“I don’t think the American people want shared sacrifice. I think that they want shared prosperity.”—John Watson of Chevron, testifying this month against a proposed $2 billion cut in oil-companies’ annual tax breaks in a year when they are on track to make $100 billion in profits

Gas at $4 per gallon (or higher) has left working families very cautious about using their cars during a time of falling wages, food-price increases and widespread economic insecurity. Similarly, millions of Americans with health insurance are now afraid to actually use their insurance to seek treatment.

The reason: Employers have successfully shifted a huge portion of costs to their workers, so working families face such a daunting barrier of high deductibles and co-pays that they have become reluctant to go to the doctor or the hospital or request a particular course of treatment.

The New York Times’ Reed Abelson concisely captured the cruel reality that working families now confront while insurers rake in record profits and CEOs collect record salaries and bonuses:

The nation’s major health insurers are barreling into a third year of record profits, enriched in recent months by a lingering recessionary mind-set among Americans who are postponing or forgoing medical care.

The plight of typical patients was outlined in a Times interview with a California grocery worker:

For someone like Shannon Hardin of California, whose hours at a grocery store have been erratic, there is simply no spare cash to see the doctor when she isn’t feeling well or to get the $350 dental crowns she has been putting off since last year. Even with insurance, she said, “I can’t afford to use it.”

In just nine years, the cost of family coverage has doubled, from $9,235 in 2002 to $19,393 in 2011, Maxwell Strachan reported in the Huffington Post:

Take away costs paid by employers, and the employee’s share of costs has still doubled. In 2010, the average employee paid $8,008 for his family’s healthcare, up from $3,634 in 2002…. Of that $1,319 increase [in the last year], employers … paid for 48.6 percent of the increase, while the additional 51.6 percent was the responsibility of employees.

That $8,008 may easily consume 20 percent of many working families’ incomes, meaning that rising health costs are fattening the profits of insurers while forcing families to cut back severely on spending, even for necessities.

A ‘DEFECTIVE AND UNRELIABLE’ PRODUCT

For-profit health insurance is a product that is “both defective and unreliable,” as Dr. Steffie Woolhandler of Harvard Medical School aptly depicted it.

Particularly disturbing is the growing trend toward high-deductible insurance, which provides no insurance until a very high level of expenses has been paid by the hapless family stuck with such a policy. These policies are spreading rapidly:

In 2010, about 10 percent of people covered by their employer had a deductible of at least $2,000, according to the Kaiser Family Foundation, a nonprofit research group, compared with just 5 percent of covered workers in 2008.

But while it is the worst of times for some, it is the best of time for those in the healthcare insurance industry.

Thanks to what CIGNA called “lower usage” that allow insurers to retain more premium income; profits are once again on a trajectory to set ever-higher profits.

Thus, insurers are directly profiting from Americans avoiding needed tests on troubling or suspicious health conditions, leading inevitably to patients being in a far more acute state when they can no longer put off seeking treatment.

Further, for-profit insurers continue to aggressively “purge” small-business accounts from coverage whenever someone in the group comes down with an illness that is expensive to treat, observes Wendell Potter, former CIGNA public-relation director and author of Deadly Spin. As Potter explains:

The purging of less profitable accounts through intentionally unrealistic rate increases helps explain why the number of small businesses offering coverage to their employees has been declining for several years and why the number of Americans without coverage reached a record high of nearly 51 million last year.

According to the National Small Business Association, the number of small businesses that provide health insurance to their employees fell from 61 percent in 1993 to 38%…. Along with “rescinding” (cancelling) the policies of individuals who become seriously ill, purging small businesses that employ workers who get sick is a tried-and-true way of meeting Wall Street’s expectations.

But even when seemingly sitting on top of the world with an ever-growing streak of record profits and the prospect of 30 million new customers required to buy insurance under the Affordable Care Act (ACA) passed into law last year, the for-profit insurers are pushing for more. As the Times’ Abelson noted,

Yet the companies continue to press for higher premiums, even though their reserve coffers are flush with profits and shareholders have been rewarded with new dividends…Because they say they expect costs to rebound, insurers have not been shy about asking for higher rates.

In Oregon, for example, Regence BlueCross BlueShield, a nonprofit insurer that is the state’s largest, is asking for a 22 percent increase for policies sold to individuals.

NEITHER ‘SHARED SACRIFICE’ NOR ‘SHARED PROSPERITY’

The writing on the wall could not be clearer: the health insurance industry is not interested in either “shared sacrifice” via lower profits (i.e. lower premiums) or “shared prosperity” through covering the uninsured.

In sharp contrast to the incredibly slow implementation of the Affordable Care Act passed by the Democrats last year (it won’t be fully implemented until 2014), Medicare managed to be up and running 11 months after passage in 1965, a feat all the more astonishing given the lack of computers were not universally available.

America’s healthcare crisis—acutely felt by both the insured and uninsured—is getting worse. It will continue to do so, and even with the ACA in full effect, isn’t likely to reverse course.

By Margaret Flowers, M.D. for FireDogLake –

Leadership in Washington recognizes the damage our soaring health care spending is doing to our entire economy. Although their rhetoric differs, recent budget proposals from both Republicans and Democrats mistakenly place the blame on Medicare and Medicaid. Cuts to and privatization of these important public insurances will place us on a dangerous path that will leave health care costs soaring and more patients unable to afford necessary care.

Medicare and Medicaid must be left out of the discussion entirely until leadership has the courage to address the real reasons why our health care costs are rising, the toxic environment created by investor owned insurances and the profit-driven health care industry.

Health care spending in the United States is the highest in the world and in some cases is two times higher than spending in other industrialized nations, which achieve nearly universal coverage with better health outcomes than the U.S. Our soaring health care costs outpace our growth in GDP, inflation and wages. By any measure it is an unsustainable situation.

If we look at the various health care models in the United States, we find that the rise in spending is lower for traditional (non-privatized) Medicare and Medicaid than it is for the private sector. Our public insurances are our most efficient insurances with administrative costs of around 3%, despite the fact that they cover our most vulnerable and least healthy populations. Administrative and marketing costs for private plans are 15% or more, and the plethora of private plans further increase cost and complexity as patients and health professionals try to navigate their arbitrary and ever-changing rules.

Medicare and Medicaid are the victims of our current fragmented and profit-driven model of paying for health care which has resulted in high prices for health services and medications.

Private health insurers are financial institutions designed to create profit by obstructing, denying and restricting access to health care. They add no value to our health and in fact their business practices have polluted health care financing causing all insurances to adopt their practices in order to ‘compete’. They have also fragmented the health care market and thus the ability to negotiate for fair prices for goods and services leading to the highest prices for pharmaceuticals and procedures.

The commonsense solution is to eliminate wasteful and costly private health insurance and adopt a universal health care system modeled on the strengths of Medicare and given the power to negotiate for reasonable prices.

It is counterproductive to even discuss cuts to Medicare and Medicaid before addressing the fundamental reasons for rising costs. Yet, both Democrats and Republicans have focused on cuts to Medicare and Medicaid in their budget proposals.

