A Week in the Senate Healthcare Debate: A View from One Doctor

08/01/2017

 Healthy Living – August 1, 2017
William Sturrock, MD – Eastern Maine Medical Center
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If you were off on a news vacation last week you would have missed a dramatic and fascinating close to the Senate’s efforts at repealing (and replacing?) the Affordable Care Act,  often referred to as ‘ObamaCare’. The image of a bruised yet defiant Senator McCain arriving from his hospital bed to cast the decisive vote is almost a scene from a Hollywood movie, described as a tragedy or a victory depending on one’s political stripes. As a  doctor who is privileged to serve many years as a small-town primary care provider, yet has also been involved in leadership at the State level for public health issues, I have been approached by many who have wondered why all the major providers in the medical marketplace (American Medical Association, American Nurses Association, American Hospital Association, American College of Surgeons, among many others) agreed with Sen. McCain as well as Maine senators Collins and King that the Republican sponsored legislation was not right for the country. While there may be varied answers, I think an article written by Dr. Aaron Carroll in last week’s Journal of the American Medical Association entitled “Why is US Maternal Mortality Rising” gives a good scientific perspective for this shared position.
 
Maternal mortality, defined as the number of women who die in the year after giving birth per 100,000 varies a lot from state to state.  Overall we do not compare well to most other developed nations: in 2015 that number for the US as a whole was 25, while only 9 in the UK and just 7 in Canada.  But let’s look at two states to simplify things a bit. California and Texas have more similarities of demographics, economy population growth (both legal and otherwise), but differ in one important respect: California took advantage of the ACA provision to expand access to its poorer citizens and received the federal dollars to expand Medicaid, while Texas did not. During the years 2010 to 2014 the California maternal mortality figures have shown a strong downward trend to 7.3 deaths per 100,000 women, similar to Canada’s. During this same time frame, Texas has seen a very concerning increase that actually doubled their rate to 35.8.  And the numbers for women of color is really disturbing, going from 42 in 2010 up to 83 deaths per 100,000 in 2014, which rivals the statistics of the poorest countries in the third world.
 
In addition to having fewer poor mothers covered with insurance, Dr. Carroll points out another factor that may have played a role in the worsening of the Texan experience. In 2011 the legislature slashed the Family Planning budget to defund Planned Parenthood, which was another feature in the recent Republican Senate bill. The result was that by 2013 only half of the clinics that could provide both prenatal and family planning services were still open in Texas.  During this same time-frame Senator McCain’s state of Arizona did choose to expand Medicaid and the most recent look at their mortality statistics showed it to be 9.5 per 100,000, which is only 25% of the Texas rate of  35.8 in 2014.  How this happens is easy to explain: people with health insurance are more likely to see a medical provider, and early prenatal care is reliably associated with better outcomes. 
 
Now I can’t say for certain what tipped the scales in Sen. McCain’s mind but as a doctor who is concerned about why the US has so many women that die in the first year after they give birth, I could not in good conscience advise we go down the same route as Texas. Don’t get me wrong, I think the Lone Star state is a wonderful place. I’ve enjoyed vacationing on the Gulf coast, riding a motorcycle in the hill country north of Austin, as well as hiking in the wilderness at the Big Bend National Park.  But if I were pregnant, I would rather be next door in Arizona, because my chances of surviving the physical challenge of pregnancy would be four times better. All major associations of medical providers in the United States had indicated that a prime factor in their decision to oppose the senate legislation was the decreased number of individuals covered, particularly in higher risk populations. Even if you look at it from the narrow position of what is best economically for the nation, it’s hard to argue that is makes any sense to increase the number of folks, particularly pregnant women, who cannot get earlier care to prevent more expensive adverse outcomes that ultimately will affect all of us.
 
The recent defeat of the Republican offering to reform US health care should not be the end of this effort. Far from it. As a member of the Maine Medical Association’s Legislative committee, I would now agree with Maine Senators, Collins and King, as well as courageous colleagues such as Senator McCain, that now is the time for bipartisan efforts to make changes that could offer real improvement to healthcare. In our current polarized political environment this may seem a stretch, but real progress comes from folks working together on problems that face all of us.  Americans deserve healthcare policies that do not have the risk of worsening our current maternal mortality statistics, but offer a promise for better outcomes for all.