The shocking influence of skin color on health care
By Brenda Gazzar
Code Wack Podcast, May 22, 2023
Why do Black women have a 5-year mortality risk from endometrial cancer that’s 90 percent higher than White women? Is it about race or racism – and what can we do about it?
To find out, we spoke with Dr. Diljeet Singh, a women’s health advocate and integrative gynecologic oncologist who has practiced for nearly 25 years. She’s also the vice president of Physicians for a National Health Program, which advocates for Medicare for All. (part one available HERE).
Transcript
Dispatcher: 911, what’s your emergency?
Caller: America’s healthcare system is broken and people are dying!
(ambulance siren)
Welcome to Code WACK!, where we shine a light on America’s callous healthcare system, how it hurts us and what we can do about it. I’m your host, Brenda Gazzar.
(music)
This time on Code WACK! Why do Black women have a 5-year mortality risk from endometrial cancer that’s 90 percent higher than White women? Is it about race or racism – and what can we do about it? To find out, we spoke to Dr. Diljeet Singh, a women’s health advocate and integrative gynecologic oncologist who has practiced for nearly 25 years. She’s also the vice president of Physicians for a National Health Program, which advocates for single-payer Medicare for All.
Welcome back to Code WACK! Dr. Singh
Singh: Thanks so much for having me back.
Q: So before we start out, can you tell us what you do as a gynecologic oncologist?
Singh: So I take care of women who have endometrial cervical ovary, vulva, or vaginal cancer. And then I see a certain number of people who might have cancer and are being evaluated because there’s that possibility. And I also take care of people with some precancerous of all of those things. And people who have inherited predispositions to ovarian, you know, and endometrial cancer. Those are the biggest ones that we have identified that have inherited predispositions. And so for all of those things, we do lifestyle modification for people who have cancer and if strong risks. We sometimes do surgery, sometimes do radiation, sometimes do chemo, sometimes do immunotherapies or hormone therapies. There’s combinations of things. And as a gynecologic oncologist, I kind of get to use all those tools for women and hopefully offer them a chance of potentially getting rid of their cancer forever, living with their cancer, dealing with all the issues that come along with that.
Q: Endometrial cancer is the most common gynecologic cancer. And Black women have a five year mortality risk that is 90% higher than White women. 90 is a startling number. Does this mesh with what you’re seeing with your patients?
Singh: Absolutely. There’s not only the disparity, but there’s increasing incidents of endometrial cancer in general. And the disparity between White and Black women is getting bigger. And so absolutely we see that in the office. The cancer I take care of most often and it absolutely makes sense in a lot of ways. You know, we know that endometrial cancer is closely related to hormones. And as we think about exposure to hormones, both in our environment, in our food, and our own hormones, and for women, one of the more important ones when it comes to cancer risk is perimenopausal and postmenopause, our body will take fat cells, adipose tissue and convert it into a weak form of estrogen. And so as the rates of obesity and overweight have gone up in America, we kind of see parallel increases in the rates of endometrial cancer because we’re seeing that extra estrogen being around stimulating the lining of the uterus leading to pre-cancerous and cancers.
And so part of this increasing incidence we think is related to that. And then there’s other protective factors that might be around a little bit less. The issue of racial disparity, of course, is tied up in all that stuff. And it’s tied up in lots of things. And I think the research in cancer is actually a little bit more clear than in maternal mortality and infant mortality because we can break up the pieces, so to speak. And there is good research sort of saying like, okay, if there’s a higher mortality, how many of these people had just a more aggressive kind of cancer? Okay, that’s a piece of it. And then how many people had advanced stages when they came to us? And so that might not be connected to anything other than lack of access to healthcare. Right? And then we see treatment differences of like in the same hospital at the same stage, how many women got surgery that were eligible and how many women weren’t offered surgery?
How many women got minimally invasive surgery? How many women didn’t? How many women should have been offered chemotherapy and didn’t get chemotherapy? And in all of those ways, the data says Black women are less likely to get a biopsy done when they came into the office and had abnormal bleeding. So somebody didn’t adhere to standard medical protocols when they took care of them. And then once they had cancer, it may be more advanced because they didn’t have health insurance. It took ’em longer, it was harder to get to a specialist. Unfortunately, it is not surprising that we see this difference.
Q: Why?
Singh: We know there’s racism and misogyny in medicine that when women complain about period problems, like ‘well, periods are just bad. So you know, you just need to live with that, dear.’ ‘It’s hard to be a woman, isn’t it?’ Same as we don’t listen to people in pain. I’ve been having this pain in my side. ‘Well, you know, you’re probably not exercising enough. Or maybe you’re getting older and you’ve gained some weight maybe’ as opposed to like, ‘no, maybe you have an increasingly enlarged uterus.’
So the way we talk to women, the way we listen to their symptoms, the way we ignore them in our own society, let’s talk about body dysmorphia. You know, I take care of a lot of people who notice changes in their health, but they think it’s just cuz they’re not exercising enough, they’re getting fat, they’re getting old, right? They’re less likely to report symptoms and get things and then when they get in and actually report the symptom, they’re less likely to be heard.
You know, we’re talking about endometrial cancer, but certainly with ovarian cancer it’s really clear that women have symptoms. You know, when I grew up in medicine, you know, I finished my training in 99. We used to say, oh, ovarian cancer is a whisper. Well now there’s a whole bunch of data that women have symptoms for a year to a year and a half before they get to a gynecologic oncologist and get an ovarian cancer diagnosis. It’s not a whisper, it’s just that we ignore symptoms when women report them. And women themselves are trained and taught to minimize their own physical symptoms, especially when they’re female oriented.
Q: I got it. Okay, thank you. A 2020 study in the American Journal of Obstetrics and Gynecology found that the greater mortality rate for Black women from endometrial cancer can be partly attributed to genetic markers. But the study also found that Black women are less likely to receive the proper care for this disease than White women. They’re less likely to receive necessary surgery at every stage of endometrial cancer and are more likely to be diagnosed at an advanced stage of the disease. What do you think is behind these differences?
