent recurrence should be obvious. But the effort to suppress teaching of this history, parallel to suppressing teaching about the Holocaust (which is not suppressed in Germany) is ongoing, vicious and wrong. To add insult to injury, advocates are adopting the language of microaggression, justifying their racist efforts to whitewash history with ostensible concern for “making white children feel bad about themselves”.

This is, in addition to every other evil and reprehensible aspect of it, also a way to divert those children – and their parents – from knowing and worrying about the things that they should be worried about, such as climate change and nuclear war. And the incredible inequities in American society (not to mention the world!) that have actually led to terrible social and individual outcomes. For example, the drop in life expectancy in the US. Yes, drop. People living shorter lives than they used to. Due in part to the COVID pandemic, but due in the US more to the vast inequities in wealth, social support, access to health care, jobs, use of harmful substances (such as alcohol, opioids, and tobacco) and every other determinant of health. What this has to do with self-deception and living in the past is the false idea that things are always, automatically, better in this country, the USA, a belief that persists in the face of evidence.

Of course, some things were, in fact, better in this country for earlier generations, some of whose members are still alive and sentient. America may not have always welcomed its immigrants, even those from Europe, and viciously and continuously repressed and oppressed members of many minority groups (particularly Natives and the descendants of Black slaves), but in the first half of the 20^th century, major parts of life were often better here for poor people than in many other countries. This was even more so after World War II, when the economies of most of the rest of the developed world were destroyed but the US' was intact, with no wars fought on its soil. This resulted in great success for US manufacturers (no competition!) and other benefits. One was life expectancy, due in large part to better nutrition. In the second half of the 20^th century it was widely observed that children of immigrants were bigger than their parents, because from infancy they were better nourished. Then, even later, at the end of that century and into the 21^st, some of the major causes of premature death saw a decline, mainly tobacco use.

But the premature death rate in the US is going up, life expectancy is going down. An important paper, published in 2014 in the Annual Review of Public  Health by Mauricio Avenando and Ichiro Kawachi, ‘Why do Americans have shorter life expectancy and worse health than people in other high-income countries?’, provides extensive documentation and discussion, including a supplement with several tables comparing life expectancy among different countries (a representative one, Female Life Expectancy at 40, is reproduced here).

 

While it has long, forever, been true that the life expectancy of underserved minority populations was less than for white people, the decrease in life expectancy for the “majority” group was shockingly revealed by data provided in 2015 by economists Anne Case and Angus Deaton, “Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century”, and has been demonstrated for larger and larger portions of the US population. As I noted in this blog (Rising white midlife mortality: what are the real causes and solutions?, November 14, 2015) this was a shock for those who held to the belief that it was only true for minorities (and in perverted way, found this reassuring). Indeed, while the life expectancy for Black Americans was and is still shorter than for whites, it was slowly rising while for many whites (of course, especially lower-income whites) it was dropping. Case and Deaton, noting the large increase in mid-life death (kind of an oxymoron, but meaning “middle age”) attributed this to “deaths of despair”, specifically due to opioids and suicide. On November 29, 2019 I wrote about an article by Steven Woolf and Heidi Schoonmaker, “Life Expectancy and Mortality Rates in the United States, 1959-2017” (Decreasing life expectancy in the US: A result of policies fostering increasing inequity), and I noted that, amazingly, women in lower income groups born in 1950 had shorter life expectancies than their mothers born in 1920!

Woolf and his colleagues RK Masters and LY Aron have recently come out with a new publication looking at life expectancy in the US and other OECD countries for 2019-2021. (Note: at the time of publication, the paper, in medRxiv, had not been peer-reviewed). They found that the pandemic shortened the life expectancy in almost all countries, but

US life expectancy decreased from 78.86 years in 2019 to 76.99 years in 2020 and 76.60 years in 2021, a net loss of 2.26 years. In contrast, peer countries averaged a smaller decrease in life expectancy between 2019 and 2020 (0.57 years) and a 0.28-year increase between 2020 and 2021, widening the gap in life expectancy between the United States and peer countries to more than five years.

In addition, ‘The decrease in US life expectancy was highly racialized: whereas the largest decreases in 2020 occurred among Hispanic and non-Hispanic Black populations, in 2021 only the non-Hispanic White population experienced a decrease in life expectancy.’ So while in 2020 the most vulnerable populations took the greatest additional hit from COVID, by 2021 they were slowly recovering, while white populations continued to lose life expectancy.

So why? This may be cognitive dissonance for the self-deluding, or racist, or narrow-minded, or those who think “America is always better”, but it is true. And the reasons for it are the inequities of American life, much of which is detailed in the Avenando and Kawachi paper, as well as Masters, Aron, and Woolf. We do not have universal health insurance, and we do not have universal access to health care. Even many “insured” Americans have very poor insurance, many Americans do not have geographic or physical access to health care services, and thus many people forego health care altogether or until it is too late. Our infant mortality rate is far higher than that of comparable countries. We still have large numbers of people who are “food insecure”, which often means chronically hungry and undernourished, not to mention those who are “housing insecure”, often homeless. And we have phenomenal income inequities which have grown tremendously since the 1980s Reagan assault on the social safety net. A paper by economists Emanuel Saez and Gabriel Zucman, widely covered, shows examples of this: since 1982 the wealth of the 0.00001% (18 families!) has increased from 0.1% to 1.2% of all US wealth.

 

Just from 2009-2022 the wealthiest American has gone from $40B to $265B, while average income has decreased from $54,283 to $53,490, and the minimum wage ($7.25/hr) has stayed the same! So the US remains an outlier, with great social and economic inequity, poorer health, and shorter (and decreasing) life expectancy. You can believe what you want in terms of political and social theory, but you have to be willing to accept the consequences.

