In this age of the insanity of Trump, health care, for the wrong reason - the violent death of a health care executive - has once again become the focus of attention. A 2024 Gallup showed only 28 percent of those surveyed showed strong approval of their health care coverage.
The current health care system is dysfunctional. America, the richest country in the world, spends 20 precent of its Gross Domestic Product on health care, that is close to 5 trillion dollars a year, around about 14,000 dollars per person. That cost is double the average of the other rich countries with the worst outcome measures such as longevity, maternal and fetal mortality.
That doesn’t mean that America doesn’t deliver the most sophisticated and revolutionary management of disease. However the latter comes at a massive cost financially, and in the geographic distribution of where health care is available. Healthcare is not acknowledged as a right but rather a commodity to be bought and sold in the free market.
Jay H. Ell will not attempt to address the whole health care subject but will focus on one state, Texas, and one aspect of health care - women’s health and the factors that influence it.
The women’s health care situation in Texas was bad enough before Roe v Wade, which enshrined the right for women to control their bodies, was overturned on June 2022 and Is so much worse in December 2024. Now all the "red" States are exponentially worsening what is on its way to a full blown crisis in health care. None of this could have happened without the first Presidency of Donald Trump.
(There is one fact that has been neglected and cannot be overestimated in the current abortion debate, namely that abortion care cannot be differentiated from miscarriage care and the comprehensive ongoing care of women in general).
MATERNAL DEATH RATE IN AMERICA AND TEXAS
The maternal death rate in America is 32.9 per a 100,00 live births which is far higher than the world’s other rich countries where it is between 2 and 3. In America, California has the lowest mortality 4 per 100,000 and Arkansas at 43. 5 the highest. In fact it is most of the “red” states that are in the worst half with Texas at 28.1 percent.
As far as women’s health care is concerned Texas has been rated 50th out of 50 states by "The Commonwealth Fund”.
The Gender Equity Policy Institute noted that maternal death rate increased in Texas by 56 percent between 2019 - 2022. This compares with 11 percent nationally which also is indicative of sub par health care delivery. This is prior to the anti abortion legislation.There has been an increase in mortality in 2023 and 2024.
According to the Austin Community Foundation 80 percent of the maternal deaths in Texas were preventable. There is a racial disparity with African American women three times as likely to die then white women to have a pregnancy related death.
So what has Trump done to exacerbate the crisis in American and Texas maternal care to reach rock bottom?
PRESIDENT TRUMP
It is fair to state that sans President Elect Trump the constitutional right to an abortion until viability of the fetus, 23 weeks, would not have been overturned in June 2022. The 45th President's position has evolved over the years. From a lifetime supporter of a woman’s right to choose, in his 2016 campaign overturning this provision was the central plank. In addition he responded to Chris Mathews of MSNBC that women that seek an abortion and doctors that assist them should be “Punished”.
Trump promised to deliver Supreme Court judges that would do his bidding although they appeared unaware of this certainty at their ratification processes in the Senate. It is history that Trump's awareness of their judicial philosophy was vindicated. In litigation before the Supreme Court, which didn’t even ask for a complete revocation of the 50 year old precedent's Constitutional right to "privacy'"with regard to a women's right to control her reproductive decisions. The confidence in American Federal Courts where the Supreme Court garners the overwhelming amount of public exposure is according to Gallup, at its lowest point in memory 35 percent - on a par with the judiciary of Syria.
Trump changed his position in 2024 from an absolute abortion ban to declaring that “what everyone wanted - each state to decide”. He claimed further that he was, “the protector of women’s rights whether they liked it or not”. Nevertheless Trump nominated an anti abortion hardliner, Ed Martin to his staff. He believes that there are no, nada, nil exceptions for an abortion including saving a woman’s life or for a 10 year old pregnant as a result of incest.
What followed the revocation of the woman's freedom of choice in the “ Red” states, including Texas?
TEXAS LAW ON ABORTION POST JUNE 2022
Texas had passed “trigger” abortion legislation in 2021 in the event of Roe v. Wade being reversed. So on June 2022, Chapter 170A came into effect. The latter banned abortions “outright” then stated “except in certain circumstances”. This phraseology created chaos as the “circumstances” were to save a woman’s life. This judgement call has resulted in patients bleeding to death in car parks, hanging around till they were so close to death that the doctors’ were able legally to do an abortion.
There were several court challenges to Chapter 170A where the Attorney General of Texas, Ken Paxton has zealously pursued the law. The Texas courts to date have backed him. There are women that have come forward to explain their horrific experiences. Most that can afford it leave the state for care. Some have received the medication mifesterone, which can induce an abortion, by mail. Paxton has taken the unprecedented action of suing a New York doctor who prescribes the medications to Texas patients. A common medical practice since telemedicine has been practiced for years, especially important for under doctored areas. New York like 7 other States have laws to protect their doctors from any civil or criminal prosecution for their telemedical activities.