Singh: Let’s like clear the air on that. Like let’s make it Black and White to people. That doesn’t mean Black women have a higher risk of getting cancer when they’re born based on the color of their skin. It doesn’t mean that genetic markers in cancers or gen molecular markers in cancers are the changes that happen to the body cells over time that lead those cells to develop cancer. And those guys, right? They can be from all kinds of things. They can be from the environment, they can be from stress, they can be from diet, they can be from smoking, they can be from all of those things that lead to – they can be from chance. You know, like we don’t understand all of them, but this discussion that racism is what is contributing to higher rates of cancer as well as worse quality of care at multiple levels.
Both of those are absolutely accurate. And we have to think about ways of fixing those. If we’re going to decrease the likelihood of somebody of African-American descent dying of endometrial cancer, we’re going to have to like look to healthcare providers, look to the system, figure out how to fix that. We’re going to have to give everybody health care universally regardless of, you know, background regardless of their job, regardless of their age, et cetera. And then we’re gonna have to figure out how to improve the environment that people live in, whether it’s the food they have access to, the kinds of exercise and stress management they have access to, whether they’re living close to a landfill, whether they’re in jobs where they’re exposed to more environmental risk factors, all of those things of the things that that feed into those genetic changes that ultimately become cancers and potentially more aggressive cancers that we see in Black women.
Q: Got it. So when they talk about genetic markers, they’re not talking about the genes people are born with?
Singh: So when they say molecular and genetic markers, they’re talking about now I’m looking at that cancer and I’m looking at the genes of the cancer, not the person I see. Relatively few uterine cancers – there are uterine cancers that are inherently predisposed to, and it’s about the genes you were born with, but most endometrial cancers are about the genetic changes that happen to your body over time and why genetic mistakes happen and accumulate over time has to do with how we live, which how we live obviously influenced by what the color of our skin is in America.
Got it. Thank you for explaining that. That was super helpful.
Singh: Yeah, yeah, absolutely. So I did actually send you a study that I think kind of tried to look at this really specifically by looking at this adherence to treatment protocol as like a way to try to say like, okay, for a lot of these cancers, no offense to me and my colleagues, like it’s not rocket science.
Like it’s pretty clear if someone has this, these are the treatment options and based on who they are, this is what you offer them and you know what you do, right? That’s how we write. National Comprehensive Cancer Center and the NCCN, the National Comprehensive Cancer Network, I think are some of the best cancer guidelines for gynecologic cancer – really well thought out, you know, revised every year. Anyway, these guidelines, so what they tried to look at was like how often do we adhere to those guidelines when we treat people and consistently Black women did not get treatment that matched these guidelines, right?
And there have been numerous studies that kind of speak to that. And then going back even before you get to cancer, thinking about the American College of OBGYN and how we’re taught to take care of women who have abnormal bleeding and when do we do a biopsy to go looking for cancer and pre-cancer, that all of those things also warned were consistently not adhered to.
And so we can think of like, what are those things a measure of once you’re in the system, then they’re a measure of how you’re being treated. And when it’s consistent that we see something different in Black women, then it’s about racism. Right? Now there’s parts of that that are about access to healthcare, right? There’s, I’m having abnormal bleeding and I’m having it for a couple years and I went through menopause two or three years ago, but I’m not quite 65, so I don’t actually have health insurance right this second. You know, that’s a separate thing. And that’s also right. Black women are less likely to have health insurance and are more likely to be uninsured or underinsured. You know, underinsured being you, you have insurance, but it’s only like if you show up in the ER after a car crash, not for prevention, right? Like there’s all kinds of like, problems with how, you know, insurance works, that even when you have insurance, it’s not necessarily going to serve you in the way you want it to.
Q: Mm-Hmm. Right. And that leads us to our next question. What impact could Medicare for all have on these deeply concerning racial disparities?
Singh: You know, I think say some of the impacts are similar to what we talked about as we talked about, you know, maternal mortality and infant mortality cancer is interesting from the perspective, although I guess obstetric care is the same in that those are outcomes of a lifetime of healthcare and a lifetime of exposures and a lifetime of having things addressed. Right? Having polycystic ovarian syndrome increases your likelihood of getting endometrial cancer because of hormone imbalance, but it’s completely preventable by being on the pill or having a progesterone IUD, right? And so, you know, having insurance could have made the difference there, right? And the way our healthcare system is structured and how we listen to people of course influence that is that. But if you start at the very basics that you don’t even have a chance to sit with a healthcare provider and talk about what’s going on.
So clearly if everybody was the same and everybody had access to care, we could change these things if people didn’t wait because they had to make a decision. Like were they going to like buy food or buy their medication or go see a doctor? Right? If they weren’t making those decisions, could we prevent cancer? Yes. Could we identify cancers earlier when they’re treatable? Yes. Once you’re getting treatment, are you more likely to be able to like stay on protocol and get all access to the best things you need? Yes. So absolutely in a multitude of ways we could prevent cancer and treat cancer better and help people who have cancer live better if they had health insurance. But I will say it’s not just having health insurance, it’s taking that for-profit motive out of things. It’s clearing up those trust relationships that we’ve talked about. How if you’re not sure, you know where your providers are coming from in terms of the recommendations they make, so you don’t know if you should trust them.
It’s the “are you going to get a test because your insurance approved it or not approved it?” And then like weeks go by and it doesn’t quite get approved. And so like, you know, you got diagnosed with cervical cancer today and you didn’t get treated for eight weeks because that’s how long it took in your community to get an MRI and a PET scan for somebody to be able to decide like how to do your radiation treatment. Like it’s not just having insurance, but it’s taking the profit motive out. That’s going to really impact cancer prevention, cancer outcomes, best quality of life with cancer.
Q: Great, and Medicare for All would take out the profit motive, correct?
Singh: Absolutely. Medicare for All would take out the profit motive.
Thank you Dr. Diljeet Singh of Physicians for a National Health Program.
Do you have a personal story you’d like to share about our wack healthcare system? Contact us through our website at heal-ca.org.
Don’t forget to subscribe to Code WACK! wherever you find your podcasts. You can also find us on ProgressiveVoices.com and on Nurse Talk Media.
Code WACK! is powered by HEAL California, uplifting the voices of those fighting for healthcare reform around the country. I’m Brenda Gazzar.
