How the U.S. Fails Women When It Comes to Health

Hi everyone! Welcome to The Dose. I’m Shanoor Seervai, and this episode is going to be a little different than usual. When I’m not working on this podcast, I also do research here at the Commonwealth Fund, and today we’re going to talk about a report that I helped to write. It’s about women’s health in the United States, and how this compares with women’s health in other developed countries.

Our guests are Munira Gunja and Roosa Tikkanen, both researchers here at the Commonwealth Fund and my coauthors for this study. Munira is an expert on health care coverage and access in the U.S., and Roosa is a pro when it comes to comparing international health systems.

Munira and Roosa, I’m so glad to have you on the show.

MUNIRA GUNJA: Thanks for having us.

SHANOOR SEERVAI: It was a few months ago, I remember we were sitting in a staff meeting, and Munira mentioned that she and Roosa were working on a report about women’s health. As soon as the meeting ended, I stopped her and said, wait, I want to help. That’s how I got involved, but it occurred to me when we talked about doing this episode that I didn’t know when or why you first decided to look into how women’s health in the U.S. compares with other countries. So take me back to the beginning?

MUNIRA GUNJA: Well, this is the Commonwealth Fund’s 100-year anniversary, and we wanted to do something to mark our history of addressing inequities in health care. The Fund has done a lot of work on women’s health — few people know that half a century ago, we funded the early research that ultimately led to the Pap smear. Today, this is a routine test for early detection of cervical cancer and saves thousands of lives each year.

SHANOOR SEERVAI: And more recently, in 2012 the Fund published a report similar to ours, comparing women’s health across developed countries.

MUNIRA GUNJA: Yes, but that was before we saw the impact of the Affordable Care Act. So in this report, we wanted to see if and how things have changed for women. The ACA has improved the situation for women in so many ways.

SHANOOR SEERVAI: How so?

MUNIRA GUNJA: It says maternity coverage has to be covered as part of your health plan, it limits out-of-pocket spending, and makes preventive care, including cancer screenings, free of charge. And of course, before the ACA, you could be denied insurance because of a preexisting condition — and pregnancy was one of those, so pregnant women had trouble getting coverage.

ROOSA TIKKANEN: For me, I found it fascinating that many of the ACA changes that Munira just mentioned are actually things that the other countries have had for much longer. For example, the Netherlands and Switzerland require all insurers — who are all private and nonprofit, by the way — to provide maternity care. And separate from that — this a topic important to me as a woman on a personal level. I’ve actually lived in many of these countries that we were comparing the U.S. to, including Norway, England, Australia, and Germany.

SHANOOR SEERVAI: Roosa, what did you find different in the U.S. from these other countries?

ROOSA TIKKANEN: Well, living in the U.S. was the first time I experienced being uninsured. Right after I had graduated from Harvard. To me, that was the biggest irony of all — a fresh master’s in public health graduate, having just spent nine months learning how unfair the American health care system can be — experiencing it myself.

SHANOOR SEERVAI: Wow, that must have been a real shock.

ROOSA TIKKANEN: Yeah. In so many of the other places I’ve lived, I was assigned a national health insurance patient number automatically, like when I moved to England, I was sent the name and address for my primary care doctor and my National Health Service number in the mail. Of course, I was lucky enough to not need a lot of health care, but everything I needed was always readily available to me and I never needed to think about how much it was going to cost me.

SHANOOR SEERVAI: This fear of costs is so unique to the U.S. in the developed world.

MUNIRA GUNJA: I agree. I have lived in the U.S. my whole life and work in this field and still find it confusing to navigate our health care system. I’m currently pregnant and it was incredibly difficult to first, find an OB/GYN that was in my network and accepting new patients, and second, to ensure the hospital my provider is affiliated with is also part of my plan’s network.

SHANOOR SEERVAI: And did you find an OB/GYN?

MUNIRA GUNJA: Yes, but now I am pretty terrified of receiving a surprise medical bill, despite the generous insurance coverage offered through my employer and despite the many calls to my physician’s office and the hospital billing department to ensure everything is covered. My husband and I even had to sit down with my OB/GYN just a few weeks ago to explain how important it is to us that I absolutely only receive a C-section if it’s a true medical emergency.

SHANOOR SEERVAI: I’m sorry you had to deal with that. From our findings, it doesn’t seem like women in other developed countries have to have those types of conversations with their OB/GYNs or midwives. Coming back to our report, I’m tempted to give away the punchline, but since I invited you both to be on the show, I’ll let you do the honors. What are the major takeaways about women’s health in the U.S.?

