Born in the USA (34 page)

Short of filing a lawsuit, filing a complaint with a state medical board can be a very effective means of changing the birth climate in a given state. Though few complaints actually cause physicians to lose their licenses, they can lead to other disciplinary actions, such as the loss of hospital privileges or the loss of professional credentials. In addition, many states have searchable databases of complaints, malpractice suits, and disciplinary actions against physicians, so a complaint is public information and may deter patients, which can have financial repercussions for the physician. At the very least, filing a complaint with the medical board, the hospital, and the insurance company establishes a record (letters of complaint usually remain on file permanently), so that if other patients complain about the same physician, the organizations will see a condemning trend.

Flying under the radar in the issue of obstetric litigation is the insurance industry, which has its eye on the health of its bottom line, not of women and babies. There does not appear to be any transparency, much less accountability, in the establishment of malpractice insurance premiums. Even ACOG's suggestions for reforming the “litigation crisis” start off with a call for consideration “of insurance market reforms, to answer the question: why are premiums so volatile for doctors?” The insurance industry, including those who provide malpractice insurance, certainly appears to have a healthy bottom line. They are an important but nearly invisible element in the obstetric litigation crisis and their role urgently needs investigation and transparency.
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In the face of all the legislation reviewed here protecting pregnant and birthing women, ACOG's threat to abandon women in labor because obstetricians have high insurance fees rings hollow. Clearly, the government recognizes that childbirth is of central importance to the health and future
of society, and politicians will not abide any serious threat to it. It is sad that so much of the litigation crisis dialogue is so adversarial. Pitting pregnant and birthing women against those doctors and hospitals who abuse their rights is, one hopes, only a temporary but necessary strategy in giving birth decision-making rights back to women and families.

I navigate by the stars. I may not reach them soon but they guide me in the right direction.

NORWEGIAN SAILOR'S PROVERB

In this chapter I offer my vision for a better way to be born in the USA. I consider it a guide to keep us heading in the right direction, a goal to work toward. In
chapter 9
, I will offer some practical ideas for getting from where we are to where we need to be.

My vision of a healthy maternity care system for our country is built on two sets of principles. The first set of principles guides the work of the Coalition for Improvement in Maternity Services (CIMS).
¹
These are included in
chapter 1
but are worth repeating:

•   Normalcy: treat birth as a natural, healthy process.

•   Empowerment: provide the birthing woman and her family with supportive, sensitive, and respectful care.

•   Autonomy: enable women to make decisions based on accurate information and provide access to the full range of options for care.

•   First, do no harm: avoid the routine use of tests, procedures, drugs, and restrictions.

•   Responsibility: give evidence-based care used solely for the needs and in the interests of mothers and infants.

The second set of principles were unanimously approved by more than two thousand participants at the International Conference on Humanization of Birth held in Fortaleza, Brazil, in the year 2000:

•   Humanized birth means putting the woman giving birth in the center and in control so that she, not the doctors or anyone else, makes all the decisions about what will happen.

•   Humanized birth means understanding that the focus of maternity services is community-based (out of hospital) primary care, not hospital-based tertiary (specialist) care.

•   Humanized birth means midwives, nurses, and doctors all working together in harmony as equals.

•   Humanized birth means maternity services that are based on good scientific evidence, including evidence-based use of technology and drugs.
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It is clear that many of our serious maternity care problems would be immediately and profoundly improved by establishing a national health care system. This is a fundamental difference between the maternity care provided in the United States and the care provided in those countries that have lower mortality rates for mothers and babies than we do—every one of those countries has unobstructed access to care for
all
pregnant women. In the United States, there have been efforts to extend insurance coverage to pregnant women, but these efforts have not prevented the number of uninsured pregnant women from increasing.
³

In the United States, the maternal mortality rate of Hispanic women is twice as high as that of Caucasian women. Among African American women, the maternal mortality rate is four times as high as that of Caucasian women. Each year, African American babies die at twice the rate of Caucasian babies.
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This is not a matter of race. It is a reflection of our inadequate care for women and families living in poverty.

Today fewer and fewer American women and families who are in need of maternity care have health insurance. Employment-based health insurance, the only serious source of coverage other than Medicare or Medicaid,
is in decline. The number of American workers covered by employee-based health insurance has recently fallen by 4.9 million people, and we can expect this trend to continue. Many American companies have reduced medical benefits or are planning to reduce benefits in coming years, and it is becoming more common for large companies such as Wal-Mart to hire employees who do not work enough hours to be entitled to medical insurance.
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This trend may be coming to an end now that Maryland has passed a law requiring Wal-Mart to increase its spending on health insurance, and other states may follow. But even if this is the case, it will be a long, drawn-out patching process.