Medicare for All Explained Podcast: Episode 98
The Reintroduction of Medicare for All Bills and Why We Need Medicare for All
May 15, 2023
Podcast host Joe Sparks discusses the new Medicare for All bills in the House and Senate, and summarizes why we need Medicare for All now.
He opens with a sobering statistic: “Our current health care system causes more than 76,000 preventable deaths and hundreds of thousands of bankruptcies every year.”
Additional episodes will be uploaded twice monthly. Subscribe in iTunes, or access a complete archive of the podcast, below.
Ady Barkan’s Alert on Medicare Advantage
Summary: Mr. Barkan, a resolute and articulate advocate for single payer / Medicare for All, warns us about privatization of Medicare via Medicare Advantage. We must unite to battle the corporate takeover of our premier public insurance program.
How Medicare Advantage Could Kill Medicare, The Nation, May 17, 2023, by Ady Barkan
Today, Senator Bernie Sanders, Representative Pramila Jayapal, and Representative Debbie Dingell introduced the Medicare for All Act in the Senate and House.
In 2019, The House of Representatives announced that it would hold its first-ever hearing on the Medicare for All Act. I was the first witness in the overflowing Rules Committee room. I spoke through my computer; paralyzed by ALS at age 35, I embodied the reality that we all will need health care, no matter how lucky and privileged we feel.
I had become a prominent champion for universal health care, particularly for strengthening and expanding Medicare. But I am now embarrassed to admit that I actually didn’t understand the massive changes that had been happening to the Medicare system. For more than two decades, health insurance companies have been privatizing our cherished Medicare program. Now, I’m worried that once they have it we may never get it back.
The Medicare Advantage program was created with the promise that the private sector could reduce costs by better managing care. But, as The New York Times reported in October – which is when I finally understood the scale and gravity of this problem – the hunger of health insurance corporations for profits that these plans supply has been insatiable. The program is more costly than traditional Medicare, not more efficient.
Health insurance companies and private-equity firms are buying up primary care as fast as they can and extracting profit however they can.
As more people enroll in Medicare Advantage, and fewer in traditional Medicare, there may be less political will to improve traditional Medicare. The future of health care in this country might in fact be Medicare Advantage for All.
There is a better way. American voters from across the political spectrum support Medicare and Medicare for All. Generations of activists and leaders have pursued this same vision. But to get there, we will need to stop the corporate takeover of Medicare.
Comment:
By Don McCanne, M.D.
The opportunity to enact and implement a universal, comprehensive, affordable, high quality, equitable health care program – an Improved Medicare for All – is rapidly slipping away from us, and Ady Barkan explains why. You should read his full article in the Nation and share it with others.
Then we should act on it. New legislation for Medicare for All has been introduced this week in both the House and the Senate. Clearly the time calls for political activism. That doesn’t mean that we leave it to the politicians. It has to be the work of the people. We all have to join together to make it happen. The alternative is exposure to suffering, misery, bankruptcy, and even death.
http://healthjusticemonitor.org…
Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.
Medicare-for-All Legislation in the Senate & House
Summary: Senator Bernie Sanders & Representative Pramila Jayapal re-introduced their Medicare-for-All bills on May 17th. Although prospects for passage are low this Congress, enthusiasm for organizing is high. By including everyone in health care, we save money. If only the Right and Left could unite on this eminently practical solution to our health care mess.
Sen. Bernie Sanders renews push for Medicare for All to end ‘totally broken’ health-care system, CNBC, May 17, 2023, by Lorie Konish
For many Americans, a medical emergency can lead to a financial crisis due to the high cost of health care in the U.S.
This week, Sen. Bernie Sanders, I-Vt., is renewing his push for a new approach — Medicare for All — that he touted as a presidential candidate.
“The current health-care system in the United States is totally broken,” Sanders said Tuesday at a Capitol Hill event.
“It is totally dysfunctional, and it is extremely cruel,” he said.
With the support of Democratic Reps. Pramila Jayapal of Washington and Debbie Dingell of Michigan, the lawmakers plan to reintroduce a bill, titled Medicare for All Act of 2023, in both the House and the Senate on Wednesday.
In the House, the proposal will have 112 co-sponsors, more than they have ever had at the introduction of the bill, Jayapal noted, despite having fewer Democratic seats than in the previous Congress.
Medicare for All would create a single-payer program, which would allow one source to collect all health-care fees and pay all health-care costs.
“It is long overdue for us to end the international embarrassment of the United States being the only major country on earth that does not guarantee health care to all of its people,” Sanders said. “Now is the time for a Medicare for All single-payer program.”
The Evidence Is Clear: Medicare for All Will Save Money and Lives, Common Dreams, May 18, 2023, by James G. Kahn and Alison Galvani
Will Medicare for All raise or lower healthcare costs in the United States? Is it affordable?
We led two academic teams that published scientific papers to address this, the only peer-reviewed medical articles on this topic in the last 30 years. We worked separately, at Yale University and the University of California.
We think it’s time to retire doubts about the net cost of single payer or Medicare for All. The evidence for big savings is real.
We came to the same conclusion: Yes, Medicare for All will save money, by removing unnecessary paperwork and insurance company profits, lowering drug costs, and other factors. These savings will more than offset the cost of improving coverage and expanding it to everyone. …
What’s the difference between these studies, which conclude that single payer would save money, and other studies that conclude it would not?
First, the Yale and University of California, San Francisco (UCSF) studies are peer-reviewed, which means that the reports were closely examined by experts in the field for validity, and refinements implemented to satisfy the reviewers and editor. Other studies were not subject to this rigorous scrutiny.
Second, the Yale and UCSF studies are based on a strict definition of what makes a healthcare financing system “single-payer.” Some studies purporting to be about single-payer include private insurers and their added costs in their calculations.
Third, the Yale and UCSF researchers do not stand to profit from the outcome. They are academics, not consultants paid by clients with strong political and policy priorities.
Comment:
By Jim Kahn, M.D., M.P.H.
Senator Sanders has long battled for Medicare for All, and Representative Jayapal, Chair of the Congressional Progressive Caucus, now spearheads the House effort.
