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.

We don't need billionaires, we need a healthy population: It is time to move forward

I recently started reading Ricardo Nuila’s book “The People’s Hospital”, about Ben Taub, the largest public hospital in Houston. This will not be a book review (which can be found in many places, such as the NY Times, Washington Post, and elsewhere); I’ve just started it. What affected me was how, even in the first few pages, Nuila’s description of Ben Taub was so like that of Cook County Hospital (now John Stroger Hospital), the public hospital in Chicago where I did my family medicine residency and later practiced and taught for many years. That should not be surprising; the characteristics of large public hospitals in major cities, and especially the circumstances of the people who come to them for their health care (a major focus of the book, per the reviews) are going to be, sadly, very similar. What was most striking, and depressing, to me was the temporal aspect. Nuila is writing about recent years, including the impact of the COVID pandemic, while my years at Cook County were in the 1970s, 80s, and 90s. And yet so little has changed, especially not for the better.

Yes, medicine has changed. What we can (or, maybe more important, could) do for people is more. When I was a resident at County, CT scanners were uncommon, and didn’t exist at our hospital. If a patient needed a CT scan, it could usually be scheduled for after midnight at the private hospital across the street, if they were accompanied by the resident. Who had been up the entire previous night doing admissions. CT scans, and other imaging, are far easier to obtain now. We now have dozens, perhaps hundreds of more antibiotics, and are able to effectively treat many more infections, although bacterial resistance to them seems to grow faster than the antibiotics themselves, both because of overuse and the special breeding capacity of bacteria in hospitals where antibiotics are so pervasive. We can treat, even  cure, cancers we could not touch in the past, although the cost of chemotherapy drugs – a bonanza for not only the pharmaceutical companies but the hospitals that get paid a huge markup from insurers for administering them – makes them often unavailable to those who are poor and uninsured.

But there have been other things that have not changed. Indeed, have often gotten worse. This is the main focus of Nuila’s book, the social conditions that so many people, especially poor people, live in that have such a major negative impact upon their health. Calling them the “social determinants of health” is largely accurate, although the “socioeconomic determinants of health” would be more so, but it tends to almost make it sound trivial. It is not trivial. The socioeconomic conditions in which people live have a far greater impact upon health than anything except, perhaps, genetics. Certainly more than medical care, which accounts by most estimates for at best 10% of health, although it is where we as a society spend more than 90% of our health-related money. It has far more impact than all those diet/exercise/lifestyle factors, or vitamin/mineral/“natural supplements” that are promoted by those who are true believers as well as those who see this as their way to cash in.

It is shocking and distressing to me that conditions for poor people are not better than they were so long ago, and are in fact worse. The same groups of people who have always been pushed into this category, especially Black and Latino and Native peoples, and indeed poor white people, have been supplemented by immigrants from all over the globe who our society treats just as badly. And even more, supplemented by the NON-poor, working and middle class Americans who often have trouble getting the health care that they need – and deserve – because of limits imposed by insurance companies and health systems, which all operate as if they were for profit.

It is still surprising to me, because although I intellectually know better, much of my instinctive reaction is deep-seated and believes that history moves in a positive direction and things tend to get better. Said so much more articulately by Dr. King, “The arc of the moral universe is long, but it bends toward justice,” it resonates with me as much as I fear it is not so. My own perspective is generational; grandparents who were immigrants and low-income, parents raised in the Depression and in WWII, myself raised after the war thinking we were now middle-class (we were working class); better off than our parents were growing up. It was in that period that CEO salaries relative to average workers were “only” about 30x as much (not the hundreds of times as much as today), unions were stronger, the civil rights movement was gaining ground. See, e.g., this from the Economic Policy Institute from 2019 showing CEO salaries gained 940%  since 1978 while average worker salary was up only 12%!

But now it is much worse. It is moving backwards, except for the wealthiest – and by the wealthiest I mean the really wealthiest. Midwifed by the Republican party (but abetted by the Democrats), especially since the Reagan 1980s, we have become a society in which not just a disproportionate share (which was always), not just most, but virtually everything goes to the wealthiest. This Oxfam report (January 2023) shows that in the last 2 years, the top 1% has accumulated nearly twice as much as everyone else in the world put together!! This is what it is all about. Yes, there is racism, and sexism, and anti-LBGTQ+ ism, and they are terrible and they often make people’s individual lives terrible, and should be fought against ceaselessly. But it is the gangster capitalism (Noam Chomsky’s term) in which there is literally no limit to the greed and the amount of money a few people have, hundreds of times more than they or their descendants could ever spend.