The Ryan budget proposal, the Path to Prosperity, would fully privatize Medicare by moving to a voucher system in 2022 forcing all seniors to purchase private insurance. The vouchers are not designed to keep up with the rate at which health care costs are increasing so that over time seniors will either have to pay more out of pocket for health insurance premiums or will choose skimpier insurance plans that leave them unprotected should they have a serious illness or accident. Nearly half of Medicare enrollees have an income that is less than twice the federal poverty level and so have little room to absorb an increased share of health care costs.

Medicaid is significantly limited under the Ryan budget proposal which plans to cut overall Medicaid spending by $800 billion over ten years and change to block grants for each state. Block grants will mean that individual states will continue to be under economic pressure to limit who and what services are covered. As fewer are covered by Medicaid, they will have to either purchase private insurance through the exchanges or either seek a waiver from or be penalized for not purchasing insurance.

The Obama administration supports cuts to Medicare through the Independent Payment Advisory Board (IPAB) which is tasked with keeping per capita Medicare spending below a target level which is set to be lower than the current rate of health care cost inflation. Rather than blatantly privatizing Medicare as called for in the Ryan proposal, the President’s plan will slowly strangle Medicare leaving seniors struggling to find physicians able to care for them.

The IPAB was actually created in the Affordable Care Act (ACA). The President’s budget proposal would increase the power of the IPAB to cut Medicare costs. Medicaid spending is also capped under the President’s budget.

Sadly, the Peoples Budget put forth by the Congressional Progressive Caucus rubberstamps the President’s approach to cutting Medicare and Medicaid spending.

Underneath cuts to Medicare and Medicaid is a dangerous trend of increasing privatization of health care in the U.S.

There is a growing trend to put more of our population into private insurances and a growing privatization of our public health insurances. Over the past few years as the number of people able to afford employer sponsored health insurance has fallen, private health insurance profits have continued to grow as they move into providing insurance to or administering plans for the Medicare and Medicaid populations.

The ACA puts more people into the private insurance market by mandating that all uninsured who do not qualify for public health insurance purchase private insurance through the exchanges starting in 2014 and subsidizes the purchase of private insurance using public dollars.

Half of the newly insured under the ACA are eventually supposed to come from an expansion of Medicaid eligibility. However, the Department of Health and Human Services has already allowed state expansions in Medicaid coverage to lapse. A recent White House Fact Sheet also supported allowing states to place their Medicaid population into private insurance through the health insurance exchanges.

Privatization of health care is a failed experiment in the United States.

The United States differs from other nations in allowing investor-owned corporations to profit at the expense of human suffering and lives. After decades of experience with this unique privatized model of financing health care, the results are clear and startling.

The United States has the highest per capita health care costs, the highest prices for medical goods and services (and lower overall usage rates) and no control over health care spending. Despite attempts to patch the current health care situation, the number of uninsured and those with skimpy health insurance that leaves them unable to afford health care or at risk of medical bankruptcy continues to grow. Suffering and preventable deaths are higher in the U.S. than in other industrialized nations.

In addition, there have been no significant gains in important measures of health such as life expectancy and infant and maternal mortality rates. Our health disparities continue to grow, especially for those who have chronic conditions. And our health care workforce continues to be inadequate as health professionals quickly burn out from trying to practice in our complex and irrational health care environment.

It is time to recognize the failure of the market model of paying for health care and embrace comprehensive and effective health reform. The model for our ‘uniquely American’ solution lies in traditional Medicare, a single payer health system for those who are 65 years of age and over. Since its inception 45 years ago, Medicare has lifted seniors out of poverty and improved their health status.

Physicians for a National Health Program advocates for an improved Medicare for all health system, one that builds on the strengths of Medicare such as its universality, administrative efficiency and the patient’s freedom to choose a health provider, and also corrects the weaknesses of Medicare such as the lack of comprehensive benefits, out of pocket costs and low reimbursement rates.

Both Democrats and Republicans are missing the point by putting the emphasis on controlling Medicare and Medicaid costs without effectively addressing the reasons for our rising health care costs. Rather than embracing the Republican rhetoric which blames our public insurances, Democrats would do well to call out the real reason for our health care spending crisis, our current fragmented and profit-driven model, and advocate for a national improved Medicare for all.

Dr. Margaret Flowers is a pediatrician who serves as Congressional Fellow for Physicians for a National Health Program (www.pnhp.org).

Rep. Paul Ryan of Wisconsin, the Republican chairman of the U.S. House Budget Committee, unveiled two proposals this week which if enacted would constitute a mortal threat to our nation’s health – particularly to the health of our seniors and our most vulnerable populations.

The first proposal, Senate Joint Resolution 10, would amend the Constitution by imposing rigid and arbitrary restraints on federal spending. The second, his fiscal year 2012 federal budget resolution (misleadingly and eerily called “The Path to Prosperity”), would essentially kill the Medicare program and gut Medicaid, among its other nasty effects.

Both proposals should be emphatically rejected.

Ryan clearly has health care on his hit list. He stressed the problem of health care costs during his final testimony to President Obama’s bipartisan National Commission on Fiscal Responsibility and Reform last December. He said then that he would borrow pieces of the commission’s report for the federal budget, but his latest proposals are in fact much more radical.

The Deficit Commission report stated that if the national health law did not control health care costs, then that ought to trigger more drastic changes in health care spending. Rather than wait for a trigger, Ryan is moving full steam toward the dismantling of our public health programs for the poor and elderly, and the creation of an even more fragmented, privatized and dysfunctional health care landscape than we have now.

Seniors to join the growing ranks of the under-insured

Ryan would change Medicare from a guaranteed benefit program to a limited spending program which pushes more seniors into the private market. Similar to the new federal health law, seniors would be given a defined amount of money that they could use to purchase private insurance on an exchange. Such subsidies are expected to grow more slowly than overall health care costs, so that as insurance premiums rise, seniors would be pushed into skimpier plans that would leave them unable to afford needed care and financially vulnerable should they have a serious accident or illness.

The dismantling and privatization of Medicare, which would be completed by 2022, would actually lead to higher overall health care costs and poorer health for our Medicare population. Health care costs would be higher because of the added private-insurer expenses of profit and inefficient administration. For example, Medicare Advantage plans, run by the insurers, currently cost about 10 times more to administer than the traditional Medicare program.

It is also possible that increased cost-sharing in the form of higher co-pays and deductibles would cause seniors to delay or forgo necessary care leading to greater costs on the back-end for a greater number of and lengthier hospitalizations. (In a darker, bone-chilling moment, one economist recently remarked that delayed care leading to early deaths results in reduced U.S. health spending.)

Further privatization of Medicare will also increase the fragmentation of our health care financing, which will weaken the program’s ability to negotiate fair prices for goods and services.

Ryan describes this change as similar to Medicare part D, for which he voted in 2003. This is another scary thought. The result of Medicare part D was greater confusion and obstacles for seniors, a huge new burden on taxpayers, and windfall profits for the pharmaceutical industry.

Medicaid will shrink in a time of growing need

Regarding Medicaid, Ryan proposes to change the federal portion of the program’s funding to block grants. This means that rather than deciding what part of the population qualifies for Medicaid and adjusting the amount of money allocated based on need, as we do now, states will instead receive a defined lump sum to use as they see fit.

This approach is misleadingly marketed as providing states with greater flexibility. However, Ryan also wants to cut Medicaid spending by $1 trillion over the next 10 years, which will effectively eliminate the Medicaid expansion envisioned under the federal health law and impose even more severe limitations on the number of people and services that will be covered.