These inspiring leaders re-introduced their legislative proposals, with many co-sponsors. Sad to say, this Congress (and this political moment) bodes poorly for passage. But it bodes well for organizing. Single payer discussion, education, and coalition-building continues, at the federal level and in the states.
The Common Dreams piece (full disclosure: I’m an author) reviews the powerful economic argument that savings (from administrative simplification and drug price reductions) means lowered costs despite increased access to and use of care, averting tens of thousands of deaths per year.
Single payer, Medicare-for-All is the right thing to do – efficient and effective. If we could only convince the GOP that it’s the Right thing to do! They certainly won’t be Left out when the US implements high quality universal health insurance. (Seriously, right and left are united on this issue in dozens of other countries, so it’s not such a crazy idea.)
http://healthjusticemonitor.org…
Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.
The Association of Childbirth with Medical Debt in the USA, 2019–2020
By Jordan Cahn, M.D., M.Sc.; Ayesha Sundaram, M.D.; Roopa Balachandar, M.D.; Alexandra Berg, M.D.; Aaron Birnbaum, M.D.; Stephanie Hastings, D.O.; Matthew Makansi, M.D.; Emily Romano, M.D.; Ariel Majidi, M.D.; Danny McCormick, M.D., M.P.H., and Adam Gafney, M.D., M.P.H.
Journal of General Internal Medicine, May 18, 2023
Abstract
Background: Medical debt affects one in five adults in the USA and may disproportionately burden postpartum women due to pregnancy-related medical costs.
Objective: To evaluate the association between childbirth and medical debt, and the correlates of medical debt among postpartum women, in the USA.
Design: Cross-sectional.
Participants: We analyzed female “sample adults” 18–49 years old in the 2019–2020 National Health Interview Survey, a nationally representative household survey.
Main Measures: Our primary exposure was whether the subject gave birth in the past year. We had two family-level debt outcomes: problems paying medical bills and inability to pay medical bills. We examined the association between live birth and medical debt outcomes, unadjusted and adjusted for potential confounders in multivariable logistic regressions. Among postpartum women, we also examined the association between medical debt with maternal asthma, hypertension, and gestational diabetes and several sociodemographic factors.
Key Results: Our sample included n = 12,163 women, n=645 with a live birth in the past year. Postpartum women were younger, more likely to have Medicaid, and lived in larger families than those not postpartum. 19.8% of postpartum women faced difficulty with medical bills versus 15.1% who were not; in multi-variable regression, postpartum women had 48% higher adjusted odds of medical debt problems (95% CI 1.13, 1.92). Results were similar when examining inability to pay medical bills, and similar differences were seen for privately insured women. Among postpartum women, those with lower incomes and with asthma or gestational diabetes, but not hypertension, had significantly higher adjusted odds of medical debt problems.
Conclusions: Postpartum women experience higher levels of medical debt than other women; poorer women and those with common chronic diseases may have an even higher burden. Policies to expand and improve health coverage for this population are needed to improve maternal health and the welfare of young families.
full study:
https://link.springer.com…
Doctors support the Medicare for All Act of 2023
PNHP urges Congress to pass bill that would guarantee free and comprehensive health care for everyone living in the United States
FOR IMMEDIATE RELEASE: May 17, 2023
Media Contact: Gaurav Kalwani, PNHP communications specialist, gaurav@pnhp.org
Physicians for a National Health Program (PNHP), an organization of over 25,000 physicians who support publicly financed Medicare for All, supports the Medicare for All Act of 2023, introduced in the House by Representatives Pramila Jayapal and Debbie Dingell, and in the Senate by Senator Bernie Sanders. The bill has 112 original cosponsors in the House, and 14 original cosponsors in the Senate.
“As we lurch from crisis to crisis in our health care system, insurance companies and private investors continue to rake in billions while Americans suffer and physicians are prevented from carrying out their sacred duty,” said PNHP president and adult and pediatric intensivist Dr. Philip Verhoef. “We need to eliminate this greed and guarantee health care for each and every person in this country. We need Medicare For All today, and this bill gets it done.”
At a town hall hosted by Senator Sanders on Tuesday, May 16, former PNHP president Dr. Adam Gaffney and PNHP board member Dr. Sanjeev Sriram spoke about the injustices of the current system. “As a critical care physician, I have seen patients with life-threatening illnesses from chronic conditions that were not treated because they could not afford the care,” said Dr. Gaffney. “Medicare for All will solve that.”
Dr. Sriram remarked on the current crisis in Medicaid following the end of the COVID-19 public health emergency. “If you don’t pick up the phone at the right time, or if you don’t fill out a form correctly,” he said, “your family and your kids could lose your Medicaid.” As many as 17 million people may lose coverage as states unwind the continuous enrollment requirement.
The Medicare for All Act of 2023 would provide comprehensive coverage to all persons living in the United States, with no copays, deductibles, or restrictive networks. It would save the United States hundreds of billions in administrative costs and waste, while also saving thousands of lives every year. Under this bill, reproductive health care and gender affirming care are fully covered and freely provided, as is dental, vision, and long-term care.
“We only have two options – allow people to continue to suffer and die, or pass Medicare for All,” said Dr. Verhoef. “For PNHP and millions of others across the country, the choice is simple.”
Read more information about the bills and what you can do HERE.
Physicians for a National Health Program (pnhp.org) is a nonprofit research and education organization whose more than 25,000 members support single-payer Medicare for All reform.
The toxic brew of sexism and racism in American medicine
By Brenda Gazzar
Code Wack Podcast, May 15, 2023
Why is it that infant mortality rates in America differ by race? Why are some American babies more likely to be born premature or underweight? And how could single-payer health care help?
To find out, we spoke with Dr. Diljeet Singh, a women’s health advocate and integrative gynecologic oncologist who has practiced for nearly 25 years. She’s also the vice president of Physicians for a National Health Program, which advocates for Medicare for All. This is the first of a two-part series with Dr. Singh.
Transcript
Dispatcher: 911, what’s your emergency?
Caller: America’s healthcare system is broken and people are dying!
(ambulance siren)
Welcome to Code WACK!, where we shine a light on America’s callous healthcare system, how it hurts us and what we can do about it. I’m your host, Brenda Gazzar.
