Featuring Dr. Ana Malinow and Dr. Aleksandar Rajkovic: Women face unique challenges when it comes to accessing health care, whether it involves their reproductive health or caretaker burdens. Yet in many cases, the healthcare system fails them. When it comes to women’s needs, we’re calling Code WACK! on America’s health care.
This episode of Code WACK!, hosted by Brenda Gazzar, features Dr. Ana Malinow, a pediatrician and past president of Physicians for a National Health Program, and her husband, Dr. Aleksandar Rajkovic, an obstetrician and chief genomics officer, UC San Francisco.
How our healthcare system fails women — and what we can do about it
—– TRANSCRIPT —–
(Opening MUSIC – “Talk Back” 10 seconds, fade down)
Welcome to Code WACK!, your podcast on the state of America’s crumbling healthcare system and how Medicare for All could help. I’m your host Brenda Gazzar.
Today, we’ll hear about the unique challenges women face when it comes to accessing health care and how Medicare for All could help. Enjoy the story!
(MUSIC – “Talk Back” 10 seconds, fade down )
—– FEATURE —–
It’s a gloomy June morning. Dr. Ana Malinow rallies with activists outside the California State Democratic Convention in San Francisco. She has this message for House Speaker Nancy Pelosi.
Audio clip: “Nancy support Medicare for All.”
Pelosi’s about to deliver a major speech about reproductive rights to the Women’s Caucus after abortion bans recently passed in several states.
The activists are wearing patient gowns and flash fake bums at pedestrians while chanting “We’re barely covered, even under Obamacare.”
They’re supporting the new Medicare for All Act of 2019 in the House of Representatives. The bill would ensure that every U.S. resident has comprehensive health coverage in a publicly funded, privately delivered system.
So how would Medicare for All benefit women in particular?
Here’s Malinow, a pediatrician in San Francisco and past president of Physicians for a National Health Program.
Malinow: “So, it has been said that single payer is rarely framed as a feminist issue, and the truth is that organizations such as Planned Parenthood have not endorsed it, or have yet to endorse it, and I believe that health care is a human right and that single payer is an issue of human rights and there are many pressing reasons why single payer is actually a feminist issue.”
A Risky Calculation
So how does our current healthcare system in the U.S. affect women? Not having health insurance can create not only a fear of exorbitant healthcare costs but a risky calculation to delay or avoid care.
I spoke to Dr. Malinow’s husband, obstetrician Aleksandar Rajkovic, about a case involving a woman in Texas more than a decade ago. It still troubles him today.
Rajkovic: “She was a young woman who was expecting her first pregnancy, and she was relatively early in pregnancy but was experiencing some pains and although her husband wanted to take her to the emergency room, she didn’t want to go because she knew that they were uninsured and they were not able to afford the bills.”
“She was telling her husband that these pains are going to pass away and that everything would be fine, and she waited for about 36 hours with these pains…Finally, she became unresponsive, and he took her eventually to the emergency room where I was called to try to examine her and also we had a trauma team attend to her also because she arrived to the hospital with no pulse and very low blood pressure… And what we discovered is she had a ruptured ectopic pregnancy and bled to death.”
When Dr. Rajkovic asked the husband what had happened, he shared their fear of incurring bills of tens of thousands of dollars that would force them into bankruptcy. The husband soon realized they had made a mistake.
“He walked out of the hospital as a broken man.”
“That struck me as a really sad state of affairs, where people are afraid to go and seek help because they do not have the means, and they do not have insurance, and a life was lost because of that. That really did actually affect me significantly.”
So could Medicare for All have prevented this woman’s death?
Rajkovic: “Well, I think a system where individuals are aware that going to a health care provider or a hospital to seek care will not cause them bankruptcy would definitely have prevented this particular case.”
While working in Texas, Dr. Rajkovic also met pregnant women who were transferred by ambulance from private to public hospitals because they either didn’t have insurance or didn’t have the right insurance.
Rajkovic: “Well, the transfer clearly is not pleasant in many ways…Because the baby could be born in the ambulance, or there could be more complications during the trip.”
Women still vulnerable
While today the ACA mandates that maternity care be covered as an essential benefit, American women still remain especially vulnerable when they’re pregnant or have recently given birth.
