African-American women suffer a much higher level of maternal mortality than the national average, and Elizabeth Warren has proposed a bold — but high-risk — plan to incentivize hospitals to root out the institutional, systemic racism that produces these terrible outcomes.
Under Warren's proposal, hospitals that continue to produce higher-than-average levels of maternal mortality for African-American patients will lose funding; while hospitals that improve will get bonuses. As Warren tweeted: "Don't just observe and debate racism in health care. Make providers pay until this crisis is fixed."
I am 100% in favor of fixing institutional racism in health-care, and maternal care is a great place to start, but I'm really worried about this kind of plan.
Structurally, Warren's plan mirrors GW Bush's "No Child Left Behind" program, in which "underperforming" teachers and schools lost money, and teachers and schools that had improved test scores got bonuses. This produced terrible outcomes: teachers whose students scored poorly due to factors beyond their control (teaching in neighborhoods with high levels of unemployment, homelessness and discriminatory policing practices that locked up their students' parents) got less money to help the students who needed it the most, while teachers and schools that had structural advantages got money they needed less than their underperforming counterparts in worse-situated schools. And then there's the incredible incentive to cheat that these carrot-and-stick measures produce.
Even without cheating, there are lots of ways that hospitals can juke their stats: when Tony Blair started punishing hospitals whose ambulances took too long to arrive, the ambulance services responded with a raft of bizarre, terrible tactics. Blair's targets specified an eight-minute response time for "immediate life-threatening cases," so the ambulance services redefined "immediate life-threatening" to exclude many serious conditions; and ambulances were replaced with EMTs on motorbikes, who could reach their patients in less than eight minutes (but couldn't do as much for them as an ambulance crew). And then there was the predictable spike in ambulance dispatches whose arrivals were recorded as coming 7:59 after the call came in.
A lot of the hospitals with high African-American maternal mortality will be situated in neighborhoods where there are a host of discriminatory practices that harm mothers' outcomes: food deserts, racist police profiling, cuts to services, underfunded schools, high pollution levels and poor transit links. The hospitals in those neighborhoods need more money, not less, but a reform measure that only looks at outcomes and not wider circumstances will cut funding to those hospitals.
It may be possible to build a more holistic evaluation scheme that avoids these traps, and I'd like to see Warren's detailed proposal to see how she addresses them.
Speaking in Houston on Monday, the Massachusetts Democrat suggested that medical providers should be rewarded with "bonus" funds for reducing those numbers, which are three or four times higher than for white women.
"And if they don't," the presidential candidate said, dropping the carrot to wield a stick, "then they're going to 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."
Warren's plan, which she discussed for the first time at the She the People conference in Texas, was greeted with sustained applause in a room largely filled by women of color — a constituency that will likely be key in deciding the 2020 Democratic presidential nomination. The audience quickly warmed to the senator, then sent her off with a standing ovation as she rolled through her growing suite of detailed policy proposals. Perhaps more than any other candidate in the field, Warren has offered comprehensive plans to match her campaign rhetoric, a dedicated strategy her aides and allies believe will ultimately translate into success in the polls.
Elizabeth Warren rolls out plan to reward hospitals that make childbirth safer for African-American women [Gregory Krieg/CNN]
(Image: Luis Prado, CC-BY)