I find these consequences, completely unnecessary, intolerable.

COVID, Vaccine, Racism, and Masks: Changing for better or for worse?

We are not yet out of the COVID pandemic. Not in the world, where hot spots linked to both bad luck and irresponsible arrogant governments continue to rage in such places as Brazil and India, as well as in some countries in Europe and in other parts of the world. Not in the US, despite the CDC indicating that it is now ok for those who are vaccinated to stop wearing masks. People are still dying in large numbers, people are still being infected, and this map of the US does not show all light-colored, low-risk counties (the gray counties, and state of Alabama, have to do with nonreporting).

But things are getting better. We no longer have an ignorant, evildoer in the White House who is intent on ensuring that as many Americans die as possible (while he himself got every a

vailable treatment when he was sick, and indeed got vaccinated), but there are still plenty of Americans who are loyal and faithful to him (or to the myth of him), and to the wacko conspiracy theorists on the dark part of the web. Many of these folks are vaccine-hesitant or vaccine-resistant.

A lot of the coverage of these attitudes has been in minority, and particularly Black, communities. There is definitely resistance there, and to a large degree it is based on the experiences of those communities with the health care system. Some of this may be, in fact, the oft-cited historical examples of exploitation and experimentation on Black people in this racist nation. These include (probably most famous) the Tuskegee study of the “natural history” of syphilis in Black men that continued even after a cure (penicillin) was discovered; they were not treated. They also include the work of the “father of gynecology”, Dr. J. Marian Sims, whose discoveries were based on non-consented (of course) surgery on Black slave women, for a foretaste of Nazi doctors. They include, more recently, the fact that the HeLa cell line, derived from a cancer in a Black woman, Henrietta Lacks, has been basis of many discoveries to treat cancer, but she was not cured and neither she or her family received recognition (or money, despite much going to researchers) for it.

Many Black Americans know these stories, and it is probably true that, to some degree, they influence the reluctance of some people to put their fates in the hand of the healthcare system and to trust the government, including the CDC. But I would posit that a larger reason is not these near-mythical (although very real) abuses, but the more mundane, everyday abuses that people, especially poor and minority people, have experienced at the hands of that system. It is no fun to be sick, no pleasure to need treatment, and the arrogance of much of our health-system culture to its patients is very often confusing, frustrating, unpleasant, and demeaning to even well-insured and well-to-do White people. How much greater are all of these indignities – and too often abuses – if you are not insured or poorly-insured? If the massive health care institutions that have been built in pursuit of profit do not really want to care for you, or offer you their special magic bullets available to those with more money? How much greater than even that is it when you are Black, and endure the overwhelming manifestations of American structural racism as delivered by the healthcare system? When the presumption is you are more likely to be the cause of your own problems, because of your behaviors, or your self-abuse, when the presumption is that you are guilty of not-always-clearly-stated malfeasances, that you are stupid and ignorant and not to be trusted?

Sure, Tuskegee and Sims and HeLa came from the same racism, but you don’t need to even know about them at all to know that the health system is stacked against your, and your family, and your friends, and your community, and not always to be trusted. So maybe you’re not sure about getting that vaccine. And many Black Americans, and other minorities are not sure. But they aren’t the majority of the “vaccine skeptical”, despite getting more attention. The “traditional” anti-vax community is largely White, educated, upper-income and centered on the coasts, especially the West Coast. It is represented by a legion of celebrities and other famous people, including Robert Kennedy, Jr., Jennie McCarthy, Mayim Bialik, even (until recently) Oprah Winfrey. In the COVID pandemic, they have been joined by another much larger cohort, overall less educated and wealthy but just as White – the Trumpers. Following the incorrect and dangerous information that continues to spew from their leader, they now believe that the vaccine is ineffective, probably bad for you, and likely a result of a conspiracy of foreigners. You can look into the Dark Web, or QAnon to find this information, or just turn your dial to FoxNews. And while there are organized efforts by Black leaders, including celebrities, to urge folks to receive the vaccine, there is no comparable campaign among by the heroes of the White right.

Many articles have appeared documenting the degree to which our emergence from the COVID shutdown is going to depend upon adequate numbers of people receiving the immunizations. Health authorities, nationally and in state after state, have dropped the age criteria for being immunized, so that at this point in many jurisdictions, only infants are ineligible. And folks are still being immunized; while the rate of immunization has decreased from the peak, it is still being actively pursued by many people. But what is scary is that there are so many who will not receive it. And they won’t wear signs.

Were you worried about a third wave of COVID? Or is it now fourth? I forget. Anyway, good idea to worry. The CDC has indicated that those people who are fully vaccinated can now not wear masks in public. There is actually good scientific evidence for this, and it would certainly help people to feel like a corner has been turned. Except – they won’t wear signs. As reported by the Associated Press on May 15, 2021, while many small businesses are embracing the new opening and taking down their signs requiring masks, not wanting to “have to play police” any more, many large chains are continuing their mask policies.

‘As many business owners pointed out, there is no easy way to determine who has been vaccinated and who hasn't.’ 

‘And the new guidelines, issued Thursday by the Centers for Disease Control and Prevention, essentially work on the honor system, leaving it up to people to do the right thing.’

Right. The honor system. The folks who stormed the US Capitol, who stood with guns outside the Michigan State Capitol to oppose masking (in the state which now has the highest COVID rates in the US), who believe that COVID is a hoax, that Trump won the election, that Nancy Pelosi is the devil, and that Jews have space lasers, will be honorable enough to wear masks when they haven’t been vaccinated.

Good luck with that.