US Maternal Mortality Rate Exemplifies Moral Bankruptcy of Our Health System

My friend, Dr. Don Frey, recently published America’s DWP Crisis: Dying While Pregnant (DWP) on his blog, “A Family Doctor Looks at the World”. It leads with shocking and distressing statistics about the US maternal mortality rate, which has long been the highest in the “developed world” and has been steadily increasing. Citing a recent article in JAMA, Trends in State-Level Maternal Mortality by Racial and Ethnic Group in the United States (LG Fleszar, AG Bryant, CO Johnson, July 3, 2023), he  points out that in the 20 years from 1999 to 2019 US maternal mortality more than doubled (it actually went up 2.5 times):

In every corner of the country, for every ethnic group, outcomes worsened.  By 2019, deaths per 100,000 pregnancies (the benchmark measure) had increased from 12.7 to 32.2.  For Black and American Indian women, the picture was much worse.  Their mortality skyrocketed to 55.4 and 49.2, respectively.

And this doesn’t even include deaths from accidents and homicide – the latter being the #1 cause of death for pregnant women in the US!

Let’s stop and think about that. In the rest of the OECD (Organization for Economic Cooperation and Development, = wealthy) countries maternal mortality is going down. For the most recent reported years, it ranges from about 1.6 to 8.8, with most below 5. When we were at 12.7 we were way out of the picture. Now we are at 32.2! And our rates for minority women are like poor countries! Even though the maternal mortality rate is high and rising for all races and ethnicities, it is made even higher by the ridiculously high rates for some populations. In what conceivable way could this be compatible with the US having “the best healthcare in the world”, or anything approaching it? Only if you accept the definition of “well, the best healthcare is available for some people, who can afford it, but not even for most Americans”.

Dr. Frey points to several reasons why our “DWP” (and our dying-while-recently-pregnant, ie, post-partum) rate is so high, and they are valid, and addressing them would certainly significantly lower it. The major one is what we often refer to as “the social determinants of health”. This is a fine term, except it has almost become routine to cite them while we, as a country, continue to do little or nothing to address them. People are much more likely to have poor health status if they are financially poor, poorly nourished, poorly housed, poorly educated and live with ongoing danger and the fear that comes from it. And when those bad things happen in childhood, their risk continues higher for the rest of their lives. We call this “ACEs”, Adverse Childhood Events, and the higher number and degree of ACEs, the worse the outcome for not only those children but for the adults that they will become. Thus a person who grew up poor is likely to have worse health status as an adult than a neighbor who did not grow up poor, even if they end up with similar incomes and lifestyles. In addition to the ACEs that have their origin in poverty, there are others, ranging from growing up in a family with adults who abuse alcohol and other drugs, to parents’ divorce, to death of a parent, to physical and sexual abuse, that can occur in any socioeconomic group.

Dr. Frey also cites the number of states that have passed – and implemented – “anti-woman” laws, usually under the guise of being “anti-abortion”. While the legislators who propose and vote for them, and the state governments implementing them, would deny that they are anti-woman, the facts speak otherwise. A good example that Dr. Frey discusses, is

Last year in Missouri, for example, the legislature debated whether to outlaw surgery for ectopic pregnancies (an embryo that implants in the fallopian tube instead of the uterus), even though such pregnancies are 100% non-viable.  Apparently, the near-certainty of a mother’s tubal rupture, internal bleeding, sepsis, and death, wasn’t particularly important.

That law has not passed (so far) but many others have so limited access to abortion that women have to travel very far, have waiting periods, get illegal abortions, and otherwise risk their lives. Despite the ostensible justification for anti-abortion laws is to protect the “unborn”, the result is to increase the risk to fetuses, newborns, and their mothers. Dramatically.

There are also medical and healthcare factors that contribute to the maternal mortality rate in this country. As much as the social determinants of health, and anti-abortion anti-woman laws, contribute to the problem, medical care can make a difference. But too many women are not able to access good medical care for their pregnancies and births, in the prenatal and especially in the post-partum period. Among the important factors are the number and type of providers, geographic distribution of those providers, preference of providers for the kind of care that they want to do (or not do), and the ownership of practices and hospital by corporations that are interested mainly in money-making.

Let’s look at providers. Usually we think of obstetricians (OB-GYNs) as the people who deliver babies. And they do. Or at least many of them do. Actually, a minority, decreasing in % as they age. Doing gynecologic surgery is much more lucrative, and doesn’t require getting up at all hours to do deliveries. Plus, like most specialists, they are concentrated in urban (but not poor or inner-city) and suburban areas. So access to them is limited, especially geographically and financially. Certified Nurse-Midwives (CNMs) and family physicians also deliver babies, but often have the same “lifestyle” disincentives. Nurse-midwives are by definition about delivering (or “catching”) babies but usually are subservient to the dictates of the OB-GYN community. OBs probably do not mind if CNMs -- or family physicians -- deliver babies where the OBs do not want to be (rural and inner-city areas) but training programs may not have enough deliveries to allow them to learn. While nurse-midwives are a separate profession, their training may not strongly encourage them to assert themselves in practice.