(music)
This time on Code WACK! Why is it that the richest Black women have about the same infant mortality rates as the poorest White women? Why do Black babies tend to have more risk factors like being born premature or underweight? And how could single payer help? To find out, we spoke to Dr. Diljeet Singh, a women’s health advocate and integrative gynecologic oncologist who has practiced for nearly 25 years. She’s also the vice president of Physicians for a National Health Program, which advocates for single-payer Medicare for All.
Welcome to Code WACK, Dr. Singh. We’re so glad you could join us today.
Singh: So happy to be here with you.
Q: So tell us a little bit about yourself. Where do you live and what do you do?
Singh: I am a gynecologic oncologist. I live and work in the Norfolk, Virginia Beach area of Virginia. Although I’m new to here. I’ve lived in Chicago and Washington DC for long periods of time, both of them. And I also work as, I don’t know if it’s work, it might be, I also “fun” as, as the vice president for Physicians for a National Health Plan and I’ve been involved in that organization for a long time.
Q: Did you have a specific experience that led you to support single-payer health care?
Singh: It’s hard to say that because I’ve been involved now for over 20 years. I think. Being involved with Physicians for a National Health Plan (PNHP) allows me to tolerate all of the bad things about our current profit driven system that make it hard for people to get care that make it unfair, that impact negatively their outcomes that limit the amount of time I get to have with them that limit the time and we spend with patients versus writing papers, filling out forms, doing things for insurance companies. So I’ll say like, there wasn’t a specific experience that made me do join, but every time I have a really bad experience with a healthcare insurance provider, I think to myself, okay, I’m doing that work for Physicians for a National Health Plan, trying to get everybody health care, trying to fix our system. But I mean, I think I have a bad experience with our healthcare system every day – like so many of my patients and the women I take care of, unfortunately.
Q: Wow. Thank you for sharing that. We’d like to talk about the recent study by the National Bureau of Economic Research, which showed the richest Black mothers and their babies are twice as likely to die as the richest White mothers and their babies. It was in the New York Times, I’m sure you caught it. The study examined women in California specifically and found that the richest Black women have infant mortality rates at about the same level as the poorest White women. Black babies tended to have more risk factors like being born premature or underweight. What are your thoughts about these inequities?
Singh: So I thought it was a really interesting study in a lot of ways, but I do want to point out the number one piece was it they were comparing to women in Sweden and everybody in America, all the kids, all the people having kids do worse in America no matter what their income, no matter what their race, which is kind of shocking considering we spend twice as much on every single person in America as they do in most of the rest of the world, for us to have such worse outcomes. The issue about why Black women are having these increasing maternal mortality, Black babies are having these increasing infant mortality. I mean, the other thing that’s interesting in that study was White women actually had higher rates of low birth weight and prematurity. And that’s thought to be related to White women at the highest income level being more likely to have twins and have gotten pregnant through infertility [treatments].
You know? And so it was kind of interesting that although they had higher rates of low birth weight and prematurity, they still had the best outcomes. Right? So we know it’s actually not that thing. You mentioned that those babies have bad outcomes because they have high risk factors. There’s something else in the system, and we know it’s everything in our system, right? It’s the access to healthcare, and we are along a person’s life, a person who decides to be a mother, do they get the opportunity to engage with health care? How much preventive work do they do before they get pregnant? During their pregnancy? What kind of care do they get? And then immediately postpartum, right? I mean, the maternal mortality rates, the all cause mortality rates that just came out. And that was in JAMA said, all-cause mortality, not just pregnancy, but homicide, drug-related death for women is up in America 2018 even compared to 2020 and all dramatically higher than the rest of the world.
Wow.
Singh: So how do we connect race to bad health outcomes? I think the majority of the data is saying to us, it’s about racism and how that manifests is really complicated, right? So there’s the chronic stressors for people who experience racism. There’s the unconscious bias of healthcare providers and how they take care of people of different races and gender. And then there’s the way we listen to and talk to women in general, and then how it impacts pregnant women as in, you know, we know if a woman shows up pregnant or not pregnant in an emergency room and she’s in pain, she’s going to wait longer than a man would wait. She’s less likely to get pain medicine. She’s less likely to get any kind of test to evaluate the pain, and she’s more likely to be given an antidepressant, right, which that’s all kind of crazy making if you think about it.
That is crazy.
And I think the tragic piece of this is, is that Black women are kind of literally at the intersection of that, right? They’re getting all the negative impact of being a woman, of being female, and then they’re getting all the negative impact of race and racism and, you know, yeah, we could talk for a while like all the things that have poor impact. But I think that sort of summarizes it. And I think we have to be really, really clear that there is a lot of sexism and misogyny and racism that’s built into American medicine. And one of the reasons we don’t have universal healthcare is because back in the 1940s when Truman was trying to introduce universal health care, the American Medical Association did not want to cover Black people, period. They wanted them to be cared for separately. So, you know, and that’s the beginning, right? Like that’s early in the history of modern medicine as it exists now in America.
Q: Right, and this happened less than a century ago, as you said in the 1940s?
Singh: Yeah, in the 1940s. Actually, if people in the audience are interested, the 1619 podcast episode four speaks of it so … it’s a really nice short way to get a good history of racism in America and how kind of worked into it. There’s also a really wonderful journalist and writer Linda Villarosa, who has a book called Under the Skin, yeah. She talks about the traditional ways of thinking. I mean, you know, now we look at these things that we think it’s stupid, right? Like, ‘oh, well Black women have worse outcomes because they’re genetically inferior or different.’ And now we look at it and we’re like, ‘wow, that would be like saying, wow, everybody who has blue eyes must be weaker than everybody who has brown eyes.’
Like, you know, even scientifically it didn’t make sense connecting skin color to other characteristics. And the funniest, or the most complicated thing about that for me is like, but now we know there is a way that race, you know, impacts genes. It’s the trauma of racism that causes those epigenetic changes that we almost think, you know, the trauma of generations before us might impact the younger generations. And that’s where even like the thing you mentioned about, you know, the highest income Black women, right? We know then race must be a part of it if it’s not about socioeconomic status. But then if we think of the generational trauma even of her parents and her ancestry and how that impacts how genes function, not what genes we have, but how well our genes work, you know, and that’s what we call epigenetics and how those things impact health outcomes and we know they do. Yeah. It’s hard to imagine that nobody could see that before and that they chose to blame it on other factors. And it’s not that low socioeconomic status and lack of insurance and poverty doesn’t play a role in health. Absolutely it does, but it’s not the only factor.