MUNIRA GUNJA: We found that U.S. women had the highest maternal mortality rate, and one of the highest rates of caesarean or C-sections, compared to women in 10 other high-income countries.

ROOSA TIKKANEN: They also had the greatest burden of illness, highest rates of skipping needed health care because of cost, difficulty affording their health care, and are least satisfied with quality of care they received.

MUNIRA GUNJA: But on a positive note, U.S. women had among the highest rates of breast cancer screenings, among the lowest rates of breast cancer–related deaths, and the shortest wait times to see a specialist.

SHANOOR SEERVAI: Now that we can look at all the findings in totality, did any of this surprise you?

MUNIRA GUNJA: I have to confess that I was surprised by the findings on emotional distress.

SHANOOR SEERVAI: So what we found was that one in three women in the U.S. report having emotional distress. This was much higher than women in most other countries in our report. For example, around one in 10 women in Germany or France reported this. Munira, why were you so shocked to see this?

MUNIRA GUNJA: Well, my research focuses on coverage, access, and affordability of health care. I don’t think about issues like emotional distress on a daily basis, but this is a barrier to achieving good health. So I found myself wondering, what is it about our lives here in the U.S. that makes women so stressed?

SHANOOR SEERVAI: Well, a huge source of stress is social — what health policy wonks call social determinants of health, like job security, education, child care, access to healthy foods, which often have a bigger impact on our health than the health care system.

MUNIRA GUNJA: Right. And we know that other countries spend a lot more on these “social” factors than the U.S. does, providing job and income protection, and guaranteeing the right to low-cost or free education — not to mention paid maternity and sick leave. So the emotional distress finding shouldn’t have been surprising to me. It was more of a “duh” moment: if people don’t have a strong support system, and if we don’t spend enough on getting them social services, of course we are going to have high rates of emotional distress.

SHANOOR SEERVAI: Makes sense. Roosa, what was surprising to you?

ROOSA TIKKANEN: Actually what surprised me, big time, was the fact that American women rated the quality of their health care the lowest out of all the 11 countries. I would have expected U.S. women to rate their care as high quality, in part because in the U.S. you can often go straight to see a specialist and don’t have to wait long to see one. And because of the more extensive use of the latest technology — for example, you get to ask your doctor to give you that new drug or treatment you saw in an ad on TV.

SHANOOR SEERVAI: Of course, this cutting-edge care may be unaffordable, so having all these choices can be an illusion.

ROOSA TIKKANEN: Right, and people in other countries don’t have that illusion of choice. They often have to wait to see a specialist, and once they do, they often have to comply with whatever treatment their doctor tells them they should have because that’s what their health system will pay for.

SHANOOR SEERVAI: So you thought that because Americans seem to have more choices and the latest treatments, U.S. women would rate their quality of care higher.

ROOSA TIKKANEN: Yes, but it seems like people in other countries are happier with the quality of their care — probably because they don’t have to pay an arm and leg to get it, and they have a peace of mind that they will get it, without having to fight insurance companies for their exorbitant medical bills afterwards.

SHANOOR SEERVAI: So in essence, we found that women in the U.S. are worse off than their peers in other developed countries in many ways. But has it always been this bad?

MUNIRA GUNJA: Actually, it’s better now than in the past. Before the ACA, being a woman was, in effect, a preexisting condition and in most states insurers in the individual market charged women higher premiums than men. Medicaid was only available to women with very low incomes, or who were pregnant, or had disabilities. And maternity care did not have to be covered in your health insurance plan. One 2012 study found that almost 90 percent of plans in the individual market did not offer maternity coverage and only nine states required insurers to include this benefit.

SHANOOR SEERVAI: That’s shocking. Remind me again, how did the ACA change things?

MUNIRA GUNJA: Most women in the U.S. now have guaranteed access to health coverage and 7 million working-age women have gained coverage since the law went into effect. All women with health insurance have access to birth control and free preventive services, including cancer screenings. And, of course, no woman can be denied coverage because they are pregnant, as insurers can’t discriminate against people with preexisting conditions.

ROOSA TIKKANEN: And this does actually bring us closer in line with women in other countries. We haven’t solved the universal coverage or affordability pieces here in the United States yet, but as Munira pointed out, the ACA has really helped to protect patients, that’s why it’s called the Patient Protection and Affordable Care Act, although it’s known as the ACA, or Obamacare.

