Elizabeth Warren has distinguished herself in the 2020 field by continually releasing smart policy proposals, but on Wednesday, the Massachusetts senator stumbled. In a speech delivered at the She the People Forum, Warren lightly outlined a plan to address the inordinately high maternal mortality rates of black women. Warren suggested a financial bonus for hospitals that improve health outcomes for new black mothers. Hospitals that fail to do so, she added, will “have money taken away from them. I want to see the hospitals see it as their responsibility to address this problem head-on and make it a first priority. The best way to do that is to use money to make it happen, because we gotta have change and we gotta have change now.”
Black women are three to four times more likely than white women to die in childbirth, NPR reported in 2017. But the candidate’s plan could harm the very patients she seeks to help. Racial disparities in maternal mortality outcomes don’t begin and end in delivery rooms. Nor is the mere fact of a financial bonus enough for a hospital to overcome the structural challenges posed by segregation and an inadequate social safety net. Warren’s proposal sounds like common sense — why give money to hospitals with poor outcomes? — but it may have outcomes she did not anticipate. By penalizing hospitals that fail to meet certain outcome standards, Warren’s proposal could actually reinforce the very injustice she wants to solve.
Warren is right to identify implicit bias as a major contributing factor to rates of death for black mothers. As ProPublica reported in 2017, black women in wealthy neighborhoods — where hospitals are likely to be well-funded, high-quality institutions – are still much more likely to die from pregnancy complications. In 2014, black Americans comprised a mere 4 percent of the nation’s physician workforce, and medical school doesn’t root out racism from the psyches of their white colleagues. Medicine’s inequities result in concrete treatment disparities. “There’s significant literature documenting that African-American patients are treated differently than white patients when it comes to cardiovascular procedures,” Aaron Carroll, a professor of medicine, recently noted in the New York Times. Black patients with HIV or cancer are also more likely to receive suboptimal treatment.
But a financial penalty for low-quality care could overburden hospitals that already lack the resources they need to serve their patients. Hospitals in low-income areas are more likely to serve patients who lack health insurance. High volumes of uncompensated care can strain hospital resources, and put hospitals with a low-income service area at a disadvantage compared to hospitals in wealthier neighborhoods. These structural inequalities can disproportionately affect black patients in need of care. The more segregated a neighborhood, the more likely it is to experience a hospital closing, Vann Newkirk reported for the Atlantic in 2016. In New York City, public hospitals are in financial free fall as they struggle to bear up under the collective weight of funding cuts and high numbers of uninsured, underinsured, and indigent patients. That’s bad news for black mothers, who are more likely to rely on public hospitals for care. Cash-strapped hospitals can’t afford to lose further resources, and neither can their patients. There’s little evidence that financial incentives even improve patient outcomes. In 2017, researchers from the University of Michigan concluded that the one such incentive program — the Affordable Care Act’s Hospital Value-Based Purchasing Program — didn’t meaningfully reduce overall rates of patient mortality.
Instead, Warren may want to borrow some ideas from her fellow Democratic candidate, Senator Kamala Harris of California. Harris’s Maternal CARE Act, which she introduced in 2018, would fund implicit bias trainings for medical professionals, along with a pilot Pregnancy Medical Home program modeled after an existing statewide project in North Carolina. North Carolina’s version assigns a case manager to pregnant Medicaid beneficiaries at high risk for health complications. For the duration of a woman’s pregnancy, her case manager arranges transportation to and from medical appointments, helps her manage medications, provides 24-hour-a-day access to a medical provider, and if she’s eligible, refers her to programs like WIC. Financial incentives encourage physicians to enroll in the program and to maintain certain standards of care throughout a participating woman’s pregnancy, but it’s all carrot, no stick. And it works. In 2017, Pew reported that women who participated in North Carolina’s program were less likely to give birth to low-weight babies. Maternal mortality rates for black and white women in the state are now nearly even. That’s due in part to an increase in white maternal mortality, Pew said, but the Pregnancy Medical Home model also appears to have an equalizing effect.
North Carolina’s holistic model works by addressing the disproportionate burdens that black women bear long before they become pregnant. Compared to white women, black women are more likely to live in poverty, have inadequate access to preventative health care, and to suffer food and housing insecurity. Warren may address these disparities in future policy proposals; her student loan proposal, for example, showed sensitivity to racial disparities in student debt loads. She may also introduce a more thoroughly considered maternal mortality proposal at a later date. But if she does, she should consider racialized disparities in hospital funding, too. Carrots and sticks might work on donkeys, but public health is a bit more complex.