The United States has a higher infant (and maternal) mortality rate than any other developed nation. Indiana specifically is the tenth worst state for infant mortality in the nation, and the third worst state for maternal mortality, which played an important role in the debates over Indiana’s partial abortion ban that was passed in the summer of 2022. Some medical professionals expressed concern that an abortion ban could exacerbate this long-standing problem. However, there are clear, long-standing issues in the healthcare system in Indiana as well as the U.S. at large that play a significantly more important role in determining infant and maternal mortality, and which could be addressed by interested policymakers.
Three issues: concentration of healthcare services, loss of autonomy, and price increases resulting from monopolistic healthcare practices
The biggest issue is a concentration of healthcare services. This is especially relevant in rural states like Indiana, as high levels of regulation and competition from better-staffed urban hospital chains make it nearly impossible for locally-owned hospitals to remain operational in large portions of the state. As a result, in Indiana, over 65% of counties are considered a primary care professional shortage area or contain a shortage population, while all but 10 of Indiana’s 92 counties are considered a mental health professional shortage area population.
[RELATED: Evaluating the cost-effectiveness of the Indiana Medicaid at-home care waivers]
As a result, residents of rural areas lose autonomy over primary care decisions, which includes obstetrics, and the lack of competition leaves healthcare costs to the whims of large corporations, some of which have been criticized for having disproportionately high costs, having a monopoly over primary care physicians, and a geographic monopoly over certain areas of the state of Indiana.
Concentration of services, loss of autonomy, and high prices all discourage primary care usage and contribute to the formation of obstetric deserts, which has caused an increase in infant and maternal mortality in Indiana and elsewhere in the country.
Possible Solutions
Since the Affordable Care Act encouraged hospital consolidation, and the Indiana legislature loosened restrictions on mergers shortly after the Affordable Care Act was passed, one possible solution to this issue is to simply ban hospital mergers. Policymakers could also greatly increase the requirements to obtain a certificate of public good allowing for a merger, and to take anti-trust action against monopoly hospital systems like IU Health that are found to no longer be acting in the public good.
However, more action would be needed to reduce the burden on rural community hospitals to make them more sustainable.
Community health workers, which are generally people trusted by a local community (e.g. a pastor) trained to provide for basic healthcare needs have been used extensively in low-to-middle income countries to address the challenges that come with rural healthcare. They have been especially effective in providing health education, essential newborn care, and psychosocial support. Health education, newborn care, and psychosocial supportwould all reduce infant mortality.
By providing grants for community hospitals and the Indiana Department of Health to train community health workers, they could reduce the burden on primary care workers in those areas, while providing much needed services to the communities with the highest risk for infant and maternal mortality.
Additionally, this would restore autonomy over health decisions to local communities as they would have pre-existing bonds of trust with those providing for some basic healthcare needs.
Finally, simply having a mandatory universal public insurance covering either primary care or catastrophic care costs for everyone could help reduce prices. Additionally, the federal government could convert EMTALA to a funded mandate, since it currently requires hospitals to treat patients who cannot pay if turning them away could cause harm without recompense (thus raising prices for everyone).
The former would reduce the strain on emergency departments, which take up a disproportionate share of hospital budgets. These departments are already harder to sustain in rural areas, partially because of a higher proportion of long-term underinsured patients.
Free preventative and primary healthcare would encourage underinsured and low-income individuals to treat health issues before they become an emergency, thus reducing prices for everyone, and increasing healthcare equity. This would also reduce the cost barrier to patients seeking obstetric care, thus improving maternal and infant health outcomes.
What’s Next?
Overall, supporting community-oriented healthcare, restoring healthcare autonomy to local communities, and reducing monopoly pricing would likely decrease the number of obstetric deserts in the state and the country. Doing so would increase both maternal and infant health outcomes, which should be a priority for both Republicans and Democrats in their respective governing bodies in the coming year, as healthcare costs continue to rise to unsustainable levels while government spending disproportionately increases compared to public health outcomes.
For further reading:
1. Tulloch, D. (2022). HPSA/MUA – Indiana Primary Health Care Association. Indiana Primary Health Care Association. https://www.indianapca.org/about-chcs/hpsa-mua/
2. Moberly, S., Maxey, H., Foy, L., Vaughn, S. X., Wang, Y., & Diaz, D. (2019). Scratching the Surface of Psychiatric Services Distribution and Public Health: an Indiana Assessment. The journal of behavioral health services & research, 46(2), 267–282. https://doi.org/10.1007/s11414-018-9626-7
3. Chen, X., Orom, H., Hay, J. L., Waters, E. A., Schofield, E., Li, Y., & Kiviniemi, M. T. (2019). Differences in Rural and Urban Health Information Access and Use. The Journal of rural health : official journal of the American Rural Health Association and the National Rural Health Care Association, 35(3), 405–417. https://doi.org/10.1111/jrh.12335
4. Goins RT, Williams KA, Carter MW, Spencer SM, Solovieva T. Perceived barriers to health care access among rural older adults: a qualitative study. J Rural Health. 2005;21(3):206–213.
5. Centers for Disease Control and Prevention. Health-related behaviors by urban–rural county classification—United States, 2013. MMWR Surveill Summ. 2017;66(5):1–8.
