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The most vulnerable deserve care and coverage for preventative health services.
Dr Brown is F. Bayard Carter Professor and Chair Emeritus, Department of Obstetrics and Gynecology, Duke University, President-Elect of the American College of Obstetricians and Gynecologists, and a past member of the Contemporary OB/GYN editorial board.
Ms DiVenere is Officer, Government and Political Affairs, the American College of Obstetricians and Gynecologists.
Recent statements by US policy makers show a shallow understanding of the issues facing low-income individuals in America. One freshman congressman, an obstetrician, said “Just like Jesus said, ‘The poor will always be with us’ … There is a group of people that just don’t want healthcare and aren’t going to take care of themselves”1 as a rationale for repeal and replacement of the Patient Protection and Affordable Care Act (ACA or “Obamacare”). Another more senior member of Congress said, “Americans have choices, and they’ve got to make a choice. So rather than getting that new iPhone that they just love and … spend[ing] hundreds of dollars on that, maybe they should invest in their own healthcare.”2
These statements are very disturbing in general but particularly when coming from a physician who has taken the Hippocratic Oath. They suggest that the poor and most vulnerable children and adults in this country deserve neither healthcare nor coverage for preventative health services.
Perhaps both these legislators and many of their colleagues believe that an individual’s current medical condition is a referendum on being poor.
ACA and Medicaid: lifelines for the poor
It’s worth noting, and too many people don’t remember, that before the ACA, nearly one-third of pregnant women had no health insurance, and 20% of women of childbearing age (15–44 years) were uninsured.3,4
Uninsured women with breast cancer were up to 50% more likely to die from the disease, and faced a 60% greater risk of late-stage cervical cancer diagnosis.5,6
The ACA put in place landmark protections for women’s health, including maternity coverage for all women in all plans, mandatory no-cost coverage of evidence-based preventive services-including all FDA-approved contraceptives-and important insurance protections.
Unfortunately, too many state and federal politicians are insensitive to the fact that Medicaid is a lifeline for the many of our elderly in nursing homes, the disabled, and the mentally ill. It’s a lifeline too for millions of low-income individuals, including the working poor and their families. The truth is that Medicaid is a US success story, improving the lives and health of those covered, especially women and children, and proving that indeed, low-income individuals do want healthcare. The Health Insurance Association of America describes Medicaid as a “government insurance program for persons of all ages whose income and resources are insufficient to pay for health care.” Medicaid is the largest source of funding for medical and health-related services for people with low income in the United States. All states have participated in Medicaid since 1982 for individuals.
Approximately 70% of practicing ob/gyns in the United States provide care for women with Medicaid in their daily practice. Indeed, ACOG recently encouraged all policy makers to understand the critically important role Medicaid plays to women’s health, providing healthcare coverage to 49 million women. The fact is, girls enrolled in Medicaid as children are more likely to attend college, with an estimated $656 increase in wages for each additional year of Medicaid coverage from birth to age 18.7,8
The ACA significantly expanded both eligibility for and federal funding of Medicaid. Individuals gaining access through Medicaid expansion programs increased their use of mammography and cholesterol checks by 60% and 20%, respectively.9,10 Medicaid covers prenatal care, ensuring healthy moms and healthy babies. Medicaid covers 48% of US births, and 75% of public family planning dollars.11-13
Medicaid expansion programs in 32 states, including the District of Columbia, have increased use of primary care, improved affordability of medications, reduced likelihood of emergency department visits, and increased outpatient visits, screening for diabetes, and care for chronic conditions. The number of adults reporting excellent health increased significantly.12,14
The Women’s Preventive Services Initiative (WPSI), led by ACOG Past President Jeanne Conry, MD, PhD, outlined preventative health services for women by age group based on the best evidence.15 All physicians and other healthcare providers who care for women should inform them of age-appropriate preventative health screenings such as mammography, cervical cytology, and colonoscopy. For poor and uninsured women, such preventative screenings would not be possible without the provision provided in the ACA and through Medicaid Expansion.
When Texas ended state funding for Planned Parenthood clinics, Medicaid births increased by 27%, making it a truly penny-wise and pound-foolish policy move.
Dangers of stereotyping
In 2002, the Institute of Medicine (now the National Academy of Medicine) published Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.14 That report addressed the potential harm accruing patients because of providers’ cultural biases and ignorance as related to bias, stereotyping, prejudice, and clinical uncertainty.
In 2010, the Association of American Medical Colleges (AAMC) asserted, “Assembling a workforce that is diverse along many dimensions is critically necessary, but not sufficient to adequately care for patients from different populations. Medical students and physicians must learn how to handle each patient sensitively and competently. They require training on the effects of values, needs, traditions, and perceptions of patients from backgrounds that differ from their own.”15
Clinicians involved in medical education must remind their students, residents, and faculty that social issues are quite literally found in the back yard of medical training programs. Many teaching hospitals serve poor and minority populations in the immediate surroundings of that community. We all must examine how our personal background and education prepares us to care for patients from diverse backgrounds and circumstances.
