COMMENTARY

December 2004: The Year in Review -- Ob/Gyn & Women's Health

Ursula Snyder, PhD

Disclosures

January 24, 2005

Lack of Access to Healthcare -- Poverty and Racial Disparity in the United States

Everyone has the right to a standard of living adequate for ... health and well-being of himself and his family, including food, clothing, housing, medical care and the right to security in the event of ... sickness, disability.... Motherhood and childhood are entitled to special care and assistance....

Universal Declaration of Human Rights, Article 25

Women have the right to the enjoyment of the highest attainable standard of physical and mental health. The enjoyment of this right is vital to their life and well-being and their ability to participate in all areas of public and private life.... Women's health involves their emotional, social and physical well-being and is determined by the social, political and economic context of their lives, as well as by biology.... To attain optimal health, ... equality, including the sharing of family responsibilities, development and peace are necessary conditions.

Beijing Declaration and Platform for Action adopted by the Fourth World Conference on Women: Action for Equality, Development and Peace, Beijing, 15 September 1995

Prematurity has many factors, from poverty to inadequate prenatal care and infections, but for the clinicians who treat these women, this [increasing prevalence of preterm births] is clear evidence of a healthcare system in crisis.

Georges Benjamin, MD, Executive Director,
American Public Health Association

[I]t is important for healthcare providers, administrators, and community and national leaders to publicly recognize the dirty little secret that is finally catching the attention of mainstream America: Poor, medically underserved, and minority patients experience significantly worse health outcomes than those with higher socioeconomic status, health insurance, or white race.

Mohan Nadkarni, MD[223]

The US health system spends far more on the "technology" of care (eg, drugs, devices) than on achieving equity in its delivery. For 1991 to 2000, we contrasted the number of lives saved by medical advances with the number of deaths attributable to excess mortality among African Americans. Medical advances averted 176,633 deaths, but equalizing the mortality rates of Whites and African Americans would have averted 886,202 deaths. Achieving equity may do more for health than perfecting the technology of care...

SH Woolf and colleagues[224]

Although this study shows that more good would be done by correcting disparities than by improving the effectiveness of treatments, Congress allocates $300 million a year to the agency with lead responsibility for addressing the disparities issue and $28 billion to NIH, which devotes most of its research budget to improving drugs and other treatments...Is this a balance in priorities that makes sense?

Steven H. Woolf, MD, MPH,
Virginia Commonwealth University, Fairfax

Pregnant women and infants are among the most vulnerable populations in the country, and ACOG believes that providing them with full insurance coverage must be a primary step in the process of providing coverage for all Americans. However, it is only the first step; it is critical to expand the basic benefits and coverage for all Americans.

ACOG Committee Opinion #308, The Uninsured [225]

In June, the report entitled "America's Health State: State Health Rankings," was released. (See Medscape Medical News story.) The report highlights 3 key trends: the first rise in infant mortality rates in 4 decades, the rapidly increasing prevalence of obesity in all age groups, and the number of uninsured individuals, which increased in 38 states between 2003 and 2004. As Dr. Benjamin notes, the increasing prevalence of preterm births is evidence of a healthcare system in crisis. Earlier in the year, I wrote an editorial that considered social determinants of preterm birth. I reviewed some of the statistics on health insurance coverage and poverty. Some of the data have since been updated. The latest data from the US Census Bureau suggest that the number of uninsured rose from 43 million to 45 million between 2003 and 2004; 21.1million (14.4%) are women.[226] In addition, health insurance premiums for workers rose approximately 3 times faster than their wages, and on the order of 14 million Americans are spending a quarter of their earnings on health costs.[227] About 85.2 million people went without health insurance for some time between 2003 and 2004; > 50% of these people were uninsured for at least 9 months. It is also worth mentioning that a report by the National Low Income Housing Coalition released in December 2004 has found that most Americans who rely on just a full-time job earning the federal minimum wage cannot even afford the rent and utilities on a 1- or 2-bedroom apartment.

Income inequality in the United States is greater than in other major industrialized countries (eg, Australia, Canada, Europe), and the racial disparity in US healthcare is blatant. As mentioned in a recent ACOG committee opininon,[225] "of the 30 countries in the Organization of Economic Cooperation and Development, only Mexico and Turkey have a higher uninsured rate than the United States." Low-income and minority women in the United States are suffering and dying. In March 2003 the American College of Physicians released a position paper aimed at eliminating racial and ethnic disparities in healthcare. Position 2 states that "providing all Americans with affordable health insurance is an essential part of eliminating racial and ethnic disparities in health care." In December 2004, ACOG called on healthcare providers "to be advocates for the goal of securing quality, affordable coverage for every American with active support of proposed local, state, and national legislation."[225] There is much work to be done.

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