In times of growing unemployment and poverty, with more people needing Medicaid, there will be fewer dollars and no guarantee that people will be able to enroll. This will effectively leave millions of our most vulnerable citizens unable to receive necessary services, leading to increased suffering and deaths.

Ryan seriously suggests that those who qualify for Medicaid should be put into the private insurance market in the mistaken belief that this will provide greater choice and cost efficiency. But this is ludicrous, given the well-known track record of the private insurers.

Correct diagnosis, wrong prescription

Ryan does get one thing right: he correctly observes that health care costs are intimately tied to our nation’s budget problems. Health care expenses are expanding way out of line with our economic growth. And yet for all of this spending, a third of our population is either un-insured or under-insured, the medical bankruptcy rate is high, and our health outcomes are relatively poor.

What Ryan fails to understand is that Medicaid and Medicare are not the cause of our rising costs, but rather are the victims of our broken health care system. Medicaid and Medicare costs are actually rising more slowly than our private sector costs. For more on this, see this summary from a congressional briefing on Medicare and the deficit.

Ryan’s plans mirror the austerity measures being pushed in many states across the country and represent an escalation of the worst proposals put forth by the bipartisan Deficit Commission. These growing threats to our social programs require that we step up our defense of the public health infrastructure and make an even louder case for an improved Medicare for all.

As for Ryan’s proposal for a constitutional amendment to cap federal spending, one wonders how much of it is driven by political grandstanding.

S.J.Res.10 would limit federal spending to 18 percent of the gross domestic product, something that hasn’t occurred since 1966. (It’s currently around 24 percent of GDP.) This may sound like a laudable goal until one realizes that during an economic downturn, as we are currently experiencing, there is a much greater need for government spending on programs such as food stamps, unemployment benefits and public health insurance.

A new, arbitrary ceiling on federal outlays could prove disastrous. Noted economist Joseph Stiglitz makes the case that a temporary increase in investment in public programs is required in a downturn in order to make economic recovery possible.

Rep. Ryan hinted at his true agenda during the final meeting of the Deficit Commission when he said that he liked discretionary caps. Significantly, his constitutional amendment would exempt military expenditures in times of war (a seemingly permanent condition for the U.S. today) from such caps.

Greater urgency to protect our right to health care

Section 4 of S.J.Res.10 is also a matter of concern, particularly for single-payer advocates. It states that any bill that raises taxes or imposes a new tax may only pass with a two-thirds majority vote in Congress. Because a national single-payer program would replace current health spending on insurance premiums and out-of-pocket expenses with a new, equitable, and progressive system of taxation to finance universal care, this undemocratic amendment would constitute another obstacle to enacting an improved Medicare for all.

Yet it is precisely single payer that’s the solution to our health care and economic crises: an improved and expanded Medicare-like system that covers everyone. This will achieve the goals of a universal, comprehensive health system which controls our health care costs, relieves businesses of the burden of providing health care coverage and provides a framework within which quality of care and health outcomes will improve. My testimony and that of others presented to the Deficit Commission last summer made that argument.

It is imperative that we take a strong stance to end this assault on our health. Speak to your elected officials today. Tell them to reject Ryan’s proposals. And tell them you want a real solution to our health care crisis: single-payer national health insurance as embodied in H.R. 676.

Dr. Margaret Flowers is a congressional fellow with Physicians for a National Health Program and a pediatrician based in Baltimore. She is also a board member of Healthcare-Now. She can reached by email at: margaret@pnhp.org

By Sue Saltmarsh for Positively Aware –

As a peer-led agency, the Test Positive Aware Network (TPAN) has always been staffed by many HIV-positive people, as well as others who have diabetes, heart problems, sleep disorders, cancer, and a variety of other ills that make all of us concerned about our health insurance and our access to the care we need. TPAN has always provided the best insurance possible, and I don’t think any of us are unaware or ungrateful for the efforts put forth to get the most from the tens of thousands of dollars of our annual budget that go to health insurance.

A week after the first wave of “reform” laws were enacted in September, TPAN’s insurance representative came to tell us about the changes that would go into effect when our Blue Cross Blue Shield policy was renewed. No one was prepared for the shock of discovering that our usual co-pay for an office visit to any doctor would be doubled for our primary care doc and quadrupled for any specialist we saw, including HIV specialists. The percentage of coverage went down from 100% to 90% and a $1,000 “coinsurance” cost was added, thus essentially tripling our deductible. The co-pays for drug coverage also ballooned upward. For my HIV-positive colleagues, there were a lot of deer-in-the-headlights faces. One co-worker who’s fighting cancer left the room in tears, not being able to wrap her mind around the tsunami wave of medical debt she would now incur.

The health care reform law promised us several things that kicked in on September 23 including: coverage for children with pre-existing conditions; children being able to stay on their parents’ policies until they were 26; no lifetime or annual limits; 100% coverage of preventive services; and mental health “parity.”

On the night of September 23, news reports began to surface about big insurance companies (WellPoint, Cigna, Aetna, Humana, and United Health, among others) suddenly deciding not to sell children’s insurance at all. That took care of the law requiring them to cover kids with pre-existing conditions and also, depending on the policy, the law about them being able to be covered through their parents’ insurance until age 26. Days later, news came that while there might be the possibility to cover children with pre-existing conditions, the premiums would now be so high that many parents could not afford them.

While both the preventive services coverage and the annual limits on essential benefits were acknowledged by our new BCBS policy, they came with the following caveats: “Certain preventive services will be covered 100%…the insurance industry is waiting for guidance as to exactly what preventive services will be covered this way. There are some lists of services available, but there is much debate about the topic,” and “The insurance industry is still waiting for guidance as to what exactly ‘essential health benefits’ are. We do not yet know exactly what annual limits will be removed…It also appears that although dollar limits can no longer apply, carriers may use a visit or days limit.” Uh-huh. The one benefit that they haven’t figured a way to wriggle out of is the “no lifetime limit” provision, but perhaps they realize that, considering the way the rest of the changes restrict access to care and treatment, life expectancy is bound to go down anyway. The U.S. already ranks 49th in the world in terms of life expectancy – how much further down will we slide?

In November, the Centers for Disease Control and Prevention (CDC) published the findings from their analysis of the National Health Interview Survey for 2006, 2007, 2008, 2009, and the first quarter of 2010. The survey covered 90,000 individuals from 35,000 households. The findings revealed that 3 million more people “went for a year or more with no health insurance” in the first quarter of 2010 than in 2008 and that half of the uninsured were above the poverty level [thus de-bunking the myth that only the poor aren’t insured]. “One in three adults under 65 who made between $44,000 and $65,000 a year, the ‘middle income’ range, were uninsured at some point during the year.” The growing number of people without coverage “meant more people with chronic illnesses such as diabetes and asthma [not to mention HIV] were skipping or postponing care, increasing the likelihood of costly complications.” According to the report, “40 percent of Americans have one or more chronic conditions.”

Most people over age 64 have “universal coverage,” through Medicare, but older adults who skip doctor’s visits because they lack insurance “are sicker when they reach 65, which further taxes Medicare.” But there was a nugget of good news: “Public programs such as Medicaid and State Children’s Health Insurance Programs (SCHIPs) have reduced the number of children without medical insurance from ten million two years ago to 8.7 million today.” Yes, those evil, “socialist” programs have helped almost two million children.

