What Warren Misses in Her Proposal to Address the Maternal Health Gap
Image: Serena Williams is an advocate of black maternal health.
May 2, 2019 | Elizabeth Warren has proposed among the most detailed and ambitious policies of any of the Democratic candidates for president. Recently, she participated in the presidential forum titled “She the People”, which focused on including the voices of women of color in presidential politics. Here, she unveiled her newest plan, this one targeting healthcare reform. Elizabeth Warren wants to take on racism and sexism in medicine and she’s starting with the maternal health gap.
In the United States, maternal and infant health outcomes are declining. This is in contrast to the majority of other wealthy nations. This is particularly problematic for black women in the U.S. Black women are three to four times more likely to die in childbirth than white women. Black infants are born at lower birth weights and are more than twice as likely to die before their first birthday than white infants. These facts all hold true even when comparing black families and white families who have the same income and level of education.
In Warren’s announcement, she rightfully identified this as a problem not of race, but of racism. Race and the effect that it has on medical care is complex and often misunderstood, even by doctors. Race is a social construct, determined by a few appearance cues. These appearances are affected by genetics and the environment, which often makes people think that racial difference is equivalent to biological, or genetic, differences. Racial grouping based on what someone looks like is similar to grouping zebras and skunks together because they both have black and white stripes. There are far bigger differences within groups than between groups.
Why, then, are there racial differences in health? The answer comes down to racism, the way it consistently stresses the physiology of a person, and the way that racism prevents opportunity for a person. Because of housing segregation, wealth inequity, and income inequality, many black families do not have the same opportunities for adequate healthy food, spaces to exercise, or time to get enough sleep. The effects of systemic racism can be passed on through generations, causing both biological changes in physiology and cultural changes in health-maintaining behaviors.
Racism in society causes chronic stress, especially in women of color who experience the dual burden of racism and misogyny. Chronic stress, including the stress of racism, affects the way a fetus develops during pregnancy. Women who report higher levels of stress are more likely to suffer serious complications during pregnancy such as gestational diabetes and pre-eclampsia and their babies are more likely to be born prematurely, at higher risk for developmental abnormalities, weakened immune systems, and delayed growth through adolescence. The chronic effects of racism are paired with the particular racism that black women face within the medical system. Black women are undertreated for pain, dismissed by health care professionals, and receive measurably worse care than white women in hospitals.
To read my recent piece on how a lack of pain treatment in black patients perpetuates systemic racism, click here.
Elizabeth Warren’s plan to address the maternal health gap targets the particular racism and sexism that black women face within the hospital by changing the way hospitals are reimbursed by insurance companies. Rather than pay doctors and hospitals for every individual service such as an epidural, a hospital stay, or a visit with a specialist (known as the fee for service system), Warren wants to bundle payments together for the entire course of the care. This would have several cost saving benefits: patients and their insurance companies would know exactly how much their stay would cost and it incentivizes the right care, not just the most care. Moving toward bundled payments would also allow insurers to reward doctors and hospitals with good outcomes by giving them more money and punish hospitals and doctors that don’t improve by paying less for each bundle. It sounds great, right?
Unfortunately, this is likely to end up hurting black women and babies more than it would help. Bundled payments, which have most successfully been used in short medical treatments like a joint replacement, do not work well for long term care. A bundled payment plan relies on the accurate measurement of the expected cost of care, and the quality of care that is provided over the entire bundled procedure. If a bundle doesn’t include the entire course of care, hospitals and insurers rely on measures in surrogate measures that only sometimes correlate with good health outcomes for patients. Pregnancy, birth, and infant care is long enough that one “bundle” would not be sufficient. These breaks in bundles could segment care even further, something that has been shown to increase the maternal health gap.
This payment system could also mean that black women could lose access to doctors altogether. Hospitals generally operate with razor thin profit margins and can only control some aspects of health. Under Warren’s plan, hospitals and doctors in primarily black neighborhoods would be taking patients that are at higher risk for costing them money. This is already happening in rural areas and causing rural Americans to have to travel farther and farther for medical care. If hospitals are paid more for good health outcomes, they will relocate toward patients with low risk profiles and away from the families that need them most. Even if a hospital stayed in a primarily black neighborhood, the decreased bundled payment would likely cut the kinds of services that help to address systemic racism and care continuity, which are often at the bottom of the priority list for a hospital looking to tighten the belt.
There is also an ethical problem with addressing racism in this way. Racism is a structural problem, with historical roots and ongoing impacts. This structure and history shapes the media we encounter, the houses we live in, and the way our doctors diagnose disease. However, racism in the U.S. is almost always discussed by people in power as a problem of the individual racist, who acts out of malice or ignorance. This incremental view of racism prevents well intentioned doctors and hospital administrators from recognizing the ways they participate in and are influenced by the systemic racism in their education. By attempting to address the maternal health gap by punishing individual doctors and hospitals, Warren is furthering that individualistic narrative, and making it even harder to address the systems of racism throughout U.S. society.
There are some policies that Warren could promote, either along with bundled payments or instead of her current proposal, that I think would have a more positive effect on maternal health. Regulating medical school applications to impact who can get into medical school would help increase the number of black doctors. Increasing funding for racial and gender bias training in all stages of medical education has been shown to help doctors provide better care to women of color. Midwives have been shown to reduce the maternal health gap, so creating an incentive structure that brings together interdisciplinary teams of health care providers in the bundled payment model would make sure black mothers are heard and treated with the care they deserve. Focusing on the transitions in care have also been shown to improve health of mothers and their babies, so providing a financial reward to hospital systems that integrate care for the two years around birth could incentivize hospitals to provide support systems that help black families to access consistent, high quality care.
As per usual, Elizabeth Warren brings substantive policy to an issue that is affecting Americans and needs to be addressed. This attempt to solve the maternal health gap has flaws, but the good news is she is still modifying and shaping this proposal. Hopefully Warren will recognize the issues with her own policy and adjust the proposal to more successfully address the Maternal Health Gap.
Sage Gustafson is a candidate for Master of Arts in Bioethics and Science Policy at Duke University. She has a particular interest in health policy that promotes racial and gender equity.
The views expressed in this piece do not necessarily reflect the views of other Arbitror contributors or of Arbitror itself.
Photo: “Serena Williams at TED 2017” by Steve Jurvetson with a CC BY 2.0 license.