ACOG policy also compels our members to fulfill their responsibilities “to assure [our nation meets] the health needs of all women. Fellows must not discriminate against patients based on race, color, national origin, disability, age, religion, marital status, sexual orientation, perceived gender, or any other basis. … Expanding health coverage to all Americans must become a high priority.”
Physician professionalism and compassion
When providing medical care, physician professionalism mandates that we examine factors that include:
• the social and cultural contexts from which our patients come;
• the complex interplay of patients’ values and beliefs of patients from different backgrounds and circumstances; and
• patients’ conceptions of their health and illness.
The March 2017 residency match informed senior medical students of the city and community in which they will begin residency training and the practice of medicine in their chosen specialties and subspecialties. This spring at “hooding ceremonies” at medical schools across the country, students will recite the Hippocratic Oath in the presence of family, friends, and classmates. Several stanzas of that oath should weigh heavily upon these new physicians, as well as on all our colleagues (see below).
We say to these students: if you have reached the level of cynicism that is expressed by some politicians, that poor people “just don’t want healthcare,” perhaps you should refrain from reciting the Hippocratic Oath that has become the ritual that marks the transition from medical student to medical doctor.
The good news is that most physicians believe that not only do poor people want healthcare, but that they deserve healthcare-especially preventative health services that may often be unavailable without requisite financial resources being made available. While cancer and heart disease, the leading causes of death and healthcare costs in the United States, have risk factors affected by social and environmental circumstances, these 2 conditions occur regardless of household income or insurance status.
So we, as providers of medical care to all Americans, must challenge this physician-turned-legislator and his colleague on their statements that poor people just don’t want heathcare and that low-income Americans value gadgets more than healthcare coverage.
While caring for patients has become more challenging for many reasons, the mission to provide healthcare to all regardless of circumstances should never be in question.
Facher L. Two months ago, this doctor was delivering babies. Now he’s at the nexus of the Obamacare fight. Statnews. Available at: https://www.statnews.com/2017/03/03/roger-marshall-kansas-obamacare/
Chait J. Republication congressman: Repeal Obamacare because poor people don’t want to be healthy. New York. March 3, 2017. Available at: http://nymag.com/daily/intelligencer/2017/03/obamacare-repealer-explains-poor-dont-want-to-be-healthy.html
D’Angelo DV, et al. Patterns of Health Insurance Coverage Around the Time of Pregnancy Among Women with Live-Born Infants-Pregnancy Risk Assessment Monitoring System, 29 states, 2009. MMWR Surveill Summ. 2015 Jun 19;64(4):1-19.
U.S. Census Bureau data prepared for the March of Dimes (MOD), September 2007. MOD summary, Census Data on Uninsured Women and Children. See also March of Dimes, The Distribution of Health Insurance Coverage Among Pregnant Women, 2001.
Kaiser Family Foundation. 2004 Kaiser Women’s Health Survey.
Kaiser Family Foundation. Women and Health Care: A National Profile: Key findings from the Kaiser Women’s Health Survey, 2005.
Wagnerman K, Chester A, Alker J. Medicaid is a smart investment in children. Georgetown University Health Policy Institute, Center for Children and Families. Executive summary. March 2017.
Brown D, Kowalski A, Lurie I. “Medicaid as an investment in Children: What is the Long Term Impact on Tax Receipts?” National Bureau of Economic Research. January 2015.
Frost J, Sonfiel A, Zolna M, Finer L. Return on Investment: A Fuller Assessment of the Benefits and Cost Savings of the US Publicly Funded Family Planning Program. 2014.
The Henry J. Kaiser Family Foundation. Paradise, Julia and Garfield, Rachel. What is Medicaid's Impact on Access to Care, Health Outcomes, and Quality of Care? Setting the Record Straight on the Evidence. August 2013. Available at http://kff.org/report-section/whatis-medicaids-impact-on-access-to-care-health-outcomes-and-quality-of-care-setting-the-record-straight-on-the-evidence-issue-brief/
Markus A R, Andres E, West KD, Garro N, Pellegrini C. Medicaid covered births, 2008 through 2010, in the context of the implementation of health reform. Women's Health Issues. 23(5):273-80; Guttmacher Institute.
Sommers BD, Blendon RJ, Orav J, et al. Changes in Utilization and Health Among Low-Income Adults After Medicaid Expansion or Expanded Private Insurance. JAMA Intern Med. 2016;176(10):1501-1509.
Conry JA, Brown H. Executive Summary, Well-Woman Task Force, Components of the Well-Woman Visit. Obstet Gynecol. 2015;126:697–701.
Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academy Press; 2002
AAMC.org. Diversity in the Physician Workforce Facts & Figures 2010. https://www.aamc.org/download/450388/data/diversityphysicianworkforcefactsandfigures2010.pdf