SHANOOR SEERVAI: Okay, but we all know that Obamacare has been the source of political debate for much of the time since President Trump took office. And after it wasn’t repealed, the administration found other ways to change the impact of the law, like taking away the individual mandate penalty and threatening to remove the guarantee of coverage for preexisting conditions. So that doesn’t bode well for the gains we’ve made in women’s health so far.

MUNIRA GUNJA: No, it doesn’t. Early data indicate that the cost of health insurance will go up for those who don’t have subsidized care. We don’t know by how much, but this will be worst for women with health problems.

ROOSA TIKKANEN: And plans that don’t have ACA protections, like short-term plans, may be attractive to healthy, younger people who may then leave the individual market, making it a sicker and older, and therefore more expensive, market. And most importantly these plans don’t have to cover the 10 essential health benefits, like maternity care.

SHANOOR SEERVAI: On that note, I want to come back to one of the findings we brought up earlier, on maternal mortality.

MUNIRA GUNJA: Yeah, so we found that U.S. women had the highest rates of maternal mortality due to complications of pregnancy or childbirth, while women in Sweden and Norway had among the lowest rates.

SHANOOR SEERVAI: Why is maternal mortality so high in the U.S.?

MUNIRA GUNJA: There are a number of factors — inadequate access to preventive checkups during pregnancy, high rates of caesarean sections which is a risky procedure that is not necessary for most women, lack of prenatal care, and increased rates of chronic conditions like obesity, diabetes, and heart disease. There are also considerable disparities between black and white, rural and urban, and rich and poor women.

SHANOOR SEERVAI: Yes, it’s shocking that maternal mortality is three times higher among African American mothers compared to white mothers.

MUNIRA GUNJA: That rate for black mothers is similar with the maternal mortality rate in Mongolia, Mexico, Malaysia, and Brazil, while even white mothers’ mortality rate doesn’t come close to the 10 countries in our report. White U.S. women die from pregnancy and childbirth at a similar rate to women in Bulgaria, South Korea, and Saudi Arabia.

ROOSA TIKKANEN: All the 10 other countries in this study make sure that health care is available for all mothers regardless of insurance status or job situation or income, whereas in the U.S. access really depends on whether you have a good job or earn little enough to qualify for Medicaid or can afford insurance through the individual market.

MUNIRA GUNJA: Right, and here in the U.S., it’s important to remember that despite the gains made with the ACA, there are still women who don’t have access to any affordable health insurance options. For example, they may live in a state that hasn’t expanded their Medicaid program and do not meet the requirements to qualify for Medicaid through their state’s program. They may earn too little to qualify for subsidies through the ACA marketplaces. There’s over a million American women like this, with no affordable options.

SHANOOR SEERVAI: So what can be done?

MUNIRA GUNJA: Well, one step would be for the 17 states that have yet to expand their Medicaid programs to do so. That would make it easier for low-income people to access affordable care.

But in addition to some states not expanding Medicaid, the Trump administration has proposed changes to the Title X family planning program, which provides funding for wellness exams, cancer screenings, and counseling and services on family planning. This funding is crucial to so many women, particularly low-income women. But the proposed regulations would block federal funding to family planning providers that provide abortion services.

SHANOOR SEERVAI: And many women get routine care through these providers, like primary care or behavioral health services. So cutting back on their funding will inevitably reduce access to health services for a lot of women. And that will have a direct impact on women’s health, but I’m also concerned about some of the indirect issues — the so-called social determinants we were talking about earlier — I thought it would be discussing how pregnant women are treated in the workplace.

ROOSA TIKKANEN: Well, to me it’s striking that women in the U.S. often have to make a choice between work and family because there are so little workplace protections. Specifically when it comes to three things: paid maternity leave, subsidized childcare, and flexible work arrangements for when a child is sick.

SHANOOR SEERVAI: Okay, Roosa, tell me about the difference between maternity leave policies in the U.S. and elsewhere.

ROOSA TIKKANEN: In the U.S., women are guaranteed three months of leave when they have a child, but this is unpaid. In most other countries in our report, women are entitled to at least six months to a year, and this is generously paid. It’s positive that some states like New York have started to introduce paid maternity leave for everyone, and that some large U.S. employers do offer paid maternity leave up to six months, but three months unpaid is still the reality for most working mothers.

SHANOOR SEERVAI: And then what about childcare?

