By Noah Weiland
The New York Times, May 26, 2023

Hundreds of thousands of low-income Americans have lost Medicaid coverage in recent weeks as part of a sprawling unwinding of a pandemic-era policy that prohibited states from removing people from the program.

Early data shows that many people lost coverage for procedural reasons, such as when Medicaid recipients did not return paperwork to verify their eligibility or could not be located. The large number of terminations on procedural grounds suggests that many people may be losing their coverage even though they are still qualified for it. Many of those who have been dropped have been children.

From the outset of the pandemic until this spring, states were barred from kicking people off Medicaid under a provision in a coronavirus relief package passed by Congress in 2020. The guarantee of continuous coverage spared people from regular eligibility checks during the public health crisis and caused enrollment in Medicaid to soar to record levels.

But the policy expired at the end of March, setting in motion a vast bureaucratic undertaking across the country to verify who remains eligible for coverage. In recent weeks, states have begun releasing data on who has lost coverage and why, offering a first glimpse of the punishing toll that the so-called unwinding is taking on some of the poorest and most vulnerable Americans.

So far, at least 19 states have started to remove people from the rolls. A precise total of how many people have lost coverage is not yet known.

In Arkansas, more than 1.1 million people — over a third of the state’s residents — were on Medicaid at the end of March. In April, the first month that states could begin removing people from the program, about 73,000 people lost coverage, including about 27,000 children 17 and under.

Among those who were dropped was Melissa Buford, a diabetic with high blood pressure who makes about $35,000 a year at a health clinic in eastern Arkansas helping families find affordable health insurance. Her two adult sons also lost their coverage.

Like more than 5,000 others in the state, Ms. Buford, 51, was no longer eligible for Medicaid because her income had gone up. A notice she received informing her that she did not qualify made her so upset that she threw it in a trash can.

But a majority of those who lost coverage in Arkansas were dropped for procedural reasons.

Daniel Tsai, a senior official at the Centers for Medicare and Medicaid Services who is helping to oversee the unwinding process for the Biden administration, said that more outreach was needed to help those who lost coverage that way. He said federal officials were in regular contact with state officials around the country to review early data on the unwinding and check whether people who lost coverage had a fair shot to prove their eligibility.

Gov. Sarah Huckabee Sanders of Arkansas, a Republican, has framed the unwinding as a necessary process that will save money and allow Medicaid to function within its intended scope.

“We’re simply removing ineligible participants from the program to reserve resources for those who need them and follow the law,” Ms. Sanders wrote in an opinion essay in The Wall Street Journal this month. She added that “some Democrats and activist reporters oppose Arkansas’s actions because they want to keep people dependent on the government.”

Medicaid, which is financed jointly by the federal government and the states, has become an increasingly far-reaching component of the American safety net. Early this year, 93 million people — more than one in four Americans — were enrolled in Medicaid or the Children’s Health Insurance Program, up from 71 million before the pandemic.

What has played out in Arkansas so far offers evidence of the widespread disruption that the unwinding process is likely to cause in households across the country in the coming months, forcing Americans to find new insurance or figure out how to regain Medicaid coverage that they lost for procedural reasons. The federal government has projected that about 15 million people will lose coverage, including nearly seven million people who are expected to be dropped despite still being eligible.

Among the biggest looming questions is how the process will affect children. In Florida, for instance, a boy in remission from leukemia and in need of a biopsy recently lost his coverage.

Researchers at the Georgetown University Center for Children and Families estimated before the unwinding that more than half of children in the United States were covered by Medicaid or CHIP. Many children who lose coverage will be dropped for procedural reasons even though they are still eligible, said Joan Alker, the center’s executive director.

“Those kids have nowhere else to turn for coverage,” she said. “Medicaid is the single largest insurer for children. This is hugely consequential for them.”

In Arkansas, many of the children who lost Medicaid were “the poorest of the poor,” said Loretta Alexander, the health policy director for Arkansas Advocates for Children and Families. She added that losing coverage would be especially harmful for young children who need regular developmental checkups early in life.

Most states are taking around a year to complete the unwinding, with each one using its own approach to removing people from Medicaid. But in Arkansas, legislation passed in 2021 required state officials to complete the process in just six months. State officials checked the eligibility of children with Medicaid coverage early in the process because they make up a substantial share of those who are enrolled, according to Gavin Lesnick, a spokesman for the state’s Department of Human Services.

In her opinion essay, Ms. Sanders pointed to the campaign that the state has waged to alert residents to the unwinding, called Renew Arkansas.