And there is huge gap is in post-partum care. It is not uncommon for OBs (and, perhaps, others) to believe their job is done when the baby emerges, or at least when the woman is discharged. But as Dr. Frey’s piece points out, a very large number of maternal deaths take place in the post-partum period, up to 6 weeks after delivery, from bleeding, infection, and other causes that could be identified with the kind of close follow-up that too frequently does not occur. Not to mention identifying the risks for homicide (and suicide) in the situation in which the women lives.

Finally, but far from least important, is the structure of the medical care system. I have written extensively in previous blog posts about how hospitals and medical practices are run as businesses, to make money, rather than as facilities dedicated to improving the health of communities and the people in them. Birth, and the accompanying circumstances including maternal mortality, make a particular case. The businesses, as well as the physicians who work for them, are interested mainly in providing care when and where it is relatively easy and most profitable. This is understandable, but it is unacceptable. It is, at bottom, the cause of all the other problems. Receiving care for childbirth –including the prenatal and postpartum periods, as with all necessary medical services, should not be treated as luxury goods.

It may be OK that some people have a Lexus or Tesla, others a Toyota or Chevy, and still others an old clunker, while many have to walk or ride the bus. But it is not ok for healthcare, and specifically not childbirth. Women need to have access to excellent care no matter how much money they have or where they live.

That they do not is yet another indictment of a system built on profit rather than health.

Why are we paying wealthy corporations billions to limit our healthcare?

In an excellent “Guest Essay” in the New York Times (July 18, 2023) Linan Eirav and Amy Finkelstein ask a very important question: ‘We’re Already Paying for Universal Health Care. Why Don’t We Have It?’ It is a question that many people, including me, have asked many times over many years. This article answers several important concerns. One, as indicated in the title, is that the economic argument against it (“It will cost too much”) is nonsense, as we (the US) already pays more from public funds (per capita and overall) than other countries that have universal healthcare coverage. This has been documented for decades by authors such as Woolhandler and Himmelstein; when we consider Medicare, Medicaid, government employees and retirees at all levels, military retirees and families, and (least obvious) the lost revenue from the taxes not paid on employee health insurance contributions by employers (when it would be if it were salary) it is not only more than other countries pay for covering everyone, it is more than half US health expenditures.

The authors emphasize that while the emphasis is often on those Americans who are uninsured (and despite decreases as a result of the ACA, it is still far too many), there is also great suffering and uncertainty among those who have health insurance. This is because 1) their health insurance may be of poor quality, not covering all their health needs, and subject to the whims of insurance company denials, and 2) because there is uncertainty about whether they will continue to have it. The former is a real concern:

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.

And the latter, losing health insurance, can be because temporary government programs end or because employer coverage (and amount of employee contribution) changes. Or because the requirements for qualifying for many programs can leave people out because they didn’t know they were eligible, because they weren’t aware of or able to fill out the paperwork, or for many other reasons. The most simple, profound, and perhaps important paragraph in the article is:

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.

This is incredibly important. The risk of losing coverage is an inevitable consequence of a lack of universal coverage.  The cobbling together of different mechanisms for covering different groups of people (employer based insurance, various government funded insurance, self-pay, etc.) intrinsically leaves the opportunity for people to lose their insurance coverage. Only one solution prevents this, one so subtle and elusive that every other wealthy – and most middle income – country in the world has done it: cover everyone. Period. No qualification, no sign-up, no criteria, and preferably in one program. Just cover everybody. You are American, you are alive, you are covered.

That would take care of who is covered – everyone – but in itself is insufficient, as the coverage must be good coverage. It must pay for all needed healthcare and none that is unneeded. Thus, if we were to accomplish this by passing Medicare for ALL, that Medicare program would need to pay 100% (not 80%) of what is covered and cover all health needs include mental health, eyeglasses, hearing aids, and long-term care, without payments from users at the time of service. Unlike Eirav and Finkelstein, I do not think that the best answer is to provide basic coverage to everyone and allow wealthier people (or their employers) to purchase “upgrades”  as if it were an airline. Indeed, the best way to ensure that poor, uneducated, or unempowered people get the coverage and care that they need is to require the wealthy, educated, privileged and empowered to be in the same program. They will make sure that it works for them, and that will mean it works for everyone. The “upgrades” (if you like that term) should only be to allow people to purchase things they’d like but are not medically needed (most commonly cited is purely cosmetic surgery).