This is the trend in our world and our nation while the people who seek health care at Ben Taub Hospital in Houston or Stroger Hospital in Chicago or their equivalents, not to mention those who live in places where there are not public hospitals, not to mention those from all the parts of the world to whom coming to Houston or Chicago seems like it would be Heaven, get sick and sicker and die. In fact, contrary to the proclamations of right-wing pundits, all of these problems can be solved with money. It should be the money now being amassed by the richest individuals and corporations, including those in health care (providers and insurers and pharmaceutical and device manufacturers) could, and SHOULD, be used to provide medical care, but more important provide the conditions necessary for health. For EVERY person to have adequate and healthful food, to have adequate and warm housing, to have an opportunity for an education as far as their drive will take them, to have a job to feed themselves and their family. There is enough money to do this, and yet it is being socked away in private pockets so deeply it will never be touched.

In 1850, the Frenchman Frederic Bastiat wrote in “La Loi” that "When plunder becomes a way of life for a group of men, they create for themselves, in the course of time, a legal system that authorizes it, and a moral code that glorifies it." They get to do this because we enable them. Directly, our politicians enable them; while Republicans and Democrats keep our attention focused on “culture wars”, both parties (except for the most progressive Democrats) depend upon and enable them. Indirectly, it is the rest of us, who do not demand that the politicians we elect fight for the interests of the people. If the 10,000 or so Americans worth $100M or more disappeared tomorrow, no one would miss them except (presumably) their families and the politicians who have become accustomed to being owned by them. If they averaged just $100M each, that would be $1 TRILLION ($1,000,000,000,000), but of course that is an underestimate since many are worth billions, or tens of billions.

It is well past time to take that, both in taxes and in other changes in public policy, and use it for the people.

Making people healthy or making money: What should be the goal of our health system?

In the February 16, 2023 issue of The Nation, epidemiologist Gregg Gonsalves writes about The Fight for the Soul of American Medicine. It is a particularly good and thorough review of the corruption of American medicine by the quest for profit, and the growing resistance of many physicians to its adverse effects on themselves and, more important, the health of their patients.

He cites several other recent articles that emphasize different aspects of this situation. Eric Reinhardt, writing in the New York Times about physician burnout, calls for increased unionization of physicians to counter the power of the corporate controllers of US medical care. Gonsalves also cites a JAMA Viewpoint by former CMS administrator Don Berwick calling out the many ways that greed perverts and destroys American healthcare, using the old Pompeiian phrase Salve lucrum, “Hail Profit”, and naming it an existential threat. Finally, he cites an article in the Journal of General Internal Medicine by Gondi, Kishore, and McWilliams called “Professional Backgrounds of Board Members at Top-Ranked US Hospitals” which identifies the fact that US hospitals are run by people with finance, not healthcare, backgrounds:

At top-ranked US hospitals, the most common professional background for board members is finance, far exceeding representation from physicians, nurses, and other health care workers. Over half (~56%) of board members are from finance or business, while a small minority (~15%) have clinical training or are from the health services sector.

Gonsalves notes how the perversion of healthcare, particularly medical care, by an explicit profit motive leads to the US having both the greatest cost and the worst health outcomes of the wealthy countries of the world, but then goes beyond that to further criticize our reliance on medical care as the avenue to people’s health. He cites the National Academy of Sciences estimate that medical care accounts for only 10-20% of health, with social determinants (and, one could convincingly argue, social determination) accounting for the other 80-90%. Social determination is found in the structure of our society, conceived perversely on democracy and plutocracy, rooted in the extermination of one set of peoples and the enslavement of another, and the racist roots that continue to poison our social structures today. Social determinants – including poverty, housing, food, education, childcare, and others -- are well documented, and are profoundly poorly addressed by us in the US.