“We hired extra staff and enlisted volunteers to help,” she wrote. “We texted, emailed and called tens of thousands of Arkansans who likely are now ineligible for Medicaid, and we have made a special effort to reach out to those with disabilities, those who have moved, those with afflictions like cancer, those receiving dialysis and women who are pregnant.”

Local health workers like Ms. Buford are trying to help people regain coverage if they still qualify for it. She said that she had worked with 50 to 75 Medicaid recipients who had lost coverage in April, helping them fill out forms or answering their questions about how to verify their eligibility.

Other states have also removed a large number of Medicaid recipients for procedural reasons. In Indiana, nearly 90 percent of the roughly 53,000 people who lost Medicaid in the first month of the state’s unwinding were booted on those grounds. In Florida, where nearly 250,000 people lost Medicaid coverage, procedural reasons were to blame for a vast majority.

In addition to taking different approaches to removing people from Medicaid, states are also releasing data about their progress in different ways, making it difficult to compare their strategies in the early stages of the unwinding. “We’re comparing apples to oranges to tangerines,” Ms. Alker said.

Some people who lose Medicaid coverage are expected to get health insurance through their employer. Others are likely to turn to the Affordable Care Act’s marketplaces to sign up for private insurance, and many of them will be eligible for plans with no premiums.

Debra Miller, 54, of Bullhead City, Ariz., lost Medicaid coverage in April after her roughly $25,000 annual salary as a Burger King cook left her ineligible. Ms. Miller, a single mother with diabetes and hypothyroidism, worked with an insurance counselor at North Country HealthCare, a network of federally funded health clinics, to enroll in a marketplace plan with a roughly $70 monthly premium.

“It’s a struggle because it’s a new bill that I haven’t had before,” she said. Her new plan, she added, does not include vision insurance, leaving her worried about paying for eye appointments she needs as a diabetic.

Ms. Buford said that for some people in Arkansas, marketplace coverage would be too expensive.

“You have a car, mortgage, kids, food,” she said. “You really don’t have that much left to pay that much for health insurance.”

Ms. Buford said that her job helping others find health insurance in underserved areas was a calling inspired by watching her grandmother struggle to afford her medications and rely on food pantries. Ms. Buford went to a community college near her hometown so she could take care of her sick father, who passed away in his 40s. “I love my job because I’m able to help people,” she said.

Now that she has lost her Medicaid coverage, Ms. Buford said she hoped to find an affordable marketplace plan in the near future. The family plan offered by the clinic where she works is too costly, she said.

“I’m grateful for what I have because someone else doesn’t have what I have,” Ms. Buford said. “I just wish I could have kept my Medicaid.”

https://nytimes.com…

By Matthew Cunningham-Cook and Andrew Perez
Lever News, May 26, 2023

The health insurance behemoth Humana enjoyed a banner 2022. The Louisville, Ky.-based insurer made $2.8 billion in profits last year, while paying out $448 million in dividends to shareholders and more than $17 million in compensation to its CEO.

The main driver of those earnings? The federal government spent $20.5 billion overpaying Humana and other private insurers for the Medicare Advantage plans they manage on behalf of seniors and people with disabilities. If not for those overpayments, Humana could have suffered a nearly $900 million loss in 2022, according to a Lever analysis.

Humana is the most prominent example of how insurers have built a major cash cow out of systematically overbilling Medicare Advantage, the private Medicare program operated by private interests. These overpayments are symptomatic of a broader profit-driven policy agenda that seeks to completely privatize Medicare, one of the nation’s most popular social programs, and lock program recipients into subpar private insurance plans, even when they get sicker and need the best care possible.

Medicare Advantage plans have higher claim denial rates and more prior authorization restrictions than traditional Medicare plans. Last year, regulators found that nearly one in five payment requests rejected by Medicare Advantage plans in 2018 were wrongfully denied, representing an estimated 1.5 million claims.

And while Biden administration proposals could have helped slow the for-profit takeover by tightening the screws on Medicare Advantage overpayments, insurers recently led a fierce lobbying campaign to dissuade the government from fully cracking down on the practice.

At the root of Medicare Advantage overpayments is “upcoding” by insurers, a scheme by which the companies systematically overbill the public as if their patients are sicker than they really are. Companies have offered bottles of champagne and bonuses to entice doctors to add diagnoses to patients’ records, according to government lawsuits reviewed by the New York Times.

In total, these practices led to $20.5 billion total excess payments to Medicare Advantage insurers in 2022, according to a March report from the Medicare Payments Advisory Commission (MedPAC), a federal body tasked with overseeing Medicare. In the coming years, the overpayment problem could get substantially worse. A November 2021 study suggested that Medicare costs from 2023 to 2031 will be $600 billion higher than if Medicare Advantage beneficiaries were instead enrolled in traditional Medicare.