Q: Mm-Hmm. Got it. Thank you. Right. So I know that you’re not an OBGYN, but do you happen to have any stories you can share related to the study’s findings about black women and their babies?
Singh: So I am an OB-GYN. I just don’t practice obstetrics so to be a gynecologic oncologist, first you become an OB-GYN, then you do a cancer fellowship. But I don’t take care of pregnant women except for when some context related to me comes up. But, you know, I mean, I hate to be like a media hound and you know, like talk about Serena Williams, but to me, like she’s the most telling, right, because she is the greatest athlete of all time, right? . So she knew her body. She had a history of a blood clot. She was pregnant. She had an emergency C-section. She was having symptoms of a possible new blood clot and she could not get people to listen to her about shortness of breath and that she might have a blood clot.
And she had to push so hard and advocate so hard to get the CAT scan that diagnosed her, you know, pulmonary embolism that is life-threatening and to imagine, right, somebody not as empowered as she is and talk about somebody who’s in good health, right? And she had this pregnancy related complication but didn’t get listened to … because she has everything, right? She had money, she had fame, she had a platform, she had credibility when it came to health and that her, you know, exchange with the healthcare system was so challenge and then imagining women who don’t have that piece of, you know, she’s extremely articulate. She’s been on the world stage since she was like a preteen and, you know, understands how to voice her feelings. That to me is the story that tells us the role that both race and gender play in how women interact with health care and how that has the potential to lead to bad outcomes.
Cuz if it hadn’t been her, if it had been somebody who just said, you know, oh, you must be right, I’m just in pain cause I had a c-section, the likelihood she would’ve fallen into that statistic of a maternal mortality is high and we never would’ve heard that story. And you know, we can take every one of those 26 deaths per a hundred thousand lives births. And there’s a story like that there, you know, are some of those deaths not preventable, you know, not preventable. Possibly the literature tells us, you know, in countries like New Zealand where they have five, you know, maternal deaths for a hundred thousand births, and here in America we’re in this range of 26 to 50 something for Black women and you know that there’s a story in at least, you know, 50 of those women of something preventable because somehow in the rest of the world, we are successfully preventing those deaths.
Q: Mm-Hmm. Right. Good point. Let’s talk about some of the reasons this is happening. You mentioned racism and Tiffany Green, an economist who focuses on public health and obstetrics at the University of WisconsinMadison told the New York Times that it’s not race, it’s racism. And this is about the environments where we live, where we work, where we play, where we sleep. What do you think she meant by that?
Singh: There’s two pieces to it. There’s the racism that means that in a predominantly Black neighborhood, you’re more likely to live near a landfill, right? And the pollution that comes from that and the environmental impact of that. You’re potentially more likely to not have access to fresh fruits and vegetables. You’re potentially less likely to have access to non-dairy milk alternatives. Right? There’s all these things I’m going to keep in there the complexity of socioeconomic status. That if you take the highest income Black women and they’re still having these bad outcomes, that there is something beyond the environmental interplay when it comes to those kinds of things and then we’re talking about an environment where they are subjected to some element of daily ongoing chronic stress. Their symptoms are not listened to or ignored based on the color of their skin alone.
I won’t say every Black woman of high socioeconomic status didn’t come from low…. Right. They might, she might have, people might have a history of coming from, so it’s, you know, higher, but that epigenetics or, you know, other generational trauma and how that impacts, I think it all plays in. And I think when I talk about racism in like, what does it mean, you know, it means like how do people talk to you when you come to the hospital? It means how do people listen to you? It means what do they think when they’re going to take care of it? You, and, and I do find it challenging when I talk to physicians, groups and medical students about this because I think the unconscious bias part of things is really challenging. Right. You know, the fact that the father of modern gynecology, right, Marian Sims experimented and practiced surgery on Black women slaves with no anesthesia.
And the fact that he could say like, well they don’t feel pain the same way, which was this tenant of slavery of how they could get away with treating people so poorly. But it’s hard to imagine those women didn’t cry. It’s hard to imagine those women didn’t react to being cut open.
Oh my gosh, that’s horrible.
Right? And so the, the kind of recently in 2015, there was an editorial in a major OBGYN journal written by somebody justifying his behavior, saying, well, he was just a creature of his time. He was a physician taking care of somebody. And it’s just hard for me to imagine they didn’t express pain. But meanwhile, you come now and there’s studies from 2015, 2016, and I think it came from in Virginia, somebody interviewed and did studies on University of Virginia, I believe medical students and asked them about pain tolerance. And there were medical students in our day and age who thought Black people have higher pain tolerance based on skin color again, right.
That’s this weird genetic thing of like, really pain tolerance is like built into a gene that’s connected to the melanin in your skin? Like it makes no scientific sense, but it has been a part of “science” in quotes – eugenics – not real science, but it was put forward. And I think we have to remember right, medicine is science, but medicine is culture. And so the misogynist and racist culture that our medicine grew up in, fixing misogyny and racism in medicine in many ways is not hard. In many ways it’s really difficult cause it’s so deeply ingrained.
Q: I see. So could single payer, Medicare for All affect these high rates of infant and maternal mortality among Black women in America and if so how?
Singh: So I think everybody having access to the same basic level of health care, not having to prove that you are pregnant. And so you can get Medicaid if you didn’t have insurance. Not having to make choices about what work you do in order to have insurance absolutely could make dramatic changes. And there’s a lot of well-spoken, well thought of policy advocates who say, you know, universal health care could be the most pro-women anti-racist policy we could move forward and I 1000% agree that if you automatically had access to care and the care was the same for everybody, right? It’s not like, ‘oh, you have Medicaid, it doesn’t reimburse as well so not every doctor in this hospital takes your insurance, so we’re going to put you in a slightly different category.’ Or, ‘oh, you’re from the free clinic. Hmm. That must mean you are addicted to drugs’ or you know, like all the biases and stuff.