Proponents of the Patients’ Protection and Affordable Care Act would probably urge us to wait and see how those numbers of uninsured improve as the “reform” laws are implemented. Really? As it is, millions of people will find themselves in the same boat I float in—paying thousands of dollars they really can’t afford for “coverage” that ends up resulting in inadequate or even no care. I predict the number of uninsured will continue to climb, as will the number of preventable diseases, hospitalizations, and even deaths.

I believe there’s only one way to fix this. The “free market” concept touted by Tea Partiers and “fiscal conservatives” is only available to those who can afford to participate in it. A hybrid system of private and public mechanisms will never work because those two sectors would be working at cross purposes – the private side working towards profitability and the public side working toward access. Not even the vague suggestion that we go back to the days when a patient paid his doctor directly will work unless, like in those days, docs are willing to take chickens or lawn care or car repair as payment for their services. There may be some who would be, but I somehow doubt it would be the majority, just as I doubt that doctors who are used to making $250 for a 15-minute consultation would suddenly accept making the $20 a patient like me would save up in order to have one office visit. And it’s not that I begrudge them the $250 – there is just no way I could ever pay it.

The bottom line may be a bitter pill for capitalists to take—health care can no longer be seen as a profit-driven industry. “Socialized” medicine is our only hope; a single-payer, government-run, tax-financed system as proposed in Congress as House Bill 676. And, really, seriously, should anyone profit from the pain and suffering of someone needing medical care?

Before you tape teabags to your forehead and start marching with your “Keep your hands off my Medicare!” sign (Hello-oo! Government-run!), take a minute to look at these numbers proposed by the sponsors of HR-676. Right now, 94% of us pay 1.45% of our annual income into the Medicare/Medicaid system. That money, plus another 3.3% of our income would be paid into a universal health care trust fund, making our total contribution 4.75% of our income. Consider this: what percentage of your income did you pay last year in premiums, co-pays, deductibles, coinsurance, drug costs, and costs that weren’t covered by your insurance? Chances are it was significantly more than 4.75%. In fact, by doing some simple calculations, you can figure out how much more money you’d have in your pocket if we had single-payer health care. Example: by the end of 2010, I will have spent $6,833 for health care. If we’d had single payer, my taxes would have gone up by $1,122 (less than I now pay in premiums alone), but my cost for health care would have been $1,615, thereby putting $5,218 back in my pocket.

Economic stimulus? Put a few thousand dollars back into the wallets of the much-mentioned-but-then-ignored middle class and no more bailouts would be necessary. Jobs? Take the cost-prohibitive element of health insurance off employers’ plates and they’d have more money with which to grow their businesses, thus leading to hiring more employees; plus, unions and management would no longer have to struggle with health insurance as a negotiation focus.

Yes, your taxes would be higher. But there will no longer be sleepless nights or tearful days worrying about how to pay the bills. If you hate your job and want to find a better one, you will no longer be trapped by the fear of losing your insurance. Are you stuck with a doctor you don’t like or trust because he or she is the only one near you “in the network?” No problem—in a single-payer system, every doctor is a network doc. Do you buy the alarmist warnings of the Right about the government “interfering” with the treatment you and your doctor decide is best for you? Yeah, like no insurance company bureaucrat has ever told someone terrified of having cancer that they can’t have an MRI because an X-ray is “just as good,” despite their doctor’s insistence that it isn’t. The fact is that insurance companies have a vested interest in keeping us sick. The government would have a vested interest in improving the health of every American—better health, lower costs, greater productivity, more tax money coming in, less spending on entitlement programs that support the unemployed, no Medicaid or separate Medicare costs, no ADAP.

In addition to the stimulus to our economy, there is also the benefit of people who are currently on disability being able to return to the work force. A colleague recently told me, “In 1992, a case manager awkwardly admitted that even though I wanted to go back to work (and was physically able to, despite my KS lesions), I would have to remain destitute so that I could qualify for disability. The prospect of being poverty-stricken and dependent on the state just simply to stay alive was even worse than being told I had AIDS. It was a living death.” How many others like him could become productive, tax-paying members of society if they weren’t chained to disability, if their health care was provided no matter where they went back to work?

As that CDC study revealed, the greater the financial barrier to access to care, the sicker people are when they finally get to a doctor. Just as ADAP advocates know only too well, without treatment, infections spread, hospitalizations increase, and complications multiply. Because the current system is more about money than about health, costs will continue to soar (as will profits) and instead of paying $4.75 of every $100 we make for health care, we will soon be struggling to pay $100 for every $4.75 we make, accumulating the kind of deficit only the government is capable of. And, as we know, no bailout will be coming our way.

This is not just a “fringe” issue anymore. There are currently at least 31 states that have established single-payer organizations. Vermont is progressing towards passing its single-payer legislation and Pennsylvania has achieved the unexpected success of gathering the support Republicans and the business community (Health Care for All Pennsylvania recently elected a Republican as its President). As health outcomes and access to medical care continue to decline, and the more people learn about the real benefits of a single-payer system, not just to individuals, but to every sector of society, the less “radical” an idea it will become, regardless of Tea Party posturing.

A distressing number of people who work in the HIV/AIDS field say that true universal health care is a fantasy that is eons away from happening, that we’d better just go along with this non-reform and try to make it work as best we can. They can’t seem to imagine a reality where ADAP funding is a moot point because ADAP will no longer be necessary or a day when no one will put off being tested because they figure they won’t be able to afford treatment anyway.

Being complacent about injustice has never righted a wrong. Just shutting up and taking whatever comes along has never resulted in progress or beneficial change.

If everyone in this country who’s struggling with a chronic medical condition of any kind bonded together to demand a single-payer health care system, we would be an awesome and undeniable tsunami of our own. We’d better stand up and ride that wave before we’re swept away.

To find out more and connect with other single-payer advocates, go to www.healthcare-now.org or your state’s single-payer organizations. In Illinois, www.ilsinglepayercoalition.org.

If you’re a health care provider, go to www.pnhp.org.

Representative Paul Ryan’s proposals to reform Medicare and Medicaid are mostly an effort to shift the burden to beneficiaries and the states. They have very little reform in them.
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They certainly won’t solve the two most pressing problems in the nation’s health care system: the relentlessly rising cost of care and the shamefully high number of uninsured Americans — now hovering around 50 million. Mr. Ryan is also determined to repeal the new health care reform law. Never mind that the law would make real progress on both fronts, covering more than 30 million of the uninsured and pushing to make health care delivery more efficient and effective and less costly.

One of Mr. Ryan’s most damaging ideas is to change Medicare and Medicaid from entitlement programs — covering everyone who is eligible for a defined set of services. Instead, Washington would contribute set amounts that would almost certainly grow more slowly than medical costs. You will hear a lot about how squeezing outlays will mean more efficiency. The real result is that the most vulnerable — the elderly, the poor, the disabled — will have to pay more for care or forgo treatment.

The government currently pays half or more of the costs of Medicaid, which insures the poor. Under Mr. Ryan’s proposal, the federal government would give each state a lump sum that probably would not keep pace with rising costs or accommodate surges in demand. Right now when a recession hits, the federal and state contributions rise to meet the higher rolls. The states would be given great flexibility, but many would use that to reduce benefits or drop people from coverage.