The money is there. It is currently going into the pockets and profits of insurance companies and pharmaceutical manufacturers (see, for example, How a Drug Maker Profited by Slow-Walking a Promising H.I.V. Therapy in the Jul 22, 2023 NY Times). Their greed is without limits. As I have discussed (Why do drugs cost so much? And what can we do about it?, Apr 18, 2023) Medicare is the only drug purchaser in the US with sufficient clout to negotiate down drug prices (other than the VA and TriCare, which already do). In response, the administration has carried through with its promise to the American people to let it do so, originally forbidden by the pharma-supported legislation creating the Medicare drug program, “Part D” (Fantastic (& fantastical) hospital charges: The industry + insurers + Pharma making money hand over fist!, Mar 26, 2023). This is  incredibly popular among Americans of all political persuasions, but not, of course, among the drug companies, who the NY Times reports are going all out to keep us paying the highest drug prices in the world (Drugmakers Are ‘Throwing the Kitchen Sink’ to Halt Medicare Price Negotiations, NY Times, Jul 23, 2023).

The money is also there and being pocketed by the owners of hospitals, health systems and practice groups, whether for-profit (often owned by private equity) or ostensibly non-profit but making and socking away money hand over fist. It is outrageous, but these companies are able to limit people’s access to healthcare and provide administrative or paperwork obstacles that discourage access, as shockingly demonstrated in another recent article by Chavi Karkowsky, (NY Times July 20, 2023), The Overlooked Reason Our Health Care System Crushes Patients. In discussing how her patient almost died because of the bureaucracy, Karkowsky says

This is the story of our medical system — quick, massive, powerful, able to assemble a team in under an hour and willing to spend thousands of dollars when a patient is sick.

This is also the story of a medical system that didn’t think my patient was worth a $12 medication to prevent any of this from happening.

This patient’s story is a result of the space between the care that providers want to give and the care that the patient actually receives. That space is full of barriers — tasks, paperwork, bureaucracy. Each is a point where someone can say no.

Why should we want to say no? In a rational system, everyone would be eligible and get the same benefit. No obstacles are necessary. Then the money we already spend would not only get us better healthcare, it would leave enough left over to begin to ensure that people have sufficient housing, food, and education.

All that would suffer would be the already bloated wealth of billionaires and huge corporations. And that should have zero weight.

Universal health coverage would save money. And lives. And make life a lot better for people.

Two recent Gallup polls confirm long-standing problems with the US health system. Americans Sour on U.S. Healthcare Quality finds that 

For the first time in Gallup’s two-decade trend, less than half of Americans are complimentary about the quality of U.S. healthcare, with 48% rating it “excellent” or “good.” The slight majority now rate healthcare quality as subpar, including 31% saying it is “only fair” and 21% -- a new high -- calling it “poor.” 

It is important to read that carefully; it does not say that “for the first time in two decades, Americans find problems with U.S. healthcare”. It says that for the first time fewer than half rate it as “good” or “excellent”. And “a new high”, 21%, say it is poor. This is very significant because the opinion one has about healthcare varies tremendously depending on whether one has needed it or not. If you, and your family, have been healthy, and have rarely if at all needed anything other than, perhaps, immunizations or checkups, then you are likely to perceive the system as better. Even then, you probably had some difficulty getting an appointment, getting through to find out the results of any tests you had, and difficulty communicating in general. And it likely cost a lot. If you were just a little sick, it can be irritating, frustrating, and even risk your health to some degree. But if you are really sick, and especially if you need to be in the hospital, it is very unlikely that your experience was even “fair”.

This is something that a lot of people, and a lot of pundits miss. When you don’t need health care, everything is fine, and your insurance is good and pays for all of the nothing you use; indeed even being uninsured is fine. It is just that pesky problem of it not being fine when you need it. Like anything; you don’t regret not having a down coat on a balmy Spring day, or an umbrella when it is dry. There is an old story about a traveler coming across someone whose roof is leaking in the rain. The traveler asks why he doesn’t fix it. The man responds that when it is raining it is too wet to get up on the roof, and when it isn’t, “my roof is as dry as anyone’s.” This is fine as a joke, but not as  healthcare strategy. When you or a family member is in a car accident, or gets a cancer diagnosis, or needs major (or even minor) surgery, or your newborn needs to be in the intensive care unit, is not the time to start to think about your health coverage.

And, yet, that is what many people do, are forced to do, to depend upon hope and prayer. While for some this could be in part an issue of distorted priorities – health insurance is expensive and I could be buying a nicer house or a bass boat –this is not the usual reason. It is more often “health insurance is expensive and I need to pay the rent and buy food and put shoes on my children’s feet”. And if their budget allows them to actually buy health insurance, it tends to naturally be the one that the buyer can afford – and is often inadequate, and have high patient responsibility (co-pays, maximums, and other costs). Thus “having health insurance” deludes you (and many pundits and policy makers) into thinking that you have taken care of this issue. Until you need it.