The sanctions for doctors performing an abortion In Texas are civil and criminal. Both can result in loss of their medical license and a 100,000 dollar fine. Criminally the practitioner can be jailed for 99 years. This has had a devastating impact on the providers of women’s health care which are detailed below.
But first who are these providers and what treatments do they carry out?
WHO ARE THE PROVIDERS OF WOMEN’S HEALTH CARE AND WHAT ARE THEIR AREAS OF CARE?
By and large women’s health, especially reproductively related, is managed by obstetrician/gynecologists,(Oby/Gyn). Their responsibilities includes pregnancies, where one in five end in a miscarriage, problems relating to pregnancy such as pre eclampsia which can cause fetal and maternal mortality and those who have co morbidities such as diabetes.
One of the many indications for a medical termination of a pregnancy is when there are serious abnormalities to the fetus which make continuing the pregnancy a risk to the mother and/or her future ability to fall pregnant again. There are several others relating to the pregnancy itself including heavy bleeding, complications whether they be mental, physical or social and of course major morbidities and death.
It is not surprising that on the Texas governmental website that they suggested seeking an attorney to help them interpret the law!
So what is the response of the practitioners to the Texas law?
IMPACT ON WORK FORCE OF TEXAS ABORTION LAW
Texas like most states is suffering from decreasing care generally in rural areas. The specialty of Oby/Gyn is very hard hit. In Texas 47 percent of the counties are “maternity deserts”
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Fifty - five percent of Texas’s Oby/Gyns are over 55 years of age. Twenty - one percent of all those practicing today are contemplating or planning to leave the State while 13 percent have decided to retire earlier. At worst it cuts the existing workforce by 34 percent.
The obvious answer is to replace some of those leaving. However in 2024 the applicant rate to the Residency training programs was 16 percent down. This can only get worse as the programs arrange for out of state rotations from 4 - 6 weeks for abortion care which is mandated by the professional body of Oby/Gyns. If it is not provided the residency won't be accredited.
The trainees have to by definition confront the chaos raging in Texas now. Their teachers have to be among the 76 percent of Oby/Gyns who believe that as a result of the Texas legislation they are unable to practice evidenced based care. The situation is exacerbated by the fact that 60 percent of the Oby/Gyns fear legal consequences as a result of their care of patients. Not surprisingly the residents are stating that this situation will impact on their decision as to where they will practice when they complete their training.
Dr. Anitra Beasley of the Baylor College of Medicine maintained that the out of state rotation was depriving the trainees of the comprehensive longitudinal management of patients that they need. She is worried about the quality of applicants that the programs are going to get if they don’t care that they are not receiving training that allows for longitudinal care of their patients.
THE EFFICIENCY OF HEALTH CARE GENERALLY
The number across the country that are insured has increased under the Affordable Care Act however the deductibles and co pays are still far too high. According to the retirees organization, the AARP, over 5 million patients were sent for collection in 2023. Health care costs are still the commonest reason for declaring bankruptcy.
There are also legions of complaints that private insurance companies are denying care. The Kaiser Foundation reported that 58 percent of patients had problems with claims.
Not only are the Health Care administrators paid obscene amounts so are hospital administrators sometimes with bonuses of 10’s of millions per year.
Despite the argument that the commercial agencies are more efficient their administrative costs are between 20 to 30 percent of their expenditure while Medicare, a government run program, similar costs represent 1.3 percent.
According to the Health Justice Monitor with regard to the of percentage of administration and clerical health care personnel per insurance entity the Government's Veterans Administration, (VA), insurance had the lowest 22.5 percent versus 29.5 for the others. If the VA's staffing policy was followed there would be 900,000 less non medical personnel needed in the health care industry.
AT THE END OF THE DAY
Texas like the rest of America is facing a crisis in delivering health care. The shortage of doctors in the discipline of Obstetrics/Gynecology is one aspect not to mention their distorted geographic distribution, and the high cost of care is another.
There is a prediction that abortion restrictions are just the beginning of the control of reproductive rights. Project 25 details further draconian legislation or Executive orders on contraception and IVF.
The upshot of the abortion restriction laws in Texas like in other “red” states is going to exacerbate the dysfunctional health care delivery system in the United States where a grand overhaul is needed.
Perhaps Elon Musk and Vivek Ramaswany would be better served not to pretend that there is a need to cut spending from government insurance programs. If it is efficiency they are after they should start first with the private health care systems.
Trump by nominating Robert Kennedy Jnr as head of Health and Emmet Oz as tzar of Medicare and Medicaid, is confirmation of his lack of care of Americans’ health.
What is the political impact going to be of all this when 70 percent of Americans broadly support the framework of Roe v Wade.?
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