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      in US Politics

      ‘It’s easy to dismiss Black women’s lives’: Texas drags feet on maternal mortality crisis

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      When medical staff prepped Shawn Thierry for an emergency C-section, she knew something was very wrong. After an epidural, excruciating pain ran through her legs. Soon, she could barely breathe.“I felt like my heart was going to jump out of my chest and that I might die,” she said.She screamed for her doctor to put her under anesthesia – which happened to be the solution. The epidural, Thierry later found out, was given too high in her spine, causing a paralysis that inched toward her heart.“I was an attorney who had full private healthcare coverage and I almost died,” said Thierry, of the birth of her daughter in 2012. “I cannot imagine what the outcome would be for the thousands of other African American women without health insurance.”Years later, as a member of the Texas House, Thierry was “stunned” to learn of the state’s maternal mortality crisis.The US has the highest maternal death rate among similarly developed countries and is the only industrialized nation where such deaths are rising. But according to data from the federal Centers for Disease Control and Prevention, in Texas the maternal mortality rate is above the US average, at 18.5 deaths per 100,000 live births.Black women in the state are “disproportionately” affected, accounting for 11% of live births but 31% of maternal deaths. Wide racial and ethnic disparities exist nationally too.I was shocked that black mothers like myself are three times more likely to die than our white counterparts“I was shocked that black mothers like myself are three times more likely to die than our white counterparts,” said Thierry. “And no one in the legislature was really talking about it.”She has repeatedly filed legislation to combat the glaring problem. Her proposals included racial bias training for medical professionals and a bill to fix a “severe” maternal health data backlog by creating a centralized registry.They did not advance in 2019, or in the current legislative session which ends this weekend. Focused on restricting abortion rights, the male- and Republican-dominated state legislature has dragged its feet on maternal mortality.Health advocates were cautiously optimistic that in 2021 Texas lawmakers would at least usher through a proposal to extend Medicaid care to a year after birth.Lawmakers did take action. A proposal was sent to Governor Greg Abbott on Friday. But it stopped short of providing the full Medicaid expansion.‘A large racial disparity’A state maternal mortality and morbidity review committee found that out of pregnancy related deaths in Texas in 2013, about a third occurred 43 days to a year after the end of pregnancy. It also discovered that nearly 90% of such deaths were preventable. Among the leading underlying causes of death with the highest chance of preventability were infection, hemorrhage, preeclampsia and cardiovascular conditions.“It was really striking,” said Dr Amy Raines-Milenkov, a University of North Texas Health Science Center professor and member of the review committee. “We found that most of these deaths could have been prevented but the system is just not set up to prevent them. And we found a large racial disparity, which is a reflection of how we in society value women, especially African American women.”Since 2016, the committee’s No1 recommendation to help save lives has been to extend Medicaid coverage postpartum for low-income mothers to a year. Currently, Texas kicks new moms off Medicaid after 60 days, leading to delayed and less preventative care. The American Medical Association and the American College of Obstetricians and Gynecologists support longer postpartum care.