Elizabeth Warren Does Not Want to Take Healthcare Away From Underserved Populations
“We’ve done this in other areas of health care. Let’s do it here. If providers deliver quality care to black moms, they’ll make more. If they don’t, they’ll make less. Don’t just observe and debate racism in health care. Make providers pay until this crisis is fixed.”
Elizabeth Warren recently revealed a plan to make hospitals focus on increasing accountability in how Black mothers are treated by medical providers.
This plan has already come under attack by a piece in the Intelligencer under the argument that this plan would increase disparities in health due to its reliance on lump-payments. While it is noble to prioritize the care of Black mothers given the United States’ historical brutality towards and oppression of Black women, it’s an entirely different thing to spread harmful disinformation.
To be clear, this piece takes for granted that Black mothers have a much higher chance of dying during or after childbirth than women of most other races with the exception of Native American women, that this disparity in treatment remains unfixed across the board, with studies suggesting that a surprisingly large number of practicing doctors believe that Black patients experience their pain differently than people from different racial backgrounds, and that these ideas are unfortunately as ancient as they are pervasive.
The argument here is that both the presentation of Warren’s views on the model and the current research on the success of the model in the Intelligencer piece is unfounded, and the way the piece is currently written only serves to harm its readers’ understanding and support of healthcare policy change.
Activity-Based Payment Already Exists in Our Healthcare System
To start with the simplest misconception, Elizabeth Warren is not the first to propose the lump-sum payment model (also known as ‘activity-based payment’ or ‘ABC’). Movement to this ABC model is neither a focus of the Warren campaign nor has it been a focus for her career in the Senate. Bundled payments were proposed on a federal level as a part of the Affordable Care Act back in 2009 with implementation achieved in 2011 and already accounts for a portion of Medicare spending.
The piece that Warren adds to this admittedly wonkish, policy-focused conversation is a focus on racial health disparities. Given that ABC is currently trendy in the healthcare policy field, there’s value in adding a historically overlooked perspective and suggesting early implementation.
If lump-sum payments begin being adopted nationwide, a pre-emptive focus on black maternal mortality rates brings to the table one method of increasing equity in healthcare that is not currently considered by adopters. And while this conversation may be evident and popular in some circles, bringing this idea to a public without advanced degrees serves to undermine the criticism that there is no proof of racism when there so evidently is.
And They May Be Effective, Too
The Intelligencer piece also notes that lump-sum payments may exacerbate health disparities and cites one University of Michigan study, noting that this model did not improve outcomes.
However, the piece itself notes that its findings were not representative, concluding that “critics of health reform measures instituted in recent years should not be quick to call the value-based concept unsuccessful. Instead, they should work on revamping it.”
Additionally, the article points to another study which found a differently implemented version of the system was very successful.
In a broader view, because this model is relatively new and findings with regards to its efficacy are so system specific, it’s safe to say that there is no scientific consensus on whether or not the ABC system is effective.
But it is important to note that the worries of the Intelligencer piece, that there may be worse outcomes for Black mothers actually contradicts the preliminary findings of a number of research studies.
In one study, the payment model not only does not increase the financial risk to hospital systems, it also produces better patient outcomes. One systematic review of the literature concluded that activity-based care is overall more effective and efficient than the current rate-based model of care.
Additionally, rural and historically underserved populations are already experiencing the dramatic collapse in coverage that the piece is concerned with, a trend that has been growing in the past few decades. The current model is also the reason why for-profit hospital systems have been able to acquire so many rural care centers, who then proceed to acquire and relocate the assets of the buyout (ie the doctors and equipment), finally resulting in the closing of the clinic once they are deemed unprofitable.
Notably, it is the existing rate-based payment model that makes this issue worse, with policymakers suggesting that transitioning to the ABC model will help ameliorate the lack of care, not make it worse. One study by the Kaiser Family Foundation noted that one of the reasons why rural clinics fail was due to state policy that restricted them from being able to adopt the more efficient ABC system.
The Case Against Implicit Bias Training
The author cites Kamala Harris’ plan to introduce implicit bias training to hospitals in order to reduce disparities. While this may indeed be an additional tool, this ignores the mountain of evidence that the Implicit Association Test is not only ineffective at measuring someone’s ‘innate’ racism, it also ignores the criticism that training around these biases largely misses the point.
Without going too much into the weeds, the basic assumption that racism is some unconscious, innate trait that can be eliminated by training does not engage whatsoever with an intersectional, progressive view of race. To understand racism, individuals need to understand that not only is white supremacy the default cultural attitude in the US but that they themselves have both internalized it and are complicit in sustaining it.
However, implicit bias training posits that this is all unnecessary, that simply modifying our in-the-moment reactions to people from different racial backgrounds is enough to eliminate conditioned, learned behaviors and assumptions, as if individuals who undergo the training are blank, colorblind slates only needing a little tuning, ignoring the long history of institutional and cultural anti-Black racism that has been with this country since its founding.
Additionally, ongoing racial sensitivity training is already a part of the medical field, and, as recent high-profile incidents reveal, they have not been effective in teaching white medical professionals to take Black mothers at their word nor have they been effective in rectifying the issue of white supremacy in any corporate workplace setting.
While it is evident that the author and Kamala Harris both mean well, suggesting that a widely discredited, pseudoscientific method of eliminating racism is more effective than a financial incentive in a largely capitalism rooted society in eliminating racial bias is harmful.
Warren’s plan acknowledges ongoing health policy discussions and presents a grounded, realistic way of beginning the huge, generations-long project of reducing racial disparity in a society where it is pervasive. To castigate this plan as being possibly harmful when there is only evidence to the contrary and then to suggest an actually discredited if popular plan is irresponsible and unethical.