Vote, for Health's Sake

If you had on your political bingo card that our former President Trump would survive an assignation attempt, or that President Biden would drop out of the race a few weeks before being renominated for 2024, then you’re playing a more advanced game than I was (on the other hand, the chances that Trump would get convicted of felonies or that Biden would have a bad debate almost seemed inevitable). If we thought 2020 was the most consequential election of our lifetimes, then fasten your seat belt, because 2024 is already proving to be a bumpier ride, with more shocks undoubtedly to come.

Voting does matter. Credit: Bing Image Creator

I don’t normally write about politics, but a recent report from the Commonwealth Fund serves as a reminder: it does matter who you vote for.  It is literally a matter of life and death.

The report is the 2024 State Scorecard on Women’s Health and Reproductive Care. Long story short: “Women’s health is in a perilous place.” Lead author Sara Collins added: “Women’s health is in a very fragile place. Our health system is failing women of reproductive age, especially women of color and low-income women.”

The report’s findings are chilling:

Using the latest available data, the scorecard findings show significant disparities between states in reproductive care and women’s health, as well as deepening racial and ethnic gaps in health outcomes, with stark inequities in avoidable deaths and access to essential health services. The findings suggest these gaps could widen further, especially for women of color and those with low incomes in states with restricted access to comprehensive reproductive health care.

"We found a threefold difference across states with the highest rates of death concentrated in the southeastern states," David Radley, Ph.D., MPH, the fund's senior scientist of tracking health system performance, said in a news conference last week. "We also saw big differences across states in women's ability to access care."

Joseph R. Betancourt, M.D., Commonwealth Fund President, said: “Where you live matters to your health and healthcare. This is having a disproportionate effect on women of color and women with low incomes.” Dr. Jonas Swartz, assistant professor of obstetrics and gynecology at Duke Health in Durham, North Carolina agreed, telling NBC News: “Your zip code shouldn’t dictate your reproductive health destiny. But that is the reality.”

The study evaluated a variety of health outcomes, including all-cause mortality, maternal and infant mortality, preterm birth rates, syphilis among women of reproductive age, infants born with congenital syphilis, self-reported health status, postpartum depression, breast and cervical cancer deaths, poor mental health, and intimate partner violence. To measure coverage, access, and affordability, it looked at insurance coverage, usual source of care, cost-related problems getting health care, and system capacity for reproductive health services.

There are, as you can imagine, charts galore.

The lowest performing states – and I doubt these will be a surprise to anyone -- were Mississippi, Texas, Nevada, and Oklahoma. The highest rated states were Massachusetts, Vermont, and Rhode Island.

Just to round out the bottom ten states, they were Arkansas, Georgia, Alabama, Arizona, Tennessee, and Wyoming. You will, perhaps, notice that almost all are red (purple for Arizona and Nevada) states, and there is a significant overlap with states that did not expand Medicaid under ACA.  

"It's hard to stress how critical a source of coverage Medicaid is for pregnant women," Dr. Radley said. "Medicaid covers approximately 42% of all births in the US." Even though non-expanded Medicaid does offer more coverage for pregnant women, Dr. Collins noted that wasn’t enough: “It means that women enter their pregnancy having had less access to healthcare, particularly if they’re poor or low income. It’s pretty clear that having health insurance that’s adequate… is really necessary to access the healthcare system.”

Equally concerning, the report found that states with abortion restrictions “tend to have the fewest number of maternity care providers.” It details:

Of these 24 states, 21 have the fewest number of maternity care providers relative to the number of women who might need them. In 2023 and 2024, fewer medical school graduates applied to residency programs in states that banned abortion, both in obstetrics and gynecology and across all specialties, compared to states without bans.

Dr. Radley lamented: "Approximately 5.6 million women live in counties that are considered maternity care deserts."

It is worth noting that just three months ago the Commonwealth Fund issued another state-by-state report, focusing on racial and ethnic heath disparities, with many of the same low performing states showing up on that list as well. An overlay of poverty would track as well.

“These inequities are long-standing, no doubt,” Dr. Betancourt at the media briefing. “But recent policy choices and judicial decisions restricting access to reproductive care have and may continue to exacerbate them.”  I.e., the Dobbs decision overturning Roe v. Wade and subsequent state actions to restrict abortion access, which the authors say “significantly altered both access to reproductive health care services and how providers are able to treat pregnancy complications.”

It would be easy, and not entirely wrong, to blame all these on underlying social determinants of health (SDoH), but coverage of the Commonwealth Fund’s report introduced me to a related term that I think is equally to blame: “political determinants of health.” That term, as espoused by Daniel E. Dawes, points the finger directly at legislative and policy decisions.

“When you think of the structural conditions that many folks find themselves in, there is an underlying policy – political action or inaction – that has determined those conditions and structured the resources that has enabled those conditions to exist,” Professor Dawes told The Guardian.

The report grimly concludes:

Ongoing judicial action at the federal level, along with the potential for a policy reversal under the next administration, raise further concerns over the future of women’s health… Our findings suggest that urgent action by Congress and state policymakers is necessary to ensure women have timely access to complete health and reproductive care, regardless of who they are, what they earn, or where they live.

These findings, and a host of other reports on state-by-state disparities, shouldn’t just be of concern to women, or to people of color, or to low-income families. They’re not just something for clinicians to address. These are political issues that can impact us all.

SDoH can take decades to reverse, but political determinants of health get influenced in every election. It’s up to us to vote thoughtfully. So vote like your health depends on it – or like your mother’s, sister’s, or daughter’s health does.