Mr. Ryan would largely privatize Medicare starting in 2022. New enrollees would be given “premium supports” to help them buy private insurance. The rich would get lower subsidies, the sickest and poorest would get additional assistance. Once again, the federal payments would likely grow more slowly than costs forcing individuals to buy skimpier coverage or pay more.

Republicans hope that competition among the private plans would lead them to use the most efficient doctors and hospitals. The reform law also seeks savings from such competition but goes far beyond that, starting pilot projects and establishing new organizations to spread the most promising reforms throughout the system.

For decades the Republicans have made clear their antipathy toward Medicare and Medicaid. Now they are trying to use the public’s legitimate concerns about the deficit to seriously cripple both programs. This isn’t real reform. If it moves forward, Americans will pay a high price.

House Republicans plan this week to propose more than $4 trillion in federal spending reductions over the next decade by reshaping popular programs like Medicare, the Budget Committee chairman said Sunday in opening a new front in the intensifying budget wars.

Appearing on “Fox News Sunday,” the chairman, Representative Paul D. Ryan of Wisconsin, also said Republicans would call for strict caps on all government spending that would require cuts to take effect whenever Congress exceeded those limits.

“We are going to put out a plan that gets our debt on a downward trajectory and gets us to a point of giving our next generation a debt-free nation,” Mr. Ryan said, even as he predicted that the politically charged initiatives he intended to lay out in the 2012 budget beginning Tuesday would give Democrats a “political weapon to go against us.”

“But they will have to lie and demagogue to make that a political weapon,” he said.

Republicans and Democrats remained divided over how to reach an agreement that would avert a government shutdown, which could come as early as Saturday, when a budget bill now financing the government is set to expire.

Senator Charles E. Schumer of New York, the chamber’s No. 3 Democrat, said progress was being made, but neither he nor other top lawmakers could guarantee that government agencies would be able to stay open after Friday.

Mr. Schumer said Democrats were urging Republicans to consider reducing some of the automatic annual spending in Agriculture, Treasury and Justice Department programs to reach a target of about $33 billion in cuts rather than insisting that it all come out of what is known in budget parlance as discretionary accounts.

A Democrat involved in the negotiations, who spoke on the condition of anonymity, said alternative spending cuts from the White House and Senate Democrats would range up to $8 billion. But to the Democrats’ dismay, not only were Republicans resisting those cuts, they were also proposing more spending than the Pentagon wants for military and homeland security programs.

“If you just cut from domestic discretionary, you’ll have to cut things like helping students go to college; you’ll have to cut scientific research, including cancer research,” Mr. Schumer said on the ABC News program “This Week.” “These things have created millions of jobs through the years.”

Continue reading…

Medical, nursing, and public health students from around the country organized a rally to support universal, single-payer health care in Vermont.

The March 26, 2011 event was led by student members of Physicians for a National Health Program (PNHP) and co-sponsored by the American Medical Student Association (AMSA).

At the request of Sen. Ben Nelson (D-NE), the Government Accountability Office put out a report examining several alternatives to the individual mandate that could be used alone or in combination to increase the number of insured if there were no mandate. Nine of the possibilities looked at by the GAO were:

• Modify open enrollment periods and impose late enrollment penalties.
• Expand employers’ roles in auto-enrolling and facilitating employees’ health insurance enrollment.
• Conduct a public education and outreach campaign.
• Provide broad access to personalized assistance for health coverage enrollment.
• Impose a tax to pay for uncompensated care.
• Allow greater variation in premium rates based on enrollee age.
• Condition the receipt of certain government services upon proof of health insurance coverage.
• Use health insurance agents and brokers differently.
• Require or encourage credit rating agencies to use health insurance status as a factor in determining credit ratings.

Many of these ideas, like a back premium penalty and auto-enrollment programs, should be familiar to readers of FDL.

Note the strange absence of single payer or even a basic default public plan.

For some reason, the GAO didn’t directly make reference to the most effective alternatives that would do an even better job than the individual mandate at decreasing the number of uninsured–single payer or a basic public plan that would enroll the uninsured by default. Interestingly, though, the report indirectly makes reference to the basic plan concept as part of option five.

Impose a Tax to Pay for Uncompensated Care:

Expert Views on Alternative Approach:

Rather than a penalty associated with a mandate, a tax could be imposed on all taxpayers to help cover the costs of emergency room and other uncompensated care incurred by people without health insurance. The tax could be rebated or waived upon proof of health insurance, and would be assessed on a sliding scale based on income.

A government program that uses taxes to collect money to make sure every American’s use of the health care system is paid for is basically the concept behind single payer. Taxing for only those without other insurance makes it effectively a universal default public insurance plan, although designed in the most indirect and idiotic way possible.

It never ceases to amaze me how thoroughly single payer or even just automatically providing the uninsured with a basic public plan have been totally excised from the discussion of health care reform in Washington, DC.

Single payer is the clearly superior and widely used solution that dare not speak its name.

The Obama administration is delaying until next January its enforcement of some new rules designed to protect patients who appeal insurers’ decisions to deny or reduce health care benefits.

In the meantime, the Labor Department said in a posting on its website that it will revise the requirements to deal with objections raised by insurers. These rules were mandated by the health care law, and federal officials had earlier said they would start enforcing them in July.

The delays were defended by the administration and the insurance industry but worry consumer advocates.

Among the rules now on hold are:

– A reduction in the amount of time an insurance company is allowed to review a denial of coverage in urgent cases, from no more than 72 hours to 24 hours.

– A requirement that insurers provide information about the denial and how to appeal in appropriate language for non-English speaking beneficiaries.

– A requirement that insurers must provide consumers with specific details, which would include diagnostic codes used by doctors, hospitals and insurers, about what treatment isn’t covered and why.

When the administration first released the appeals rules, it said they would go into effect last January. Last fall officials revised that timeline to say enforcement of some rules would not begin until July to allow insurers appropriate time to get procedures in place.

But the low-key announcement posted on the Labor website March 18 tells insurers and self-insured employers that the enforcement grace period has been extended until 2012 because the government intends to modify the rules “in the near future.” What those changes might be were not disclosed, but the prospect concerns consumer advocates.

“We want to be sure that delays don’t mean it won’t happen,” said Cheryl Fish-Parcham, deputy director for health policy at Families USA, a health advocacy group.

“Once again the rights that were promised under the Affordable Care Act are going to be further delayed,” said Timothy Jost, a health law professor at Washington and Lee University School of Law and a consumer representative to the National Association of Insurance Commissioners.

The appeals announcement is the latest of several moves by the administration that slow down implementation of the health law. It has granted temporary exemptions to states seeking more time to comply with certain provisions of the law and given waivers to insurers offering limited-benefit policies known as “mini med plans.”

The government is “under a lot of pressure from businesses and insurers to make things work more smoothly,” said Jost.

But a Labor Department spokesman said in a statement that the new decision “struck a balance” in response to a variety of groups that had submitted comments on the rules, including health insurers, states, patient advocacy groups, employer-sponsored health plans and other.

In its comments to the government, America’s Health Insurance Plans, a trade association representing 1,300 insurers, said that providing detailed explanations to consumers using diagnostic codes would be an administrative burden and could even delay getting denial notices to beneficiaries. The group also said that since some urgent care decisions don’t involve emergencies, they don’t have to be made within 24 hours.