Because of such overpayments, big insurers like Humana have become highly dependent on Medicare Advantage. Humana, for example, earned more than 80 percent of its revenue from Medicare last year, and now has nearly 5 million Medicare Advantage customers. Wall Street loves this business model: Humana’s stock has outperformed the S&P 500 by 23 percent over the past five years.

Humana isn’t alone in benefiting from Medicare Advantage overpayments. The other major for-profit insurers — UnitedHealth, Centene, and CVS Health, which owns Aetna, would have seen major hits to their 2022 profits had the government eliminated the overpayments.

UnitedHealthGroup would have seen its profits deteriorate by more than one-third, from $14.4 billion to less than $8.8 billion, according to an analysis by The Lever. CVS Health would have seen its profits cut by more than half, from $4.1 billion to $1.9 billion. And Centene would have seen its profits deteriorate by more than one-quarter, from $3.4 billion to $2.4 billion.

Experts say the enormous sums of money going towards overpayments endanger the overall financial stability of Medicare as a whole.

“It’s threatening the solvency of our Medicare trust fund,” said Ana Malinow, a physician active in pro-Medicare for All groups. “The trust fund is made up of payments that people make throughout their entire working lives. If you are working, you’re paying into Medicare every two weeks with your paycheck. Instead of money going to pay for health care for seniors and people with disabilities, it’s going to UnitedHealth and Humana.”

Cutting back Medicare Advantage overpayments could be transformative for the social program, said David Lipschutz, associate director of the Center for Medicare Advocacy, which lobbies for a robust Medicare system. “These are huge amounts of money that could be directed to shoring up Medicare’s finances,” said Lipschutz. “Or expanding benefits for everyone, not just in Medicare Advantage plans.”

The government’s inability to crack down on Medicare Advantage overpayments is a product of major lobbying campaigns by the industry. Two Biden administration proposals that would have tightened the screws on Medicare Advantage overpayments by enhancing audits and cutting the growth of payments to Medicare Advantage plans were both scaled back in the face of aggressive industry lobbying and TV campaigns.

Instead, while there will likely be some cutbacks, the Medicare Advantage gravy train will continue. The number of people enrolled in Medicare Advantage is set to outpace traditional Medicare for the first time ever this year, with more than 30 million beneficiaries.

Better Medicare Profits

In February, the Centers for Medicare and Medicaid Services (CMS), which oversees Medicare, proposed a rule that would have reined in upcoding abuses by reducing extra payments that insurers receive for certain diagnoses, including diabetes “with complications” and a rare form of malnutrition. But in the face of widespread industry lobbying, the agency settled on a weaker three-year phase-in effort.

Even the original proposed rule might not have been enough to address Medicare Advantage overpayments. MedPAC called the initial proposal “insufficient” in a comment letter, and said that Secretary of Health and Human Services Xavier Becerra had “not taken significant action” in response to MedPAC’s analyses of fraudulent billing in Medicare Advantage.

Another way to crack down on upcoding schemes would be to limit government payments to Medicare Advantage plans, since it would send a message to Medicare Advantage providers that overall program costs are far too high. Last December, CMS did so by proposing increasing payments to Medicare Advantage plans by just 1 percent, compared to the 8.5 percent payment increase it approved last year.

In response, the Better Medicare Alliance, an advocacy group for Medicare Advantage plans, spent at least $13.5 million on ads pressuring the administration to increase the planned rate hike.

The group also spent $570,000 lobbying Congress in the first quarter of this year, nearly double the $330,000 spent in the prior quarter. All told, the four major publicly traded health insurance companies that operate Medicare Advantage plans, as well as the insurance lobby America’s Health Insurance Plans, spent nearly $19 million on federal lobbying in the first quarter of 2023, a 66 percent increase from the prior quarter, according to a Lever analysis of data from OpenSecrets.

That lobbying paid off: Instead of a 1 percent increase in payments to Medicare Advantage — which the insurance industry cast as a reduction because the growth rate had slowed dramatically — CMS announced a 3.3 percent payment increase at the end of March.

“The industry’s aggressive lobbying campaign showcases that they clearly want to protect their profit stream,” said Lipschutz. “Their disingenuous campaign tried to paint some very minor payment adjustments as being catastrophic to the Medicare Advantage program. They tried to ‘Medi-scare’ beneficiaries into contacting their elected officials to get CMS to back off — which CMS did to a certain extent.”

While industry analysts have said that this modest rate increase will strain insurers’ prodigious profits, the bond ratings agency Moody’s declared in April that “we believe [Medicare Advantage] will continue to be a growth driver for the industry and will take further market share from traditional Medicare.”