“So many health problems can develop in this really sensitive time period, so it is critical that new moms have that full year of extended coverage,” said Raines-Milenkov. “To think new mothers can identify problems, get timely appointments and follow up with their doctors within just two months of having a baby is unrealistic. Anything less than 12 months is really insufficient.”The Biden administration recently initiated incentives for states to expand postpartum coverage to 12 months. Illinois was the first to have its extension approved and other states including Florida and Virginia hope to implement measures soon.Toni Rose, a Dallas representative, joined Thierry in filing HB 133, to do just that in Texas. The Republican-dominated House passed the bill with rare bipartisan approval and nearly 70 groups, from the Texas Medical Association to the rightwing Texas Public Policy Foundation, expressed support.When it comes to saving the lives of Texas mothers, ‘splitting the difference’ is not appropriateHowever, the ultra-conservative Texas Senate – which ushered through extremist anti-abortion bills in March – did not pass the bill until the final minutes of its session. Even then, the legislation was not what was proposed. Without explanation, Republican Lois Kolkhorst of Brenham reduced the year of coverage to six months.Rose called the legislation a “victory” but said it still “falls short”. Thierry expressed dismay.“The data is clear that women are still at risk of maternal mortalities and pregnancy related complications for up to one year postpartum,” she said. “While the six months negotiated by the Texas Senate is better than the status quo, many new mothers will still be deprived of quality healthcare at a time when they are most vulnerable.“Given that this is an issue in which I have both personal and professional experience, I am disappointed. When it comes to saving the lives of Texas mothers, ‘splitting the difference’ is not appropriate.”Marsha Jones, executive director of the Afiya Center, a Dallas group that supports Black women with reproductive healthcare, said the lack of substantial progress was partly a reflection of the legislature’s misplaced priorities and lack of diversity.The Texas legislature is comprised mostly of white males: 61% of lawmakers in the House and Senate are white, even though white Texans make up just 41% of the population. Women are vastly outnumbered by men.“Black women are dying at an alarming rate for reasons that could be prevented and our state leaders cut down the main proposal that a state-appointed committee recommended to help them – why would that even happen?” said Jones. “I think it’s because it’s so easy to dismiss Black women’s lives.”The legislature expended time and energy on restricting abortion access, including passing one of the most extreme bans in the country, which allows any citizen to sue an abortion provider, as well as a “trigger” bill that bans the procedure in the event Roe v Wade, the 1973 ruling which safeguards the right to abortion, is overturned by the US supreme court.Both measures were “top legislative priorities” for the Senate leader, Lt Gov Dan Patrick, who did not make maternal mortality a listed priority.“It seems the only time we want to stand up and care about a life is when it’s in the womb,” Rose told Republicans on the House floor in May.‘Women are obviously choosing a life’In an ideological quest to punish abortion affiliates, Republicans have decimated the Texas reproductive health safety net by blocking low-income Medicaid patients from receiving life-saving preventative care at Planned Parenthood, a move resulting in reduced access to contraception and increased rates of Medicaid births, according to the Texas Policy Evaluation Project.A recent study in the medical journal Contraception showed a correlation between high maternal mortality rates and states that pass abortion barriers.“We have a maternal health crisis and conservative legislators once again made anti-choice bills a priority,” said Thierry. “They fail to realize all the women threatened by maternal deaths are obviously choosing life – they shouldn’t have to do so in exchange for their own.”Lawmakers made no significant gains for Medicaid in general. Texas is home to the highest number of uninsured residents in the US as well as the highest percentage of uninsured women of childbearing age, but it has declined to expand Medicaid under the Affordable Care Act and Republicans blocked legislative efforts to help extend healthcare coverage for the working poor.Texas has one of the steepest Medicaid eligibility requirements in the US. Of 1.4 million Texans who would benefit from expanded Medicaid, 75% are people of color.“Once again, we are kicking the can down the road with many of these solutions,” said Thierry. “It’s absolutely imperative we continue to work on reducing maternal mortality. One death is too many, especially when it’s preventable.” More

