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The Politics of Women's Health

National Health Care: Interview with Presidential Candidate Hillary Clinton

Conference Call with Laurie Rubiner, Legislative Director for Hillary Clinton, and Women's Health Activists

Discuss Clinton's health care plan at Our Bodies, Our Blog

Listen to the interview  

Interview Begins

Kiki Zeldes: I'm Kiki Zeldes and I'm the web editor for Our Bodies Ourselves, and I'll be moderating the call today.  And I want to welcome Laurie Rubiner, the legislative director for Hillary Clinton and thank her for joining us and answering our questions. 

Ms. Rubiner is a healthcare expert who worked for Senator John Chafee for many years and later served as vice president for public policy at the National Partnership for Women and Families.  In 2005 she returned to Washington to work for Senator Clinton and helped shape Clinton's healthcare plan, the full text of which is available at the Clinton campaign website.

In a minute I'll introduce today's participants, I just first wanted to note that Our Bodies Ourselves will be recording the call and will be posting the transcripts of this at our website, www.OurBodiesOurselves.org, and we'll also be making the audio available as well as a podcast.  And I also just wanted to add that we're all very excited to think that we may see some movement on women's health issues with the new administration.

I'm going to introduce today's participants in the order that they'll be asking questions. Our first person is Cindy Pearson, who is the executive director of the National Women's Health Network. We're also joined by Maureen Corry, the executive director of Childbirth Connection, and Byllye Avery, the founder of the National Black Women's Health Project, which is now called the Black Women's Health Imperative.  And Judy Norsigian, the executive director of Our Bodies Ourselves.  
Laurie, before we begin with questions, would you like to say a few words about Senator Clinton's healthcare plan? 

Laurie Rubiner: Sure, thank you Kiki, and I'm really thrilled to have this opportunity as well.  And let me just say that I am doing this as a volunteer, on my volunteer time, because I am a Senate employee, so I'm taking some time off to do this. 

Just in terms of Senator Clinton's plan, and Kiki sort of alluded to this, we're all really excited that we think there's a real possibility of something happening with this next president, and hopefully it will be Senator Clinton. 

But we're very optimistic that we can come to a consensus, and I think that the plan that she has laid out is one that she's been thinking about for a long time.  She's spent a lot of time talking to every different stakeholder in America with regard to healthcare.  She's talked to doctors, she's talked to patients, nurses, healthcare practitioners, consumers, and her goal was really to try to understand what the American public is thinking, where they want their country to go with regard to healthcare.  And I feel very excited about the plan that she's been able to come up with because I think it really addresses so many of the issues that so many of you struggle with every single day. I look forward to talking with you more about what's in the plan and answer your questions. 

Kiki Zeldes: Thank you.  Cindy, do you want to begin with the first question?

Cindy Pearson: Yes, thanks.  This is Cindy Pearson from National Women's Health Network.  I think that for women's health activists and women in general concerned about being able to get care if they don't have it now or continuing to have care if they have access now and looking to improvements in their care, probably the key question they would ask themselves is what's the difference between Senator Clinton's plan and between Senator Edward's plan.  So how could you describe that in a way that would be tangible and easy to understand for an average person?

Laurie Rubiner: Well, Cindy, I think the really good news here is that when you look across the spectrum of plans that are offered, at least on the Democratic side, there's more in common than there is different.  And I think that's actually a very good sign for the future of healthcare reform, because what it reflects is that there is a general consensus about the way this country should go with regard to healthcare reform.  There is a consensus between Senator Clinton and Senator Edwards that the program should be universal and both of them achieve that goal through an individual mandate that is distinguished from the Obama plan that does not have that element to his plan and so therefore would not be universal.