If it were all the same, that would change. And as we think about like, how do New Zealand and Sweden and Canada and Denmark and the UK and Germany have maternal mortality rates that are, you know, five versus 50 for Black women. Right? How do they do that? Well, everybody gets health care and most people get care within the same system and they get access to everything long before they became pregnant and cared for long after. So I think by kind of raising the bar on health care, on prevention, absolutely will make a difference. Is it the only thing we need to fix? Nah, we got other things that we would need to fix as well.
Thank you Dr. Singh of PNHP. Stay tuned next time when we talk to Dr. Singh about why Black women face a greater risk of gynecologic cancers.
Do you have a personal story you’d like to share about our wack healthcare system? Contact us through our website at heal-ca.org.
Don’t forget to subscribe to Code WACK! wherever you find your podcasts. You can also find us on ProgressiveVoices.com and on Nurse Talk Media.
Code WACK! is powered by HEAL California, uplifting the voices of those fighting for healthcare reform around the country. I’m Brenda Gazzar.
Insane Drug Prices & Gaming = Huge Profits for Pharma & PBMs
Summary: Two news items this week lay bare US drug cost problems. The underlying cause is prices several-fold higher than elsewhere. Exacerbating that is convoluted gaming – moving money around to boost and retain profits. Who wins? Pharma and Pharmacy Benefit Managers (partnered with insurers). And loses? The rest of us.
Senators Call Out PBMs, Drugmakers for High Prescription Drug Costs, MedPage Today, May 11, 2023, by Shannon Firth
Drugmakers and pharmacy benefit managers (PBMs) traded the blame over high drug prices during a hearing of the Senate Health, Education, Labor and Pensions Committee on Wednesday.
Each side argued the other was trying to fleece patients and the government, but Sen. Bernie Sanders (I-Vt.), chairman of the committee, argued there was plenty of blame to go around.
“Let’s be clear, while Americans pay outrageously high prices for prescription drugs, the pharmaceutical companies and the PBMs make enormous profits every year,” he said.
In 2021, the 10 major drug companies made $100 billion in profits, and in 2022, the three largest PBMs made over $27 billion, Sanders noted. Moreover, the three pharmaceutical companies that produce insulin — Eli Lilly, Novo Nordisk, and Sanofi — have hiked the price of the drug dozens of times over the last two decades for “the same exact product,” he added.
Meanwhile, 1.3 million Americans have been forced to ration their insulin because of its high cost, and some, including 23-year-old Alec Raeshawn Smith, have died. …
Several lawmakers argued that PBMs benefit from higher list prices because higher prices mean higher rebates, and PBMs keep a portion of rebates. …
In their testimony, the PBM witnesses all stated that they pass about 98% of their rebate onto their customers, which include employers, health plans, and unions. …
Notably, however, because of vertical integration, the three largest PBMs, CVS Health, Express Scripts, and OptumRx … are all owned by or partnered with health plans. UnitedHealth Group owns OptumRx, Cigna owns Express Scripts, and CVS Health and Aetna merged in 2018.
Sen. Markwayne Mullin (R-Okla.) likened this setup to “the fox guarding the henhouse.” He pointed out that when PBMs say 98% of rebates go to customers, health plans are included among their customers.
“So you’re rebating yourselves. That is just — wow — [a] great business model,” he said.
Wonking Out: Attack of the Pharma Phantoms, New York Times, May 12, 2023, by Paul Krugman
The U.S. health care system, unlike health systems in other countries, isn’t set up to bargain with drug companies for lower prices. In fact, until the Biden administration passed the Inflation Reduction Act, even Medicare was specifically prohibited from negotiating over drug prices. As a result, the U.S. market has long been pharma’s cash cow: On average, prescription drugs cost 2.56 times — 2.56 times — as much here as they do in other countries.
Strange to say, however, pharmaceutical companies report earning hardly any profits on their U.S. sales. … a striking chart comparing 2022 revenue and profit for six major pharma companies:
… 2022 was an exceptionally profitable year for these companies, but the pattern — large revenue in the U.S. market, with very low reported profits — has been consistent over time.
How do the pharma giants do that? Mainly by assigning patents and other forms of intellectual property to overseas subsidiaries located in low-tax jurisdictions. Their U.S. operations then pay large fees to these overseas subsidiaries for the use of this intellectual property, magically causing profits to disappear here and reappear someplace else, where they go largely untaxed.
Comment:
By Jim Kahn, M.D., M.P.H.
These two pieces, a news report on a Senate hearing and an op-ed by a prominent economist, succinctly characterize the massive cost problems we face with prescription drugs.
First, prices are more than 2.5 times as high in the US as in comparison wealthy countries.
Second, drug companies avoid paying US taxes on those profits by setting up intellectual property havens in other countries with low tax rates. They pay themselves (their foreign entities) inflated amounts for patent use, thereby shifting profits to where they can keep them.
Third, PBMs – an invented intermediary structure — manipulate prices and rebate schemes to grab another huge slice of income and profits. The “rebates” are largely to the insurance companies with which they share corporate structure.
Single payer would replace this convoluted profit-maximizing drug marketing maze with a straightforward, proven and transparent system of drug price negotiation and payment. This shift would save enough money, along with administrative simplification, to make single payer the economic unicorn: a “free lunch” — a cost–saving expansion to universal high-quality insurance.
http://healthjusticemonitor.org…
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Primary Care Corporate Takeover a Challenge for Single Payer
Summary: The large-scale corporate appropriation of primary care reflects and enables the profiteering that now dominates US health care. The doctor-patient relationship suffers. Single payer financing may falter if corporations own the vast majority of providers. What are our reform options?
Corporate Giants Buy Up Primary Care Practices at Rapid Pace, The New York Times, May 8, 2023, by Reed Abelson
Why are multibillion-dollar corporations, particularly giant health insurers, gobbling up primary care practices?
The appeal is simple: Despite their lowly status, primary care doctors oversee vast numbers of patients, who bring business and profits to a hospital system, a health insurer or a pharmacy outfit eyeing expansion.