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      in Elections

      After 4 Years of Trump, Medicare and Medicaid Badly Need Attention

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      President-elect Joe Biden has pledged to “marshal the forces of science” in his administration. Undoubtedly he needs to start by bolstering the credibility of the Food and Drug Administration and the Centers for Disease Control and Prevention.But a third health agency, central to the lives of older Americans, low-income families and the disabled, is sorely in need of his attention. Science has also been under assault at the Centers for Medicare & Medicaid Services, which provides federal health insurance to more than 130 million Americans at a cost of more than $1 trillion, nearly twice the Pentagon’s budget.C.M.S. does more than just write checks for medical care. Its scientists and analysts determine which treatments should be offered — I am the chairman of the committee that advises Medicare on those decisions — and how best to care for the patients it serves.Unfortunately, the Trump White House has steadily eviscerated the agency’s dispassionate approaches to making those determinations.Recently, for instance, the Trump administration set in motion a plan to strip C.M.S. of its ability to assess for itself whether new medical devices approved by the F.D.A. are appropriate for the older patients it covers. This is important because the benefits and risks of such devices and procedures, which range from implantable hips and cardiac stents to digital apps and laboratory tests, can vary widely based on patient age and disability.The proposed rule requires Medicare to pay for any new device so long as the F.D.A. labels it a “breakthrough.” And that word does not mean what you think it does.The F.D.A. calls a device a “breakthrough” when it is expected — though not yet proved — to be helpful to patients with serious conditions. The designation has nothing to do with how the device works in older patients, or even if it was studied in that population at all. The proposed rule would also require Medicare to cover any new drug or device if at least one commercial insurer covers it for its members, even if its members are young and healthy.Already, companies seldom generate enough data on their products for C.M.S. to assess their value for its patients. In 2019, for instance, data was insufficient in just under half of new F.D.A. drug approvals to assess benefits or side effects in older patients. The proposed rule would drain the last remaining motivation that companies have to study their treatments in the patients who are likely to ultimately receive them.C.M.S. scientists and analysts do more than evaluate new treatments. They also test alternative ways to organize and pay for patient care. The agency has found, for example, that enrolling people at risk of diabetes in gym sessions reduced how often they were hospitalized. But some seemingly obvious ways to improve health care don’t work: C.M.S. also found it could not reduce hospitalizations for cancer patients by paying their doctors to actively manage their patients’ care.The fact that so many promising ideas don’t work as expected is the reason C.M.S. needs to double down on evaluations of how medical care is delivered to its patients.This administration has gone in the other direction. Just before the election, the White House conjured up a plan to send older people a $200 prescription drug discount card in the mail. Research has already demonstrated that if you give people money to buy prescription drugs, they will buy more of them. The pharmaceutical industry knows this, too. That’s why it hands out coupons worth billions of dollars.These same studies also show that when people are indiscriminately given cash for medicines — instead of only those who need that money the most — it costs much more overall than it saves. No wonder the discount card giveaway would have cost around $8 billion. Fortunately, the president has yet to follow through with it.In another troubling development, the administration announced on Nov. 20 that it would run an experiment in which reimbursements to physicians will be cut for dozens of high-cost drugs they administer in the office, such as chemotherapies and treatments for inflammatory diseases.C.M.S. financial analysts warned that the cuts will lead many Medicare patients to lose access to these important treatments. Scientists should evaluate this prediction by including a comparison group of patients whose doctors would not receive a cut in payment. But the agency administrator made it clear that she didn’t believe the warning. No comparison group is planned. That is no way to evaluate whether our nation’s vulnerable would be helped or hurt by this significant policy change.Another example of a poorly designed experiment involved taking Medicaid coverage away from able-bodied people who are not working or going to school, under an ill-founded theory that doing so would inspire them to seek employment. Such a study is best done narrowly, so that any harms are minimized. Instead, the administration invited multiple states in 2018 to test the outcome.A Harvard study found that a work requirement in Arkansas led to a rise in the number of uninsured people and no significant changes in employment. Thousands of Medicaid beneficiaries in Michigan and New Hampshire were set to lose their coverage before work requirements in those states were ended. Given those results, the overall program should have been canceled. The administration broadened it.Through its reliance on scientific evaluation of what it should pay for, and how, C.M.S. has remained financially viable for more than half a century. As the new president plans to fix the damage done by the current president, this vital agency demands his attention.Peter B. Bach is a physician at Memorial Sloan Kettering Cancer Center. He served as a senior adviser to the administrator of the Centers for Medicare and Medicaid Services in 2005 and 2006.The Times is committed to publishing a diversity of letters to the editor. We’d like to hear what you think about this or any of our articles. Here are some tips. And here’s our email: letters@nytimes.com.Follow The New York Times Opinion section on Facebook, Twitter (@NYTopinion) and Instagram. More