But there really is more in common than there is different.  But let me just, I want to back up a minute just to say something about women's health and medical care needs because I think that's a really critical issue that you raise, and it's a threshold matter.  And one of the things that we spent a lot of time thinking about as we were crafting this plan is: Who is it that we're trying to target?  Who are the uninsured and how are we going to best bring them into the system?  And I see this as one of the seminal women's issues of the 21st century, because the design of the healthcare system that we have today, which is essentially if you're not poor enough to qualify for Medicaid or elderly and qualify for Medicare, or you're not a veteran, you are left to the whims of a voluntary employer-based system where your employer can decide to cover or not to cover you.  And it is based on an employment model that is particularly outdated for working women.

I say that because it was designed around the post-industrial revolution when we were sort of the era of the company man and you were a man with a stay-at-home wife and children and you worked for the same company for 40 years, and you got your healthcare benefits through that company and you insured your wife and your children.  And that system worked then well for that model, but as we all know on this phone that's not the way our system reflects the way people work today, and we have far more women in the workforce, we have far more two-parent families working.  And as a result of the way our system is designed, women are disproportionately left out of the current voluntary employer-based system and that's because they're more likely to work part-time jobs that don't offer coverage, they're much more likely to work in the sort of low-wage jobs that also offer no coverage, and they're more likely than men to be covered as so-called dependents on their husbands care.  And, therefore, they're much more likely to become uninsured if their husband dies or they get divorced.

So one of the sort of very seminal premises of her plan was that your health insurance status should not be determined by your marriage status or your employment status, and that is a very outdated notion of how to provide such a critical benefit to millions of women across this country.

So, the first order of business, we felt, was to make sure that we get everybody into the system, and that includes the millions of women who are disproportionately represented among the uninsured, and her plan would do that.  And we had to make sure that the plan was affordable, that it provided quality coverage.  We had to make sure that there were reforms to the insurance laws that allow insurance companies now to deny healthcare to anybody who has a pre-existing condition or let's say women of child bearing age because they know that

Cindy Pearson: Well, Laurie, can I use that phrase as an excuse to interrupt you? Because we had several questions planned out and we know you have limited time, and rather than spend proportionately more time on generalities, I'd rather let the next questioner go on and get into some more specifics. Thanks for understanding.

Laurie Rubiner: Sure.  I think it was Maureen Corry who was

Maureen Corry: Hi Laurie and all.

Laurie Rubiner: Hi there.

Maureen Corry: It's Maureen Corry from Childbirth Connection in New York City, formerly known as Maternity Center Association.  Laurie, you probably saw the questions before so I'm going to shorten as much as I can to be quick so we can move onto other areas, but Childbirth Connection does most of our work around one aspect of women's health and that is pregnancy and childbirth.  And we're very concerned about what we perceive as quality problems in maternity care today, most associated with overuse and underuse, and the fact that care that is routinely given to most pregnant women does not appear to be evidence-based.  And we know that Senator Clinton is a great proponent of evidence-based medicine to help consumers and policy makers make informed decisions about healthcare. 

So we're wondering -- What is your current thinking on the focus on maternity care quality improvement, and what might you do as time goes on to address this issue, because it doesn't seem to be addressed at the national level?  Chronic care, chronic disease, and Medicaid-related issues certainly are on the top of the agenda, but we feel strongly that we've got to move maternity care up there, too, because of the four million women and babies that are born each year.

Laurie Rubiner:  Of course, and we couldn't agree with you more, Maureen.  Senator Clinton divided up her approach to healthcare into three parts and introduced three separate proposals on each.  The first was on cost, and she introduced a 10-point plan to bring down cost in the healthcare system.  The second was on quality and got to this very issue, and then the third was on universal coverage.  So let me talk a little bit about what she said in the second part of her approach, which was on quality.  You raise some very important issues, and they're not particular to maternity care.  I mean, this is across the board in our healthcare system we're seeing this problem of not using evidence-based care and therefore people having not necessarily the best outcomes or getting the best treatments, so she has a couple of different proposals that were outlined in her quality speech.

The first is that we have to help doctors stay current on the latest advances and techniques.  And doctors do have their own programs called Maintenance Certification Programs and these are programs that provide lifelong learning opportunities to help doctors stay up-to-date.  They're generally run by the boards of various specialties, so for example the OB-GYNs would run the one for obstetrics, and it's been proven that doctors who participate in these programs have better outcomes for their patients. 