Translating appeals information to languages other than English would also create administrative challenges, the group said. The association’s spokesman, Robert Zirkelbach, said that it was better for consumers to talk to a live person who can answer questions rather than translating information in writing.

“The goal is to have a process that will work better and more efficiently for consumers,” Zirkelbach said.

One aspect of the new appeals rules that is not affected by the latest government announcement is the timeframe given to consumers to file an appeal. Under most plans, beneficiaries have 180 days after receiving a denial notice to request a review. The announcement also does not affect the right to appeal when coverage is canceled or denied because the treatment was not medically necessary, said Fish-Parcham.

A report released last week by the Government Accountability Office, the independent investigative arm of Congress, underscored the importance of appeals. The GAO analyzed data from four states and found that 39 percent to 59 percent of consumers succeeded in reversing a coverage denial when they appealed to their insurance company.

The suspended rules apply only to the first stage of an appeal, one that is filed internally with the health insurer and is required in most cases before the consumer can appeal outside the company. In February, 24 consumer organizations and patient advocates sent a letter to Health and Labor officials urging them not to relax some rules affecting the law’ provisions establishing the external appeals process.

Kaiser Health News is an editorially independent news service and a program of the Kaiser Family Foundation, a nonpartisan healthcare policy research organization. Neither Kaiser Health News nor the foundation is affiliated with Kaiser Permanente.

With 99% of maternal deaths occurring in developing countries, it is too often assumed that maternal mortality is not a problem in wealthier countries. Yet, statistics released in September of 2010 by the United Nations place the United States 50th in the world for maternal mortality — with maternal mortality ratios higher than almost all European countries, as well as several countries in Asia and the Middle East.1, 2

Even more troubling, the United Nations data show that between 1990 and 2008, while the vast majority of countries reduced their maternal mortality ratios for a global decrease of 34%, maternal mortality nearly doubled in the United States.1 For a country that spends more than any other country on health care and more on childbirth-related care than any other area of hospitalization — US$86 billion a year — this is a shockingly poor return on investment.3, 4

Given that at least half of maternal deaths in the United States are preventable,5 this is not just a matter of public health, but a human rights failure.6 The Universal Declaration of Human Rights states that “every human being has the right to a standard of living adequate for the health and well-being of himself and his family, including medical care and necessary social services”.7 This means that the United States health care system must provide health care services that are available, accessible, acceptable and of good quality.8 In addition, the health care system must be free from discrimination, must be accountable and must ensure the active participation of women in decision-making. Yet, instead, too many women in the United States face shortages of providers and facilities and inadequate staffing; financial, bureaucratic, transport and language barriers; care that is not culturally appropriate or respectful; a lack of opportunity for informed decision-making and the lack of a system to ensure that all women receive high-quality, evidence-based care. The comparatively high rates of maternal deaths in the United States is an indicator of the failure to ensure that women have guaranteed lifelong access to equitable, quality health care, including reproductive health services. Indeed, in countries such as Canada and the United Kingdom where maternal deaths are reviewed and universal access to health care is guaranteed, fewer women die of preventable causes during childbirth than in the United States.

Overview

The rise of maternal deaths in the United States is historic and worrisome. In 1987, maternal death ratios hit the all-time low of 6.6 deaths per 100,000 live birth.9 These ratios were essentially maintained for more than a decade. Around 2000, the ratio began to increase and has since nearly doubled, hovering between 12 and 15 deaths per 100,000 live births between 2003 and 2007.10 The overarching statistics only scratch the surface: “near misses” (maternal complications so severe the woman nearly died) have also increased by 27% between 1998 and 2005, now affecting approximately 34,000 women a year;11 and appalling disparities in maternal health outcomes exist between racial and ethnic groups, and among women living in different parts of the United States.

The leading complications causing maternal deaths in the United States overlap with the main global causes; hemorrhage, pregnancy-related hypertensive disorders and infection are among the top causes of death in both the United States and the developing world. Other leading causes of maternal death in the United States are thrombotic pulmonary embolism, cardiomyopathy, cardiovascular conditions, and other medical conditions, whereas in developing countries, other leading causes of death are obstructed labor and unsafe abortions.12, 13

For the last 50 years, black women who give birth in the United States have been approximately four times as likely to die as white women.14 The greater risk of death for black women does not simply reflect a greater risk of an underlying complication occurring; in a national study of five medical conditions that are common causes of maternal death and injury (preeclampsia, eclampsia, obstetric hemorrhage, abruption and placenta previa), black women did not have a significantly higher prevalence than white women of any of these conditions.14 However, the black women in the study were two to three times more likely to die than the white women who had the same complication.14 Likewise, a study comparing maternal outcomes for Mexican-born women and White non-Latina women in California found that while Mexican-born women were less likely to suffer complications overall, they did face a greater risk of particular obstetric complications such as postpartum hemorrhage, major puerperal infections and third- and fourth-degree lacerations, suggesting that the intrapartum care they received may have been of poorer quality.15

Clearly, contrary to common assumptions, the racial and ethnic disparities in outcomes are not always due to women of color having a higher prevalence of diseases. But as these studies illustrate, women of color often are less likely to receive beneficial treatments that could have prevented their death or injury. As the studies above also demonstrate, disparities in outcomes occur when there is a mismatch between the need for efficacious treatments and access to quality services. Eliminating disparities faced primarily by women of color and poor women must be a priority. Improving the health of women alone will not eliminate disparities; we also need system-level improvements to ensure that all women receive high-quality, equitable maternity care.

Reasons for the increase in maternal mortality

Some of the increase in reported deaths can be attributed to better case identification resulting from the shift from International Statistical Classification of Diseases and Related Health Problems (commonly known as ICD) death certificate codes version 9 to version 10 definitions and an increasing number of states adopting a pregnancy check box on death certificates.16 While it is unclear how much of the increase is due to reporting, these changes alone do not adequately explain the near doubling of maternal deaths. Indeed, the rise in maternal mortality rates has caused sufficient alarm that The Joint Commission issued a Sentinel Alert on the topic.17

The explanations beyond better case ascertainment can be grouped into two categories: (a) the overall health and well-being of each woman and (b) the quality of the care a woman receives. It is well known that healthy women have better outcomes. However, overall good health is not sufficient to avoid complications or to eliminate preventable deaths. Women have limited options in what type of health care coverage is available to them, who care for them and whether their clinicians provide them with high-quality care. In addition, clinicians may struggle to provide high-quality care in a hospital system where financial constraints have led to less money for training, fewer nurses and doctors and higher rates of leader turnover. System-level improvements ensuring a uniformly high quality of care are also needed, and these improvements are beyond the control of the individual woman or an individual provider.

We have sufficient data to know that women in the United States face a range of barriers preventing them from obtaining the services they need for a safe and healthy pregnancy and childbirth.

Barriers and problems putting maternal health at risk

Complications of pregnancy often begin even before a woman becomes pregnant, when many women are uninsured and lack affordable access to primary care including contraceptive services and information. In the United States, nearly half of all pregnancies are unintended,18 and women with unintended pregnancies are more likely to develop complications and face worse outcomes for themselves and their babies.19 Of the 17.5 million women in the United States estimated to be in need of publicly funded family planning services and supplies, Medicaid and government-funded clinics (Title X clinics) cover just over half of this need, leaving more than 8 million women without affordable family planning information and services.20 Policy and legislative measures also limit access to contraception for some.