Medicare Advantage payment increases like Biden’s 3.3 percent hike will result in higher dividends to shareholders at the expense of the solvency of traditional Medicare.

The insurance industry also took aim at a recently proposed rule to claw back years of inflated risk adjustment payments, which are made to incentivize Medicare Advantage plans to accept riskier patients.

Initial proposals floated by CMS included retroactive audits of risk adjustment payments going back to 2011. Instead, the final pared-back proposal released in March only included retrospective audits going back to 2018.

Lipschutz said he does give the administration some credit for the audit rule change and the smaller rate hike for Medicare Advantage insurers relative to the prior year.

“On the other hand, it can be seen as far too little too late,” he said, adding that federal policy being so weighted towards Medicare Advantage plans at the expense of traditional Medicare is a “serious imbalance that is long overdue for course correction.”

Privatizing Medicare

Traditional Medicare operates on a fee-for-service basis. This means that doctors and hospitals are paid directly by Medicare for the services they provide. Private plans have operated as part of Medicare since just after the program was launched in 1965, but typically did so on a very limited basis. That changed in 2003, when Congress substantially increased subsidies for plans to enter the market, after intense industry lobbying.

While the traditional Medicare model is not without problems — Medicare only covers 80 percent of expenses, which means that seniors need either Medicaid or a Medigap insurance plan to get full coverage — it has major benefits relative to Medicare Advantage.

The principal benefit of traditional Medicare is that there is not a profit-driven insurer attempting to limit the scope of care that a patient needs.

Medicare Advantage “seems like a good idea,” said Ted Doolittle, the State Health Care Advocate for Connecticut. That’s because Medicare Advantage plans often offer expanded benefits like dental, vision, or wellness. They also eliminate the need for a potentially expensive Medigap plan if a senior isn’t eligible for Medicaid coverage.

But then, said Doolittle, “The scholarship shows that when patients get sick, they try to go back to traditional Medicare.”

According to Doolittle, most people who are either Medicaid eligible or who could afford a Medigap plan would balk at signing up for Medicare Advantage plan “if folks had adequate information about the nature of Medicare Advantage versus traditional Medicare, and the higher denial rates and the prior authorizations required for care in Medicare Advantage.”

Doolittle pointed out that there’s a key barrier to patients to getting full medical coverage if they try to switch back to Medicare once they become sick: In most states, Medigap insurers are allowed to discriminate against seniors on the basis of preexisting conditions if they are already enrolled in Medicare Advantage, something that is prohibited when seniors first become eligible for Medicare three months prior turning 65.

This problem is amplified by the rapid growth of Medicare Advantage. In 2010, a little over one-quarter of Medicare beneficiaries were in Medicare Advantage. By 2016, it was still less than one-third. But this year, a majority of Medicare beneficiaries will be on the private plans.

And the exorbitant government costs of Medicare Advantage are not limited to just overpayments related to upcoding. This year, Medicare Advantage plans will receive taxpayer rebates averaging $196 per participant. These rebates have more than doubled since 2018.

The total cost of the rebates could be as high as $75 billion this year, according to analysis by Bill Kadereit, president of the National Retiree Legislative Network.

“The extra $196 is spent on fringe benefits, and only on fringe benefits that go towards Medicare Advantage beneficiaries,” Kadereit said. “The other 30 million people in traditional Medicare get nothing. When Joe Manchin in West Virginia says ‘I like sending money to the Medicare Advantage plans, give them more,’ well, 40 percent of his people in West Virginia are not on Medicare Advantage, so they don’t get a nickel.”

Expanded attention to Medicare Advantage abuses has led some members of Congress to speak up and pressure the Biden administration to rein in the industry, even in the face of aggressive lobbying.

In February, 70 lawmakers, led by Congressional Progressive Caucus chair Pramila Jayapal (D-Wash.), sent a letter to the Biden administration pointing out that “as enrollment in [Medicare Advantage] grows, spending per beneficiary has grown faster in [Medicare Advantage] than original Medicare, and that spending is being funneled into corporate profits under the guise of operating costs instead of into care for patients.”

That said, there is no voice in Congress advocating for the phasing out of Medicare Advantage and allocating expanded benefits equally to all Medicare beneficiaries, which is by far the most cost-effective option.

And the larger Medicare Advantage becomes, the more politically difficult it will be to rein in, noted Doolittle.

“As Medicare Advantage keeps getting more embedded in Medicare, the situation keeps getting worse,” he said. “It’s gotten up to a real critical mass at this point, which makes it very hard to stop.”

https://www.levernews.com…

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).

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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.

https://heal-ca.org…

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.

https://medicareforallexplained.podbean.com

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.

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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.

https://heal-ca.org…