Here’s Dr. Kathleen Healey, a retired ear, nose and throat specialist from Napa County, California. She’s also the co-chair of the Napa County Chapter of Physicians for a National Health Program.
Healey: “One of my friends is an ob/gyn. They get called to the emergency room frequently for women who are in labor who have no prenatal care. That’s most likely because they are undocumented or they don’t have access to insurance.”
“Our high maternal mortality rate in this nation, they have calculated that 60 percent of those deaths are preventable, and African American women have about 3 1/2 times the mortality (rate) of white women.”
What distinct challenges do women face when it comes to accessing high-quality, affordable health insurance? American women have borne a heavier burden in terms of healthcare cost, quality of life and personal independence.
Women are more likely than men to end up in low-paying jobs and less likely to be covered through their employers.
Meanwhile, women may have to take on part-time work to fulfill family obligations, but part-time jobs don’t offer the same level of benefits that full-time jobs do, according to Malinow.
Malinow: “First, women are much more likely than men to take on the role of caretaker, either of their own children or the elderly, such as their parents, and as a result they end up seeking more flexible employment. Right? And flexible here means more work and less pay. They end up relying less on the bedrock of our for-profit healthcare system, which is as we know employer-sponsored health insurance. Most people in this country get their health insurance through their employers. This is a health insurance system or healthcare system that is based on a capitalist system. It’s a for-profit profiteering system and very patriarchal.
“And now what does it mean for women who are caretakers? They are less likely to be employed in an industry that offers health benefits. And we can actually look at the trends. Companies with majority female workforce end up offering less generous health coverage, and the majority of low-income workers, of which women and especially women of color make up a large percentage, are offered health benefits less often.
“And importantly, women that live in states that did not expand Medicaid as a result of the Affordable Care Act… and our working poor, don’t have access either to employer-sponsored health insurance because it’s too costly for them and their families or to Medicaid because they likely make too much – which is in quotation marks — to qualify.
“To summarize, women, either because of their caretaking role or because they are poor or because they get paid less than their male counterparts, suffer.”
Malinow argued that this is partly because the system privileges those who work full-time in large and mostly unionized companies, which tend to be male-dominated.
While 89 percent of women up to age 64 have health insurance either through work, public programs or direct purchase, 11% have no health insurance at all. The percentage of uninsured men is even greater at 14%.
However, women use health care more often, report more chronic conditions, pay higher out of pocket costs, and have greater familial responsibilities that can complicate access.
We know that having healthcare coverage is why some women get married in the first place or remain married. But how did the Affordable Care Act, known as Obamacare, improve the system for women?
Malinow: “Amazingly, it actually extended health insurance to more women than to men, mostly because it barred health insurance from offering policies that discriminated on gender. So in the past, health insurance companies were permitted to charge higher premiums for women than for men.”
So before Obamacare, women were actually penalized for their gender? That doesn’t seem fair.
Malinow: “And it also codified something known as the 10 essential health benefits…Now it includes maternity care, newborn care, mental health coverage…And we know that women seek care for depression more than men. And it barred health insurance companies from disqualifying women from coverage due to pre-existing conditions, such as pregnancy.”
“And being a woman was seen as a pre-existing condition as well because of the potential of becoming pregnant. And so the ACA actually barred all of that from taking place and so that was good for women. Women had more health insurance and had better health insurance, although not necessarily more affordable health insurance.”
But the Trump administration has reversed some of the gains made under the ACA, according to Malinow. For example, there are new regulations which exempt employers and college health centers from offering contraception based on religious beliefs or moral objections. Prior regulations only granted an exception to houses of worship.
In addition, states can subsidize non ACA-compliant short-term plans, sometimes referred to as skinny or junk insurance, that cost less but can deny coverage for pre-existing conditions, prescription drugs, and even maternity care. These plans used to be limited to three months in the Obama era but now can be extended indefinitely, Malinow noted.
Malinow: “So we’re really going backwards.”
Who uses healthcare services more often? Women – and one reason is that they have babies – a critical function for a thriving society. Yet ironically – before implementation of the ACA – only 12 percent of health insurance policies provided maternity benefits.
Maternity & marital status
There are other challenges women in the U.S. face. I spoke with a lady in New York, a human resources manager and Australian immigrant, who gave birth to her daughter while employed in her previous job. She asked that her name be withheld.