For many women, the cost of health care puts comprehensive health care beyond reach. Low-income women are more likely to be uninsured prior to becoming pregnant, and consequently are more likely to enter pregnancy with unmanaged chronic health conditions that increase their pregnancy risks. For women who become eligible for publicly financed care upon becoming pregnant, complicated bureaucratic hurdles and a lack of providers willing to accept patients paying with Medicaid increase the likelihood that these women will face significant delays in obtaining early prenatal care.

Women who receive no prenatal care are three to four times more likely to die of pregnancy-related complications than women who do.21 Those with high-risk pregnancies are 5.3 times more likely to die if they do not receive prenatal care.22 Healthy People 2010 — national health objectives developed in 1998 by US federal health agencies — set a goal of 90% of women receiving “adequate prenatal care” (defined as 13 prenatal visits beginning in the first trimester).23 However, data suggest that, for 25% of women, their care falls short of this goal.23 This figure rises to 32% for African American women and 41% for American Indian and Alaska Native women.23

Many women receive inadequate or poor-quality intrapartum care. Hospitals and clinics, particularly those serving low-income communities, are often overcrowded and understaffed.24 Understaffing can create pressure to care for a high volume of patients, making it difficult or impossible to provide good-quality care.25, 26 The current economic downturn and the increased use of medical interventions during childbirth are is likely to exacerbate the problem of understaffing while increasing the pressure on facilities in medically underserved areas, as more people become uninsured.

Providing quality postpartum care in the United States would both help reduce maternal deaths and improve the overall health of women. Most health plans in the United States only cover a single visit to a health care provider around 6 weeks after birth unless the woman has a recognized complication. By contrast, in many countries in Europe, multiple home visits following birth are standard for all women. Increasing the standards in the United States would prevent complications — such as infection, deep vein thrombosis and postpartum hemorrhage — that can develop after women have returned home.

Overuse of medical interventions

In contrast to many countries where women lack access to life-saving medical interventions, women and infants are often exposed to more procedures than are medically necessary or beneficial. This overuse of medical procedures increases injuries as well as costs. Indeed, we are unaware of any study indicating that the 56% increase in the rate of surgical births from 1996 to 200827 as improved outcomes. However, there are data to show that the overuse of medical procedures has increased both infant28 and maternal morbidity.11, 29

Because all medical interventions carry risks, their use in situations when they are not demonstrated to offer benefits exposes women to risks that are unwarranted. For example, overuse of induction of labor and of cesarean sections, and lack of access to vaginal births after cesarean sections, all can lead to higher incidences of postpartum infection and higher rates of hysterectomies.30, 31

Countries such as the United Kingdom and the Netherlands, where women have routine access to woman-centered care and where there is better match between medical need and the number of medical interventions performed, have fewer deaths and lower health care costs. Hospital systems in the United States such as Intermountain Health Care32 and the Health Care Corporation of America29 have also demonstrated that a reduction in the overuse of medical interventions hits the sweet spot where both costs are reduced and outcomes can be improved.

Lack of data and accountability

The lack of comprehensive data collection is masking the full extent of maternal mortality and morbidity in the United States and is hampering efforts to analyze and address the problems. Reporting of pregnancy-related deaths as a distinct category is mandatory in only six states, and despite efforts in some other states to use additional methods to track maternal deaths (such as death certificate pregnancy check boxes and data-linking birth certificates with death certificates of women of childbearing age), systematic undercounting of pregnancy-related deaths persists.16

Many states, and some other countries, most notably the United Kingdom, have established maternal mortality review processes that have successfully identified system problems, developed and disseminated recommendations and set priorities in order to improve maternal care and prevent unnecessary maternal deaths.33, 34, 35 But 29 states have no such processes.6 The establishment of a comprehensive nationwide system to collect and analyze data on maternal deaths, complications and performance measures is also needed to increase accountability, develop targeted solutions and reduce maternal deaths. In the United Kingdom, this type of systematic approach has worked. For example, the mortality review process in the United Kingdom led to recommendations for deep vein thrombosis prophylaxis for women who have surgical births, and implementation of these recommendations led to fewer deaths from this cause.

Call to action

For more than 20 years, the authorities have failed to improve the outcomes and disparities in maternal health care. Recent health care reform focused on improving access to care and reducing the growth in health care spending. However, improving health care coverage alone would leave largely unaddressed the issues of discrimination, systemic failures, optimizing quality of care and accountability. It is essential that the debate goes beyond providing health care coverage and ensures access to quality health care for all in a way that is equitable and free from discrimination.

We must also initiate, support and advance positive legislative and policy developments at all levels of government that demonstrate potential to reduce maternal mortality. Recently, three new pieces of federal legislation were introduced by Representatives Lucille Roybal-Allard, Lois Capps, Eliot Engel and Sue Myrick to measure and improve the quality of maternal care; support research into and promotion of best maternity practices; identify and reduce shortages of maternity care providers; increase coordination and prioritization of maternal care within Health and Human Services, improve quality of maternal care by establishing quality measures, and help to create a stronger, more diverse maternity care workforce. Additional related bills are expected to be introduced in the coming months. Clear priorities include eliminating racial disparities, improving systems to ensure that care is of uniformly high quality for all women and expanding comprehensive performance measurement, data collection and analysis to provide the basis for developing and implementing concrete strategies to reduce maternal deaths.

We in the United States must lengthen our stride and lead by example if we are going to be a credible part of the international community advocating for the United Nations Millennium Development Goal #5 — the reduction of maternal mortality by three fourths by the year 2015. The United States is facing a public health crisis that requires us to scrutinize the situation from every angle possible, as quickly as possible, and implement the needed interventions to eliminate preventable maternal deaths and injuries. The first step we need to take is to honor the lives of the women who have died by investing the necessary resources to identify why they died and learn from their deaths in order to prevent other women from dying. There are no acceptable excuses when we consider the fact that we lag behind most developed countries and when numerous developing countries, such as Vietnam and Albania, with much fewer resources than the United States, are making strides towards meeting their goals of reducing preventable maternal deaths, while the United States is backsliding.36

It is a human tragedy when a woman dies giving birth; her death forever changes her community and family for all future generations. It is both a tragedy and a human rights failure when a woman dies needlessly of preventable causes in a country that lacks the political will to have prevented her death.

Francine Coeytaux
WomanCare Global
Women’s Dignity
Los Angeles, CA

Debra Bingham
Women’s Health, Obstetric and Neonatal Nurses (AWHONN)
Washington, DC

Nan Strauss
Amnesty International, USA
New York, NY

References

1. WHO . Trends in maternal mortality: 1990 to 2008 estimates developed by WHO, UNICEF, UNFPA and The World Bank, World Health Organization 2010, Annex 1. 2010. http://whqlibdoc.who.int/publications/2010/9789241500265_eng.pdfLast accessed: January 3, 2011.
   
2. Coeytaux F, Bingham D, Langer A. Reducing maternal mortality: a global imperative. Contraception. 2011;83:95–98. Full Text | Full-Text PDF (109 KB)
   
3. Organisation for Economic Co-operation and Development . OECD health data 2010 — frequently requested data 2010. http://www.oecd.org/document/16/0,3343,en_2649_33929_2085200_1_1_1_1,00.htmlLast accessed: January 3, 2011.