So Senator Clinton's plan would lend the support of the federal government to these programs.  Not only would she offer higher Medicare reimbursement rates to doctors who participate in the programs, but she would also invest $125 million to help fund the work of a public/private quality trust to certify them.  And this trust would bring together people from across the healthcare system, doctors, patients, nurses, who will rigorously review the Maintenance and Certification Programs to insure that they're up to the highest standards.

The second is that she would create a best care practices institute which would be a public/private partnership to fund comparative effectiveness research and disseminate it across the country, and right now there is just so much of the information on which drugs, which surgeries, which devices, which treatments work best that either isn't researched, isn't compared, isn't published, or isn't circulated.  So this institute will serve as a central national clearinghouse so no matter where you are, you are and your doctor and your healthcare professional can access information on what the best treatments should be.

The third point is that we have to get patients better information.  We have to empower patients and make them informed consumers.  And so she has called for a comprehensive patient friendly quality database so that with a click of a mouse patients should be able to see which hospitals have the best care, maybe which hospitals have the lowest rate of cesarean section, which have the lowest infection rates, the most efficient policies, the shortest waiting times, etcetera.  She looked at what Dartmouth Medical Center is doing as a model.  The Hitchcock Center at Dartmouth is one that is really out in the forefront in these issues.  They are making sure that the information that patients get is understandable.  The Center for Shared Decision Making approaches medical decisions as a collaboration between patients and doctors.

Judy Norsigian:   Laurie, all of us actually are pretty close to those folks so we're very familiar with what they do. 

Laurie Rubiner: Excellent.

Judy Norsigian:   So I just want you to know that. 

Laurie Rubiner: OK, well then you know she took a look at what they were saying and said, "You know, we ought to take this on a national level."  And so she would model much of her proposal on what they are doing there. 

And then, finally Maureen, medical malpractice was one of the things that you raised in your question, which of course is a huge problem in the

Maureen Corry: Laurie, before you go into the malpractice, could I just ask one question related to what you said before about supporting Medicare reimbursement?

Laurie Rubiner: Sure.

Maureen Corry: One of the problems that we've identified is that Medicaid is a different animal, of course, than Medicare, and apparently it's a lot more difficult to address quality issues in Medicaid because of the 50 states involvement.  So what would be done there?  Because most births, I think Medicaid covers 41 percent of births in our country each year, so I'm just concerned that the Medicaid piece doesn't get left out.  And what would be a way of incentifivizing or insuring that Medicaid births were looked at from a quality perspective, and that reimbursement issues and all those things that you talked about would be part of that? 

Laurie Rubiner: Well, as you know very well the structure of Medicaid is a little bit different from Medicare in the sense that it's not reimbursed in that way.  It's a shared federal/state partnership.  So we would have to look at the degree to which the federal government funds each state's Medicaid program, and we could do that through, you know we did that in the CHIP program.  We found a way to use what we called an enhanced match to give states a little extra money if they do certain things.

So, for example, the federal government pays 90 percent of family planning of costs for states because we really want to incentivize states to provide family planning coverage to their patients.  We could look at the same kinds of changes in the so-called federal matching rate to provide the same incentives.  But certainly you are correct -- I mean absolutely we have to address the same issues in the Medicaid program and her goal would be to apply the same principals and the same quality measures to Medicaid.

Judy Norsigian: There's one other thing, before we move to the next question.  One of the things that's emerged in this field is that there are very good data and very good studies in a number of specific areas, and the practice, or shall we say the routine options, available to women don't always reflect the best evidence that we've got already available.  So it's not about conducting new research, it's about implementing what we know.  For example, the increasing trends towards denying women V-BACs is one specific thing that needs to be addressed because, of course, all the literature would support its being available as an option, and obviously it would help reduce the cesarean section rate because so many of the current cesareans are repeats.

Laurie Rubiner: Right.

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