A national health care system would not only mean medical services for all pregnant women and babies, it would also allow us to monitor maternity care practices far more effectively. It is extremely hard to assure high-quality services for an entire country when we know very little about what is actually going on. Only two out of fifty states currently require hospitals to disclose their C-section rates to the public, and even in those states there is a lot of noncompliance with the law. We have very little solid information on the use and outcomes of procedures and drugs, such as Cytotec for inducing labor, that have not been adequately tested for safety. Without a national health care system, physicians and hospitals have no tradition of reporting, whether it be reportable infectious diseases such as tuberculosis and AIDS, adverse drug reactions, medical mistakes, or even usual practices such as cesarean section, making the monitoring of health care nearly hopeless. Maternal mortality cases are grossly underreported (some say that fewer than half are reported).
⁶
The FDA believes that less than 10 percent of cases where there has been an adverse reaction to a drug are reported.
⁷
Despite the fact that we have laws requiring doctors and hospitals to turn over records to patients and their families upon request, there are so many obstacles to getting case information that families feel that their only option is to file a lawsuit. With a national health care system in place, monitoring becomes part of quality control and can be easily facilitated by withholding reimbursement for noncompliance, a mechanism that has been used successfully in other national health care systems.

A national health care system would also greatly improve quality control of physician practice in the United States. Currently, every state has a medical board that grants doctors licenses to practice. When a malpractice complaint is made to the state medical board, it must investigate, and if it deems appropriate, the board has the power to take a doctor's license away. However, in reality, state medical boards rarely take any action of consequence.
I am a licensed physician in California, and for decades I have received an annual summary of the malpractice cases the California State Medical Board has investigated and what action has been taken. Almost all the cases involve drug or alcohol abuse by the physician. There are very few instances in which a specific case of malpractice is actually investigated. This is not surprising, as the board consists of fellow physicians, and as noted in
chapter 2
, asking physicians to control other physicians is fraught with difficulty due to tribal loyalties. This system provides very little protection for the American public. Even when a state board does rule against a physician, he or she can simply move to another state and practice there. Clearly, a national program of quality control, as part of a national health care system, would be much more effective—with rulings against physicians held in a national database (and made accessible to the public), more thorough investigations, and more neutral investigators.

Those who advocate keeping our present system, which is clearly unfair and sometimes even cruel to many families having babies, often argue that we are getting better care than we would with a national system. But there is a wealth of evidence that, although we pay far more than other countries for our health care, we are not getting better care.

The first evidence comes from the Organization for Economic Cooperation and Development (OECD). The OECD gathers survey data to compare the health systems of its thirty member countries (including the United States), which are all industrialized. One OECD survey concludes, “U.S. health spending towers over that of other countries with much older populations. Prominent among the reasons are a highly complex and fragmented payment system that entails high administrative costs.”
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Another OECD survey concludes, “The data show that the United States spends more on health care than any other country. However,
on most measures of health services use, the United States is below the OECD medium
. These facts suggest that the difference in spending is caused mostly by higher prices for health care goods and services in the United States.”
⁹
In other words, the OECD has found that the United States gets less in the way of health care than other industrial countries do but pays a lot more because of the high prices charged for the care.

For further evidence that the United States does not have better health care than other countries, we need only look to the fact that we have higher mortality rates for women and children and shorter life expectancies than other countries.
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Anecdotally, I can say that for several decades I have made repeated, extended visits to every other industrialized country—including
every OECD country—and have never found health care inferior to what we have in the United States.

There is also an unsupported belief among many American policy makers and politicians that private insurance is more cost-effective and efficient—that is, it allows us to get the best health care possible for the best cost and with a minimum use of time and resources. This idea is entirely false. The United States spends more than twice as much per person on health care as Britain does and almost twice as much per person as Germany and Canada do.
¹¹
There are many reasons for this, including health care providers, hospitals, and health maintenance organizations looking to maximize profits; health insurers wanting to maximize profits; higher administrative costs because our system is more bureaucratic; and higher costs for drugs and medical supplies because our system is fragmented and providers do not have the leverage to bargain successfully with drug companies and other suppliers.

A decade ago, Taiwan shifted from a U.S.-style health care system to a Canadian-style single-payer health care system, and in six years, the percentage of Taiwanese people covered by health insurance rose from 60 percent to 97 percent. Furthermore, the expanded coverage cost no more than the previous coverage because of savings in bureaucratic costs.
¹²

The fact that health services in the United States, which combine private and public-sector funding, cost more and are less efficient than health services in other countries illustrates a principle that has been proven again and again in many countries around the world. Human services—including health, education, and social welfare—must be in the public sector. They are labor-intensive, expensive, and require highly skilled people. It is not possible to make them broadly accessible, high-quality, and, at the same time, financially profitable.

In addition, to be effective in the long term, human services must be prevention-oriented, and that requires a willingness to wait years to see results. We must spend time and money today, when the desired results—improved health combined with a reduced need for medical care, leading to long-term cost savings—will take years to show. This approach is fundamentally incompatible with the need to focus on the bottom line at the end of every fiscal year.

Commenting on a series of
New York Times
articles on the rising tide of diabetes, Paul Krugman points out: “The U.S. system of paying for health care doesn't let medical professionals do the right thing. There's hardly any money for prevention. . . . ‘[I]nsurance companies will often refuse to pay
$150 for a diabetic to see a podiatrist who can help prevent foot ailments associated with the disease . . . [but] nearly all of them cover amputations, which typically cost more than $30,000.' . . . The point is that we can't deal with the diabetes epidemic in part because insurance companies don't pay for preventive medicine or disease management, focusing only on acute illness and extreme remedies.”
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