4. Andrews R. The National Hospital Bill: the most expensive conditions by payer, 2006, in Healthcare cost and utilization project, statistical brief. Healthc Cost Utilization Proj Stat Brief. 2008;7;http://www.hcup-us.ahrq.gov/reports/statbriefs/sb59.pdfLast accessed January 3, 2011.
   
5. In:  Bacak S,  Berg CJ,  Desmarais J,  Hutchins E,  Locke E editor. State maternal mortality review: accomplishments of nine states. Atlanta: Centers for Disease Control and Prevention; 2006;http://www.cdph.ca.gov/data/statistics/Documents/MO-CDC-ReportAccomplishments9States.pdf.

6. Amnesty International . Deadly delivery: the maternal health care crisis in the USA. New York: Amnesty International USA; 2010;http://www.amnestyusa.org/dignity/pdf/DeadlyDelivery.pdfLast accessed January 3, 2011.
   
7. United Nations. Universal Declaration of Human Rights, G.A. res. 217A (III), in United Nations Doc. A/810. 1948.
   
8. United Nations. Committee on Economic, Social and Cultural Rights, The right to the highest attainable standard of health. General comment no. 14 E/C.12/200/4. 2000: Geneva.
   
9. Health Resources and Services Administration . Maternal mortality. Child Health USA 2008–2009. http://mchb.hrsa.gov/chusa08/hstat/hsi/pages/204mm.htmlLast accessed: January 3, 2011.
   
10. Xu J, Kochanek KD, Murphy SL, Tejada-Vera B. Final data for 2007, in National Vital Statistics Reports. Hyattsville (MD): National Center for Health Statistics; 2010;.
    
11. Kuklina E, Meikle S, Jamieson D, et al. Severe obstetric morbidity in the US, 1998–2005. Obstet Gynecol. 2009;113:293–299.

12. Berg CJ, Callaghan WM, Syverson C, Henderson Z. Pregnancy-related mortality in the United States, 1998 to 2005. Obstet Gynecol. 2010;116:1302–1309.
    
13. World Health Organization . Make every mother and child count. Geneva: WHO; 2005;.
    
14. Tucker MJ, Berg CJ, Callaghan WM, Hsia J. The black–white disparity in pregnancy-related mortality from 5 conditions: differences in prevalence and case-fatality rates. Am J Pub Health. 2007;97:247–251.
    
15. Guendelman S, Thornton D, Gould J, Hosang N. Social disparities in maternal morbidity during labor and delivery between Mexican-born and US-born white Californians, 1996–1998. Am J Pub Health. 2005;95:2218–2224.

16. Hoyert DL. Maternal mortality and related concepts. N.C.F.H. Statistics, Editor. 2007:1-13.
    
17. The Joint Commission . Preventing maternal death. January 26, 2010. Issue 44. http://www.jointcommission.org/sentinel_event_alert_issue_44_preventing_maternal_death/Last accessed: January 3, 2011.
    
18. Finer L, Henshaw S. Disparities in rates of unintended pregnancy in the United States, 2994 and 2001. Perspect Sex Reprod Health. 2008;38:90–96. MEDLINE
    
19. D’Angelo D, et al. Preconception and interconception health status of women who recently gave birth to live-born infant–pregnancy risk assessment monitoring system (PRAMS), United States, 26 reporting areas, 2004. MMWR surveillance summaries, December 14, 2007:4 and 17. http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5610a1.htmLast accessed: January 3, 2011.
    
20. Guttmacher Institute . Contraceptive needs and services, 2006. http://www.guttmacher.org/pubs/win/allstates2006.pdfLast accessed: January 3, 2011.

21. Chang J, et al. Pregnancy-related mortality surveillance–United States, 1991–1999, MMWR surveillance summaries. 2003. February 21:[1–8]. http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5202a1.htm#tab3Last accessed: January 3, 2011.
    
22. Rosenberg D, Geller SE, Studee L, Cox SM. Disparities in mortality among high risk pregnant women in Illinois: a population based dtudy. Ann Epidemiol. 2006;16:26–32. Abstract | Full Text | Full-Text PDF (129 KB)

23. Healthy People 2010: Midcourse review. US Department of Health and Human Services. 2000.
    
24. Regenstein M, Huang J. Stresses to the safety net: the public hospital perspective, Kaiser Commission on Medicaid and the Uninsured, report no.7329, June 2005. http://www.kff.org/medicaid/7329.cfmLast accessed: January 3, 2011.
    
25. Institute of Medicine. Keeping patients safe: transforming the work environment of nurses, in Institute of Medicine Committee on the Work Environment for Nurses and Patient Safety Board on Health Care Services. Washington, DC: National Academies Press; 2004. p. 229 and 386.
    
26. Association of Women’s Health, Obstetric and Neonatal Nurses . Guidelines for Professional Registered Nurse Staffing for Perinatal Units. Washington, DC; 2010. http://www.awhonn.org/awhonn/store/productDetail.do;jsessionid=D54A4918DF5BC334CD4681C94ECD3108?productCode=SG-910 Last accessed: January 5, 2011.
    
27. Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Mathews Osterman MJK. Births: Final data for 2008. National vital statistics reports; vol 59 no 1. Hyattsville (MD): National Center for Health Statistics. 2010. http://www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_01.pdf Last accessed: January 3, 2011.

28. Tita ATN, Landon MB, Spong CY, et al. Timing of elective cesarean delivery at term and neonatal outcomes. NEJM. 2009;360:111–120.
    
29. Clark SL, Belfort MA, Byrum SL, Meyers JA, Perlin JB. Improved outcomes, fewer cesarean deliveries, and reduced litigation: results of a new paradigm in patient safety. Am J Obstet Gynecol. 2008;199:e1–105.e7. Abstract | Full Text | Full-Text PDF (100 KB)

30. Knight M, UKOSS . Peripartum hysterectomy in the UK: management and outcomes of the associated haemorrhage. BJOG. 2007;114:1380–1387.
    
31. Leth RA, Møller JK, Thomsen RW, Uldbjerg N, Nørgaard M. Risk of selected postpartum infections after cesarean section compared with vaginal birth: a five-year cohort stody of 32,468 women. Acta Obstet Gynecol Scand. 2009;88:976–983. CrossRef
    
32. Oshiro BT. Decreasing elective deliveries before 39 weeks of gestation in an integrated health care system. Obstet Gynecol. 2009;113:804–811.
    
33. Berg CJ, et al. Preventability of pregnancy-related deaths — results of a state-wide review. Obstet Gynecol. 2005;106:1228–1234. MEDLINE

34. Benbow A, Maresh M. Reducing maternal mortality: reaudit of recommendations in reports of confidential inquiries into maternal deaths. Brit Med J. 1998;317:1431–1432.
    
35. Confidential enquiries, Savings mothers’ lives: reviewing maternal deaths to make motherhood safer — 2003–2005. The seventh report of the confidential enquiries into maternal deaths in the United Kingdom, G. Lewis, Editor. London. 2007. p. 1–260.
    
36. Hill K, et al. Estimates of maternal mortality worldwide between 1990 and 2005: an assessment of available data. Lancet. 2007;370:1311–1319. Abstract | Full Text | Full-Text PDF (133 KB)