This is more than coincidental. Gonsalves refers to a book by Bradley and Taylor, The American Health Paradox: Why spending more is getting us less (which I discussed, along with a NY Times op-ed they wrote, in a blog post To improve health the US must spend more on social services Dec 18, 2011). The essential point of that book is that, while the US spends far more than other wealthy countries on medical care (twice as much as a few and three times or more as much as most others), it spends far less on other social services and social supports. Furthermore, as Bradley and Taylor document, the US is unique in that of all its spending on social service and medical care, the vast majority is on medical, dwarfing expenditures on food, housing, childcare, job training, and social supports that are far more important in maintaining health and preventing disease, while medical care is focused on treating disease once it is there (for those who can access it, at enormous cost).

These are all true things. Our society spends most of its “social services” money on medical care, and it is directed at the most expensive types of care, those that generate the most profit for the big corporate and venture capital players in the hospital, nursing home, and ambulatory care fields as well as the better-documented profiteers in the pharmaceutical and insurance industries. The burnout of physicians from overwork is real and is simply what industrial workers used to call “speed-up”, the demand for more production in the same hours (and for the same pay). In industrial workers, speed-up was and is well known to increase the rate of accidents, both minor and major, and to destroy the psychological health of those workers, so that it is unsurprising that it does the same to doctors and other health workers. What is more surprising is that it has taken so long for them to realize it; over a few decades corporations have taken over almost all of health care delivery, with independent physicians and physician groups that own themselves almost disappearing.

Most hospitals, or “health systems”, are controlled by large corporations – or so they are called if they are for profit. The non-profit health systems, however, including academic health centers, behave scarcely less like corporations, chasing increased revenue (if not “profit” per se), and are, as Gondi et al., demonstrate, just as likely to be led by people with financial backgrounds, rarely medical ones. The good aspect of for profit relative to non-profit hospitals is that they, at least, pay taxes rather than be the recipients of government largesse through being tax-free in return for ostensible, and increasingly unrealized, community benefit. The bad side is that they provide even less community benefit, and generally have worse quality care, than non-profits. In addition, the positive side of the non-profit ledger is enhanced by inclusion of those hospitals in rural areas and inner cities that actually do care for the needy. These, however, are the very ones that are at greatest risk of going bankrupt, and closing because their patients are uninsured or are underinsured, including by Medicaid and even Medicare. A NY Times article recently addressed the increasing closure of rural hospitals, and an even more recent one documents how many rural hospitals are closing their maternity units, because it is a high-cost, low-revenue “service line”, causing rural women to have to travel dangerous distances for pregnancy care and delivery.

In terms of other healthcare operations, such as physician practice groups and nursing homes, “private equity”, venture capital groups, are playing a larger and larger role. Nursing homes have long been primarily private, and of generally poor quality, but they are increasing being acquired by such private equity or health corporations. Those physician practice groups that are not already owned by hospital systems (including academic ones) are often being acquired by the same groups. The results can be disastrous for their patients, particularly when encouraged by the government, as in the ACO/REACH program which I recently discussed (Privatizing Medicare through "Medicare Advantage" and REACH: The Wrong Way to Go!, Jan 20, 2023). Of course, one reason these (misad-)ventures are successful is that their downsides tend to only be apparent once you need care, when you are sick, when the less obvious odious characteristics of such arrangements can stymie you effective access to care. And, of course (and thankfully!) most of us are not sick at any given time.

I have often written that profit, in any form, does not belong in health care. This is absolutely true. The most egregious forms are the corporations that make and sell pharmaceuticals and the insurance companies that existence as parasitic middlemen between health care and patients, not only sucking off money but also limiting care in ways that actually and frequently harm people. But that is only the tip of the corrupt iceberg. Being “non-profit” does not prevent a health system from acting in the same fashion, to maximize revenue, and reward “successful” (i.e., money-making) management accordingly in seven figures.

It is time to have no incentives of any kind that allow any person or organization in health care to make money beyond that which is required to run a high-quality operation and pay workers a reasonable salary or wage. Indeed, the impact on the health care of patients should be the sole criterion for anything that is done or reimbursed.

AND, then, we need to start taking much of the money saved by having less or none going to insurers, pharma, and hospitals and health systems and spending it on ensuring everyone has good financial health care coverage and the social systems needed to support the social determinants of health are in place.