6. Freed, C. R., Hansberry, S. T., & Arrieta, M. I. (2013). STRUCTURAL AND HIDDEN BARRIERS TO A LOCAL PRIMARY HEALTH CARE INFRASTRUCTURE: AUTONOMY, DECISIONS ABOUT PRIMARY HEALTH CARE, AND THE CENTRALITY AND SIGNIFICANCE OF POWER. Research in the sociology of health care, 31, 57–81. https://doi.org/10.1108/S0275-4959(2013)0000031006
7. Mathews, R. (2001). Third Way to a Rural Revival. In The Chesterton Review (Vol. 27, Issue 1, pp. 240–243). Philosophy Documentation Center. https://doi.org/10.5840/chesterton2001271/2121
8. Democratizing Community Health. (2015, September 1). Retrieved September 26, 2023, from https://comment.org/democratizing-community-health/
9. Loftus, M. (2017, July 26). Creating a Just and Good Healthcare System. Retrieved September 26, 2023, from https://mereorthodoxy.com/creating-just-good-healthcare-system
10. Medaille, J. (2014). Toward a truly free market. Intercollegiate Studies Institute.
11. Gøtzsche, P. C. (2018). Patients not patents: Drug research and development as a public enterprise. In European Journal of Clinical Investigation (Vol. 48, Issue 2). Wiley. https://doi.org/10.1111/eci.12875
12. Ahmed, S., Chase, L. E., Wagnild, J., Akhter, N., Sturridge, S., Clarke, A., Chowdhary, P., Mukami, D., Kasim, A., & Hampshire, K. (2022). Community health workers and health equity in low- and middle-income countries: systematic review and recommendations for policy and practice. International journal for equity in health, 21(1), 49. https://doi.org/10.1186/s12939-021-01615-y
13. McCollum, R., Gomez, W., Theobald, S., & Taegtmeyer, M. (2016). How equitable are community health worker programmes and which programme features influence equity of community health worker services? A systematic review. BMC public health, 16, 419. https://doi.org/10.1186/s12889-016-3043-8
14. Ndambo, M. K., Munyaneza, F., Aron, M., Makungwa, H., Nhlema, B., & Connolly, E. (2022). The role of community health workers in influencing social connectedness using the household model: a qualitative case study from Malawi. Global health action, 15(1), 2090123. https://doi.org/10.1080/16549716.2022.2090123
15. Matsa DA. Does malpractice liability keep the doctor away? Evidence from tort reform damage caps. [May 15, 2007]. Available at: http://www.law.uchicago.edu/files/conf/malpractice/matsa.pdf.
16. Richard Scheffler, Arnold, Daniel and Whaley, Christopher. “Consolidation Trends In California’s Health Care System: Impacts On ACA Premiums And Outpatient Visit Prices.” Health Affairs 37, no. 9 (September 1, 2018): 1409–16. https://doi.org/10.1377/hlthaff.2018.0472
17. Cory Capps, David Dranove, and Christopher Ody. “The Effect of Hospital Acquisitions of Physician Practices on Prices and Spending.” Journal of Health Economics 59 (May 1, 2018): 139–52. https://doi.org/10.1016/j.jhealeco.2018.04.001
18. Hannah T. Neprash et al. “Association of Financial Integration Between Physicians and Hospitals With Commercial Health Care Prices.” JAMA Internal Medicine 2015;175(12):1932-1939.
19. Koch, T., Wendling, B., & Wilson, N. E. (2018). Physician Market Structure, Patient Outcomes, and Spending: An Examination of Medicare Beneficiaries. In Health Services Research (Vol. 53, Issue 5, pp. 3549–3568). Wiley. https://doi.org/10.1111/1475-6773.12825
20. Laurence C. Baker, M. Kate Bundorf, and Daniel P. Kessler. “The Effect of Hospital/Physician Integration on Hospital Choice.” Journal of Health Economics 50 (December 1, 2016): 1–8. https://doi.org/10.1016/j.jhealeco.2016.08.006
21. Batarseh, F. A., Ghassib, I., Chong, D. S., & Su, P. H. (2020). Preventive healthcare policies in the US: solutions for disease management using Big Data Analytics. Journal of big data, 7(1), 38. https://doi.org/10.1186/s40537-020-00315-8
22. What do You do When Patients cannot Pay? Psychiatry (Edgmont). 2009 May;6(5):51-2. PMID: 19724736; PMCID: PMC2719438.
23. Borsky, A., Zhan, C., Miller, T., Ngo-Metzger, Q., Bierman, A. S., & Meyers, D. (2018). Few Americans Receive All High-Priority, Appropriate Clinical Preventive Services. Health affairs (Project Hope), 37(6), 925–928. https://doi.org/10.1377/hlthaff.2017.1248
24. National Research Council (US) and Institute of Medicine (US) Board on Science, Technology, and Economic Policy; Aspden P, editor. Medical Innovation in the Changing Healthcare Marketplace: Conference Summary. Washington (DC): National Academies Press (US); 2002. 3, The Costs and Benefits of Medical Innovation. Available from: https://www.ncbi.nlm.nih.gov/books/NBK220598/