And there’s an added lure: The growing privatization of Medicare means that more than half its 60 million beneficiaries have signed up for policies with private insurers under the Medicare Advantage program. The federal government is now paying those insurers $400 billion a year.
The absorption of doctor practices is part of a vast, accelerating consolidation of medical care, leaving patients in the hands of a shrinking number of giant companies or hospital groups. Nearly seven of 10 of all doctors are either employed by a hospital or a corporation. Experts warn these major acquisitions threaten the personal nature of the doctor-patient relationship, especially if the parent company has the authority to dictate limits on services from the first office visit to extended hospital stays. [The article provides examples of how corporate control of primary care leads to abusive practices to increase revenue.]
“We’re dealing with incredible levels of burnout within the profession,” said Dr. Max Cohen, who practices near Portland, Ore.
Comment:
By Don McCanne, M.D. and Jim Kahn, M.D., M.P.H.
There is not much new here in this report of the corporate takeover of our health care system except maybe for the rapidity and boundlessness with which it is taking place.
Recently single payer financing gained in popularity as people recognized how it could transform our defective insurance system to bring truly affordable, accessible, equitable care with free choices for all. But with corporations now controlling medical delivery including linchpin primary care providers, care has become less affordable and thus less accessible for many, certainly less equitable, and our choices are limited to the dictates of the corporate entity.
The complexity that this has produced was explained by Steffie Woolhandler and David Himmelstein, the founders of Physicians for a National Health Program, in a recent Jacobin interview and HJM post. Just a few years back, all we needed was a public financing program that displaced private ownership of health insurers (single payer).
But now with Wall Street’s takeover of the health care delivery system, reform of ownership of provider resources is needed. Community rather than corporate control of care seems to be what we need, but imagine the hurdle in transferring ownership of our entire health care system from the titans of Wall Street to the inhabitants of Main Street. Difficult times lie ahead, but what can we do? One thing for sure, we cannot leave control of our health care in the hands of the billionaires.
Are there any ideas out there that would actually work, short of socialized medicine (which, of course, would)? We’re contemplating this, and welcome ideas healthjusticemonitor@gmail.com.
http://healthjusticemonitor.org…
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U.S. health care: Where are we…and why?
Single Payer Would Radically Transform Health Policy Research
Summary: The May 2023 issue of Health Affairs, the leading health policy journal, has 20 articles. In our assessment, 9 of them would be unnecessary and another 7 simplified if the US had truly universal and standard health insurance. These health policy resources could be redirected to critical non-insurance issues in access, equity and disparities, and outcomes.
Health Affairs Table of Contents May 2023
(Parenthetical assessments by HJM)
Availability Versus Accessibility: Identifying COVID-19 Testing Deserts Across Massachusetts (Largely a coverage issue; simplified.)
The Role of Financial Incentives in Biosimilar Uptake in Medicare: Evidence from the 340B Program (Drug pricing issue; simplified.)
Benchmarking Changes and Selective Participation in The Medicare Shared Savings Program (ACO issue; likely moot.)
Trend Toward Older Maternal Age Contributed to Growing Racial Inequity in Very-Low-Birthweight Infants in the US (Partially an insurance issue; simplified)
Federal Funding for Discovery and Development of Costly HIV Drugs Was Far More Than Previously Estimated (Informs drug pricing; still needed.)
Medicaid Payment For Postpartum Long-Acting Reversible Contraception Prompts More Equitable Use (Coverage issue; moot.)
Insurer Market Power and Hospital Prices in the US (Insurer patterns; moot.)
Hospital-Physician Integration Is Associated with Greater Use of Cardiac Catheterization and Angioplasty (Provider ownership & practice issues; likely still relevant.)
The Costs of Disparities in Preventable Heart Failure Hospitalizations in The US South, 2015–17 (Partially insurance issue; simplified.)
Enrollment and Characteristics of Dual-Eligible Medicare and Medicaid Beneficiaries in Integrated Care Programs (Insurance issue; moot.)
The Neighborhood Atlas Area Deprivation Index for Measuring Socioeconomic Status: An Overemphasis on Home Value (Equity; still relevant)
Changes In Health Coverage During The COVID-19 Pandemic (Insurance issue; moot.)
Buprenorphine Treatment for Opioid Use Disorder: Comparison of Insurance Restrictions, 2017–21 (Insurance issue; moot.)
‘We’ll Decide for You’: A Patient Is Rushed at Hospital Discharge (Partially insurance issue; simplified.)
Inequities In the Use of High-Quality Home Health (Largely insurance issue; simplified.)
Risk Adjustment and Health Equity (Insurance issue; probably moot.)
The Neighborhood Atlas Area Deprivation Index and Recommendations for Area-Based Deprivation Measures (Equity issue; still relevant.)
The Health Plan Price Transparency Data Files Are a Mess- States Can Help Make Them Better (Insurance complexity issue; moot.)
Identifying Scalable Strategies to Maintain Coverage as Medicaid Continuous Enrollment Ends (Insurance issue; moot.)
Why International Recruitment Won’t Solve the US Nursing Staffing Crisis (Largely financial issue; simplified.)
Comment:
By Jim Kahn, M.D., M.P.H.
Much health policy research examines the harms of and potential fixes for un- and underinsurance – problems created by our chaotically fragmented health insurance.
Our review of the table of contents of the premier US health policy journal suggests that the government and academic health policy community focuses on issues that would disappear with universal high quality health insurance, including drug price regulation – under single payer.
The considerable collective skills of health policy researchers should, could, and would be re-directed to the issues that are not fully resolved with single payer, such as disparities in access, care, and outcomes related to economic status and race.
Health policy researchers would also be called upon to study and refine the performance of single payer. For example, how should drug prices be set? How do provider reimbursement levels affect care patterns and outcomes? What is the impact of covering long-term care? How do clinical outcomes in the real world vary by choice of medical strategies? In another post, I’ll more fully describe a single payer health policy research agenda.
The contributions of health policy research must be unleashed by removing from the research portfolio the highly frustrating and largely futile research focused on trying to fix our irremediably broken insurance system. Policy band-aids, no matter how cleverly designed, won’t fix major pathology.
Liberate and empower health policy research!
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