HR Manager: “Partly because I grew up in a country where we had somewhat universal healthcare, when someone has a job, you don’t typically pay out of pocket a ridiculous amount of money. I remember with my first daughter, we paid, because I had an emergency c-section at the end of the day, we paid just for me I think more than 3 grand in hospital fees after the fact. And then my daughter, her hospital fees were around $1,500 so that was on top of our already covered insurance plan so that was all out of pocket that we had to pay. So we knew roughly that we were going to pay something. I just didn’t anticipate that type of bill.”
Several states, including California and New York, have some type of paid leave that parents can take after childbirth. But in most U.S. states, employees would have to apply for up to 12 weeks of unpaid family medical leave. And there’s a little-known catch for anyone who takes time off under the federal Family and Medical Leave Act.
An employer has the right to seek reimbursement of premiums it paid to keep an employee’s health insurance in place while they were on leave.
HR Manager: “If they don’t return after their leave ends, the employer can ask the employee to pay back all their medical premiums the company has paid during that time… I think it’s quite harsh. You don’t know what your mind is going to be like — post-natal depression, or your stress, or daycare ends up being more expensive than going back to work. You don’t know the situation you’re going to be in to then have to force yourself to go back to work for at least 30 days so you don’t get penalized. That’s something difficult for a lot of people to wrap their minds around.”
So how does women’s health compare to men’s? The data is clear. Women report higher rates of disability and compromised health.
Women are also more likely to delay or not receive care, or to not receive prescription drugs because of cost, according to the National Center for Health Statistics. And they’re more likely to have a health-care visit in a given year and to have a hospitalization or emergency department visit.
Another hurdle women face is that they often depend on their spouses for their health insurance. When the relationship ends, they may be left uninsured and with no means to cover themselves.
Los Angeles activist and organizer Lauren Steiner had long been separated from her husband when she was diagnosed with cancer about a decade ago. She was lucky enough to be getting health insurance through her husband’s job at the time.
Steiner: “So it was kind of a good thing that I was because had I gotten divorced at the time when we separated, I might not have likely purchased health care for myself, and you know thinking that I’m a very healthy person and I might have just taken a chance and just paid for my very few doctors’ visits out of pocket. So, when I was diagnosed in 2008, I was happy to have this health insurance, which was a PPO through Blue Cross, because I was able to get everything covered and as you know, cancer treatment is very expensive. And I was happy to stay on that health insurance and not get divorced and was happy that my ex husband was allowing me to do that or my still-husband but separated husband was allowing me to do that because in between that time, in Obamacare getting passed, I would have been a pre-existing condition and probably would not have been able to get my own health insurance.”
In fact, divorce leaves 65,000 women every year without health insurance, according to a 2012 study in the Journal of Health and Social Behavior.
So what would she have done had she been diagnosed with cancer and been uninsured?
Steiner: “I have some savings but it certainly would not have been enough for that treatment so I probably would have had to sell my house.”
And how did she feel that she was covered — and didn’t have to do that?
Steiner: “Well, it was a relief, that would be the only emotion I can think of, it was a relief that I had it.”
In short, women’s healthcare needs are often greater than men’s yet they face challenges in getting high-quality, employer-sponsored health insurance, meaning they may have to bear more of the cost for insurance, qualify for public assistance programs or go uninsured.
Even when women do have their own employer-sponsored plans, they could face a significant financial challenge if they decide they can’t return to work after taking family leave to have a baby or care for a family member.
Women who rely on their spouses for health insurance can be left vulnerable after a divorce and not be able to afford it.
Finally, not having health insurance likely contributes to poorer health overall.
Maternal death rates in the U.S. are among the worst in the developed world, with African-American women experiencing significantly higher rates.
Here’s Dr. Malinow again.
Malinow: “I think what we need and women need is a healthcare system that removes the power of health care away from their employers and their spouses and replaces it with single payer Medicare-for-All system that is unlinked from employment and from marriage.”
That means everyone would have health insurance, regardless of their employment, socio-economic or marital status.
(MUSIC – “Talk Back” 10 seconds, fade down)
Outro
Well, that’s it for today’s Code WACK!, a podcast by HEAL California. If you like what you’ve heard, please share, follow, and like us on Twitter and Facebook, subscribe to our email updates at HEAL-ca.org. This is a project of the California One Care Education Fund, and I’m Brenda Gazzar.
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