On this week’s episode, we discuss the hard issue of maternal mortality. Representative Michael Burgess joins to help us understand why mothers are dying in pregnancy and childbirth and what can be done to prevent it.
Rep Michael Burgess has served the constituents of the 26th District of North Texas since 2003. He is the most senior medical doctor in the house and has been a strong advocate for health care legislation aimed at reducing health care costs, improving choices, reforming liability laws to put the needs of patients first, and ensuring there are enough doctors in the public and private sector to care for America’s patients and veterans.
Transcript
Beverly:
And welcome to She Thinks, a podcast where you’re allowed to think for yourself. I’m your host, Beverly Hallberg, and on today’s episode we discuss the hard issue of maternal mortality. We’re honored to have on representative Michael Burgess to help us understand why mothers are dying in pregnancy and in childbirth and what can be done to prevent it. Representative Michael Burgess has served the constituents of the 26th District of North Texas since 2003. He is the most senior medical doctor in the house and has been a strong advocate for healthcare legislation aimed at reducing healthcare costs, improving choices, reforming liability laws, to put the needs of patients first and ensuring that there are enough doctors in the public and private sector to care for America’s patients and veterans. Representative Burgess, it’s a pleasure to have you on the program.
Rep. Burgess:
Well, thanks so much for having me on Beverly. Look forward to our conversation. It’s obviously when this timely and attracts a lot of attention.
Beverly:
Yeah. And when I first saw just the topic of today and what we decided to talk about maternal mortality, I’ll be honest with you. I immediately thought, “Well, is this something that happens a lot in today’s age?” I thought this was something of decades past, and that women just don’t die in childbirth very often, but obviously that is not true. So can you first of all, break it down as to how often it does occur.
Rep. Burgess:
Yeah. The number works out to, depending upon who you read, 17 to 20 deaths per 100,000 live births. And that’s why the number is small. So most of us don’t normally think about that in when we’re thinking about things that worry us or things that bother us. You don’t have to go back 100 years to a number that was startlingly high, 1,000 per 100,000 live births. And this is something I actually have thought a lot about during my training and when I was deciding what medical specialty to enter.
My grandfather was actually an OBGYN, I never knew him, he died in 1940. His death preceded my arrival by a significant number of years, but he chose the practice of obstetrics at a time when the maternal mortality rate was quite high. And he was of that generation of obstetricians where the dramatic reduction in maternal deaths began to be began to be realized. That was just prior to the introduction of antibiotics. The antibiotics obviously had a significant ability to reduce maternal mortality in the 1940s and 1950s.
But even prior to that, there was a recognition amongst people who practiced obstetrics, some of the things that might be done to make the practice a little less risky. I’ve always sort of held my grandfather, though I never met him, I never knew him. What a great amount of courage it took to undertake the practice of obstetrics at a time in the course of medicine, when things weren’t as… They weren’t as settled as they certainly were when I entered into the practice.
Now, my attention sort of was redirected in this area. There was an article published in one of the professional journals that I still receive and read up. Just for people’s background, I practiced medicine for 25 years in North Texas, practiced OBGYN and ran for Congress in 2002 and entered Congress in 2003. I’m not actively in practice, though I am still licensed. But probably, I don’t know? 2016, 2017 there was an article published in the Green Journal that suggested the maternal mortality rate had jumped and they actually pointed out how it jumped in Texas. That turns out there was a bit of a calculation problem with that. And there was a switch with how maternal mortality was viewed and reported starting in 2003, but it wasn’t consistent among the states, and it was a check-off method on a death certificate and not every state had the box to be checked. So there was some delay in getting all of the states to more or less the same place, and that led to some actual errors in the calculation.
But still, are you worried about a mathematical calculation, or are you worried about losing someone that you shouldn’t have lost? That’s really where I tried to focus that, and respective of the fact that there might’ve been an error in that calculation. One death is too many, and let’s focus on that, and let’s try to improve that.
Actually, was some significant work done in the last Congress, Jamie Herrera Beutler, who’s a representative from Washington State had a bill that… This was H.R.1318 in the last Congress, the Preventing Maternal Deaths Act. It was a little bit difficult going through this in the last Congress. There were some people who felt strongly one way or another, but here’s the surprising thing. Congress actually came together and got this bill passed in October of 2018. And it was signed into law by the president in December of 2018.
Pretty significant happening. I do not recall, and I’ve been here for a few years, but I do not recall a standalone maternal mortality bill passing and being signed into law. Sometimes it’ll be something added to an appropriations bill or something added to some other bill, but this was a standalone bill that dealt with the creation of maternal mortality review committees in allowing the tactical expertise and the grant funding for maternal mortality review committees to be developed in all 50 states. And it was a significant step. Texas had already gone down that road and started their own maternal mortality review committee. But look, there’s value in collaborations. There’s value in people talking.
Now, subsequent to that time, there’s been some additional work done on this. We haven’t yet passed a bill this Congress, but one that did pass out of committee and has since passed on the floor was H.R.4996. And this was an approach that every state of course where… Maternal care is covered under Medicaid. Obviously Medicare is a different population. Medicaid is a federal and state cooperation, cooperative agreement to help fund health care for people who are below certain income limits. And in the Medicaid program, in some states, there is a continuation of maternal care for the first year after delivery, in some states it’s only for the first 42 days.
What this bill did was allowed states a state option to continue that care for the full 12 months after delivery. And it was actually a bill that was paid for by… There was an offset that was found in the pharmaceutical rebates, which seemed like a logical thing to do, and so the bill has passed the House. It has not yet been taken up by the Senate.