ROOSA TIKKANEN: Childcare is publicly subsidized in many other developed countries, which makes childcare more affordable, and encourages women to return to work after maternity leave. Here in the U.S., because childcare is not subsidized, it’s often so expensive — thousands of dollars each month — that it may sometimes even be cheaper for the family as a whole if the mother drops out of the workforce entirely.

SHANOOR SEERVAI: And without these workplace protections for women, employers can justify the fact that they treat women differently from men, the most obvious example being paying women less. So all in all, this really paints a grim picture, but let’s not forget that we also looked at some data that was positive news for the U.S.

MUNIRA GUNJA: Yes, that’s true — on cancer screenings. All women require lifesaving screenings for cancers that impact only women, such as breast or cervical cancers. Older women in the U.S. and Sweden are screened for breast cancer more often than women in most of the other countries analyzed.

ROOSA TIKKANEN: And we found that in many countries, higher rates of breast cancer screenings also translate to fewer deaths from breast cancer. U.S. women had among the lowest rates of breast cancer–related deaths, while having higher screening rates. In contrast, women in Germany had the highest rates of breast cancer–related deaths, while also having among the lowest rates of screening. Our report doesn’t get into whether this is direct cause and effect, but it’s clear that early screening is important.

SHANOOR SEERVAI: This reflects the high quality of cancer care delivered in the U.S., which is a combination of the extensive screenings, treatments, and technological advances we’ve made.

MUNIRA GUNJA: Yes, and that’s because of the emphasis on specialty care in the U.S. We found that U.S. women face fewer barriers to accessing specialist care relative to women in the 10 other countries analyzed.

SHANOOR SEERVAI: So the U.S. has good specialty care and cancer screenings — but is there anything the federal government can do to improve women’s health going forward?

MUNIRA GUNJA: Well, as we’ve discussed, the Trump administration’s actions could actually reverse some of the gains made under the ACA.

ROOSA TIKKANEN: But some states have taken some important steps to prioritizing women’s health care. For example, California actually halved its maternal mortality rate in less than a decade by putting in place simple measures to make giving birth safer. Today, their maternal mortality rate is just one-third of the national average — similar to Canada and Netherlands and actually lower than the rate in France and New Zealand. So this shows that as long as health care leaders choose to prioritize women, mothers, and babies, they can make a difference.

SHANOOR SEERVAI: That’s a great pivot, Roosa. And one in eight babies in the U.S. are born in California, so this makes a huge difference. But at a national level, how can we improve based on what some of the other countries are doing? Which of these lessons are actually implementable?

ROOSA TIKKANEN: Cost protections, for one. Making sure that all women have access to care, that they can afford, particularly when they are pregnant.

MUNIRA GUNJA: I think patient-centered care is a big one. That is, ensuring patients feel empowered about their health care, and are educated by their physicians to make informed decisions on their health. It’s also about coordinating and integrating clinical care with other support services and forming a relationship with not just their primary care physician, but with a social worker, and therapist, and nurse, and the whole community of people that are involved with care.

ROOSA TIKKANEN: Yeah, and coming back to maternal care, in most other countries compared in our report, all maternal care is free at the point of delivery and delivered in primary care or community-based settings by nurses or midwives, rather than by a specialist like an OB/GYN or at a high-tech hospital. In most countries, the nurse or midwife is responsible for care and has quite a lot of autonomy, for example they are able to prescribe medications. The OB/GYN only gets involved if there are complications.

SHANOOR SEERVAI: Does this make giving birth riskier in other countries?

ROOSA TIKKANEN: As we discussed earlier, it’s the opposite: the maternal mortality rates are lower in the other countries we looked at than in the U.S.

SHANOOR SEERVAI: And one of the issues that didn’t make it into the report is that other countries tend to rely more on midwives.

ROOSA TIKKANEN: Yes. The U.S. has one of the lowest numbers of midwives per capita, with midwives attending less than 10 percent of live births, while in the other countries included in our report this number is more than half. So I think that’s another aspect that the U.S. could import from other countries — engage more midwives in maternity care, both to lower health care costs as well as to reduce maternal mortality.

MUNIRA GUNJA: And we need to make sure that that runs through the life span of a woman from prevention, which includes contraception to when women are having a baby, to protection in old age.

SHANOOR SEERVAI: That’s a sobering note to end on, but it does indicate how much needs to change to improve health care for women in America. Munira, Roosa, thanks so much for joining me on the show.

MUNIRA GUNJA: Thanks for having us.

ROOSA TIKKANEN: It was a pleasure.