Theoretical vs. Actual Access to Care

Purpose: The United States has the highest maternal and neonatal mortality rates among the 45 high-income countries demonstrating enormous discrepancies between white and black mothers and infants. These outcome discrepancies have worsened over the last decade despite the availability of insurance coverage from the Affordable Care Act (ACA) to over 40 million previously uninsured Americans. We have compared differences in each state government’s acceptance of Medicaid expansion, overall insurance coverage, and ACA marketplace uptake. We next investigated how states implemented new ACA-enabled paradigms allowing the creation of very large monopolies for health care using Accountable Care Organizations (ACOs), in exchange for accepting Medicaid expansion to increase care for indigent patients. ACO’s were granted exemptions from Stark and Sherman Anti-trust prohibitions and permitted rewarding for “in house” referrals and could punish physicians for “system leakage.” However, many states did not expand Medicaid benefits, although the federal government would be paying 90% of costs. Nevertheless, they retained those regulatory waivers, actually exacerbating inequalities. Methods: Using publicly available, de-identified databases such as the US Census and CDC, we compared closures of hospital and L&D units, maternal mortality ratios (MMRs), neonatal mortality rates (NMRs), occurrence of maternity or health care deserts (DSRTs), and under-resourced (URS) areas across all states and DC. After considering several approaches for standardization including population, area, population density, healthcare deserts, proximity, and hospital beds, we selected population and square mileage as the primary denominators to compare 10 pairings of reasonably comparably sized states by their percentages of patients living in DSRTs reflecting lower rates of overall insurance coverage, Medicaid expansion, life expectancy, and multiple health morbidity rates. We evaluated ratios of DSRTs, MMR, and NMR within pairs. Results: Nationwide, there have been more than 100 hospital and 300 L & D closures since ACA. These have occurred disproportionately in rural areas, usually as large ACOs were allowed to just shut “under-performing” hospitals within their systems. Overall, US MMR for white patients is 26.6 and for black patients 69.9. NMR is 4.4 and 10.38 respectively. In NY, MMR is 14.1 and 55.6 respectively, but in GA white patients are 59.7 and black patients 95.6. (i.e. white GA ≈black NY). Overall health status declined for people of color and, when exposed to challenges like DSRTs and UNR, such stresses have disproportionately larger impacts for a lower health status group compared to a higher one. TX has DSRTs affecting 24.4% of its population vs CA at 0.09%. Dividing TX by CA gives a ratio of 271, MMR ratio of 2.69, NMR ratio of 1.28. FL/NY: DSRTs 1.71, MMR 1.18, NMR 2.37; for middle sized states: OH/PA: DSRTs 191, MMR 1.44, NMR 1.17; ; GA/IL: DSRTs 1.91, MMR 1.89, NMR 1.00; LA/OR: DSRTs 1.78, MMR 2.41, NMR 1.44, IN/MA: DSRTs 440, MMR 2.1, NMR 1.43; MO/IL: DSRTs 1.42 MMR 1.28, 1.25; TN/VA: DSRTs 1.14, MMR1.39, NMR 1.01; MS/MN: DSRTs 4.93, MMR 3.44, NMR 1.66. For smaller states: WV/ME: DSRTs 2116.5, MMR 25.1, NMR 1.0. Most differences are p<.001 (not shown). Conclusions: Theoretically, ACA coverage should have universally improved actual access to care. However, some medical metrics such as maternal-child care have significantly worsened. Not only have MMR and NMR increased, but the disparities between white and black patients have widened (not shown). Our data suggest these have been partly due to ACA/ACO sanctioned hospital and L & D closures. While health system margins increased, more DSRTs and URSs appeared, particularly impacting care for both poor white and black patients in rural areas compared to urban areas with the latter having more available care providers. Since the 1980s, the societal and political power of physicians relative to hospitals, insurance companies, and governmental authorities has significantly declined as have health care performance metrics. DSRTs is not a perfect parameter for defining risks for poor care risks, but it does identify a serious problem in how the American health care industry has changed from a professionally driven model to a big business model. Health care delivery employing big business rather than medical ethical and performance standards has fundamentally failed. As an example, mandating in-house referrals, imposed by corporate management may be cost-efficient in the short run but can deny patients access to better care that might be available in other hospitals or medical offices that can improve outcomes and ultimately better economics for patients, governments, and private insurance carriers. US medicine has reached a crossroad, and decisions must be made. As with other sanctioned monopolies like utilities, the medical enterprise representing 17% of US Gross National Product has an obligation to serve areas with low financial performance as well as those that are more lucrative. In business, unfettered monopolies lead to higher prices and lower quality goods. We now see that the business practices of healthcare monopolies have worsened maternal child health and also lead to inequalities of care.