Which brings us to the results of another Gallup poll, released at the same time, “Record High in U.S. Put Off Medical Care Due to Cost in 2022”. “The latest reading, from Gallup’s annual Health and Healthcare poll conducted Nov. 9-Dec. 2, is the highest by five points and marks the sharpest year-over-year increase to date.” Not a surprise given the information above. You can put off going to the doctor for a checkup, or a cold, or a vaccine, or even for treatment for a significant chronic disease like diabetes, high blood pressure, heart disease – at least if is not bothering you too much – but it is not very wise, since ignoring such conditions is one way to get you really sick, and into the hospital, and maybe into intensive care, and maybe, even, die. However, since we don’t have a universal health program in the US, too many people simply cannot afford to get healthcare, especially anything that is costly. I am tempted to say that there is a price list, and, like buying a car or a house or a coat, you shop within your means. Except, of course, there is no price list, and you hardly ever know what a medical procedure will cost. And there are often no good alternatives to the expensive treatment; in this way it is definitely not like buying a perfectly functional, if less fancy, car.

A third important article was published in June 2022 in the Proceedings of the National Academy of Sciences USA. “Universal healthcare as pandemic preparedness: The lives and costs that could have been saved during the COVID-19 pandemic”  by Galvani, Parpia, Pandey, and Fitzpatrick, estimates that during the pandemic a universal healthcare system would have saved 212,000 lives and $105.6B from COVID alone, in 2020 alone. This would have risen to about 338,000 lives through March 2022, as reported on in the Scientific American, and would have been on top of another $438B saved from other causes besides COVID. That is a lot of money. And a lot of lives. More than 100 times the number of lives lost in the World Trade Center attack. And (see the polls from Gallup) that is not counting the people who didn’t die, but could have. Who lost their health, their ability to work, their life savings, their ability to provide for their families.

So what is this “Universal Healthcare” thing? Some kind of pie-in-the-sky dream of liberals that would bankrupt the US? No, it is what they have in every other wealthy country in the world, and many that are not so wealthy. Those countries that don’t consider health and healthcare to be a consumer luxury, that consider it to be about people’s health rather than something for the private sector to profit from. Remember, that $105,600,000,000, and that $438,000,000,000 (2020 alone) is not going into the garbage. It is going to health insurance companies, and health care providers (by which we mean not only – or even mainly – doctors, but rather hospitals and “health systems”) and their suppliers, especially drug companies. This is detailed in the latest publication on this topic (regularly updated, and rarely improving) from the Commonwealth Fund. “U.S. Health Care from a Global Perspective, 2022: Accelerating Spending, Worsening Outcomes” shows that the US is the only wealthy country that does not guarantee health care coverage to all its people, and still spends 2-4 times as much as those other countries. The money goes, of course, to private profit. There is a name for this: corruption and graft. And words for it. Mostly obscene.

So why don’t we do something about it? We have tried – President Truman tried to get a national health insurance system in 1948. Defeated, sadly, with support from labor unions who thought it would undermine their success in getting health insurance through negotiations with employers (there’s a quaint memory). Medicare, a national health insurance system for seniors and the disabled, was passed in 1965 under President Johnson. So was Medicaid, a state/federal partnership to provide coverage for many (but certainly not all!) poor people. In 2010, under President Obama, ACA (Obamacare) was passed, which extended health coverage to many (but certainly not all!) of those left out, who were unable to afford individual health coverage but were not poor enough to get Medicaid (and in most states that is desperately poor!).  But nothing comprehensive, nothing that covers everyone, nothing that guarantees you won’t be broke and in debt at the end. Nothing that resembles the systems in any other OECD (i.e., wealthy) country.  Why?

Because private corporations make lots of money, from you, and from your employer, and from the government, and very much do not want that to go away. Indeed, as I discussed recently (Privatizing Medicare through "Medicare Advantage" and REACH: The Wrong Way to Go!, January 20, 2023), the private sector is expanding its leech-like sucking of public funds through privatization of Medicare by programs like Medicare Advantage and ACO/REACH. And are willing to spend some portion of that huge amount of money on lobbying – and making contributions to – members of Congress, to make sure that their profits are maintained at the expense of the health and lives of the American people, not to mention their money.

It is  that simple. The health and lives of people vs. the profit of corporations. Don’t be fooled by liars or obfuscators. It is time to end this incredibly expensive boondoggle that costs the lives and health of so many of us. Write your Congresspeople and demand Medicare for All, or any form of completely universal healthcare, now.

Or sooner.