Now, Texas individually looked at this in the last legislative session and decided not to expand to a full year after delivery. I’m not telling a state that they have to expand to a full year after delivery, I simply wanted to make it available to them. And again, it is done in a way that is fiscally prudent because it does have an offset, so it doesn’t add to the-
Beverly:
Right.
Rep. Burgess:
… kind of federal burden, but that’s sort of the state of play for right now. I will tell you this, and this is something that really concerned me. In this Democratic Congress the adversarial nature of things really was put on display. When this topic came up in our health subcommittee, and the statement was made that there is no more dangerous place in the world to have a baby than the United States of America.
And I thought that doesn’t sound right. I did my residency training. I did my postgraduate medical school training at Parkland Hospital in Dallas in obstetrics and gynecology. Yes, it was back in the 1970s, but at the same time, we took care of a population that was mostly minority, largely uninsured or under-insured, so a large Medicaid population to be sure.
And as I recalled from back then, our maternal mortality statistics were some of the best in the nation. I actually visited my old residency training program in August of 2019. And literally asked the question, “Is this something that you were encountering? Have your numbers become worse?” And they said, “No, our numbers are some of the best in the nation.” So just the argument that because someone is insured with Medicaid or uninsured, or just because someone is a member of a minority population, does not mean that the statistics are that you’re not going to do as well in having a child. Because again, a big city hospital in Dallas, Texas has been consistently able to do that over a number of years.
And I actually asked some questions. I said, “When I was a resident, I recalled, we used to have some various rules dealing with if there were a certain type of complication during childbirth, that it immediately triggered a series of responses.” They said, “Yes, absolutely. That’s the Parkland way. That’s how we still do it-
Beverly:
Right.
Rep. Burgess:
… and we’ve refined it so that it’s even more precise than it was when I was in training in the 1970.” I was actually encouraged by what I saw in, again, an institution that I was pretty familiar with. But at the same time, I saw that this was a problem that they took seriously. They addressed it seriously. And it does also tell me that the problem… We can reduce these numbers with attention to detail and good clinical training, it is possible.
Beverly:
Right. Well, let me ask you a little bit more about that. So you did mention the act in 2018, which is the Preventing Maternal Deaths Act, and that was signed into law. A lot of that was about sharing information across the country and the information we do have, and this is according to the Centers for Disease Control and Prevention. They say that 60% of maternal deaths are preventable. Can we get into the reasons why we are still seeing maternal deaths? Is there a trend within this? How much is happening during pregnancy versus childbirth versus even postpartum? Can you break that down just a bit for us?
Rep. Burgess:
Yeah. It’s a little difficult to get those statistics. Back in the 1970s, the historic triad for maternal mortality was uncontrolled hypertension, uncontrolled bleeding, and of course, infection still will always be on the list. Those were sort of the big three that were always of concern. As I looked at statistics more recently, there seem to have been some newer arrivals that were just as significant as far as numbers.
Suicide, for example, was reported as one of the principal causes of maternal mortality in the time period after delivery. Cardiac disease seems to have increased more so than what it was in previous years. And then a big one is opiod overdose. And we certainly dealt with that in a number of bills in the last Congress, and continuing to deal with that in this Congress. Have been a little bit harder with the imposition of the coronavirus, but certainly in the last Congress have recognized that opiate overdoses were a significant problem, and guess what? They affect this population just the same as everyone else.
Beverly:
And so what do you then say to a mother out there, let’s say somebody’s newly pregnant and they’re fearful for their life. What do you say to that mother about the steps that she can take to ensure not just the safety of her child, but the safety of her own life as well?
Rep. Burgess:
Well, bear in mind, this is coming to you with a bias of someone who practiced OBGYN for a number of years-
Beverly:
Right.
Rep. Burgess:
… so, I will say your most important research is on your physician. And it’s important to establish that relationship with a physician prior to getting the pregnancy and ensure that if there are any outstanding health factors, that those are mitigated, or at least managed prior to pregnancy. So somebody who brings hypertension to the pregnancy, for example, they possibly could have a more difficult time with hypertension during pregnancy. Superimposed preeclampsia on existing chronic hypertension have long been recognized. So you want to get that under control, or at least want to get that where it’s going to be observed more closely or managed more closely during the pregnancy.
A lot of times we don’t think about the hospital facility itself, but that’s important because the hospitals do have data and some of it is publicly available, and that is reasonable for someone to access. I think one of the things that impressed me in our hearings on this was there does seem to be some differences between hospitals. As I pointed up, my old hospital of training, Parkland Hospital has great statistics. There are other hospitals around the country that perhaps don’t enjoy those same great statistics, but Parkland manages to do it in the face of what might suspect would be some significant headwinds or difficulties of.
Low insured population, low income population, a high minority population, but they do a great job. It’s not the same to say that every hospital in the country manages that same degree of of safety. So that’s a significant factor. And this is one of the things where I think the Independent Women’s Forum has done some good work and pushing the concept of healthcare transparency. Yes, price transparency is important, but health outcomes information transparency is also important. And I think from a public policy standpoint, one of the things that I have really sought to push my entire time here has been the availability of data to the patient, to the consumer.
Beverly:
And there has been a growing trend and I don’t have the statistics, but a growing trend of women who were choosing to have home births. Based on your almost three decades in this area being an OBGYN, do you have any thoughts on the safety of home births and whether or not that’s something that women should take maternal mortality into consideration if they decide to go in that direction?
Rep. Burgess:
Well, certainly you’d want to have a conversation with your doctor and think about, are there anythings that would place someone at higher risk? Look, I’ll just tell you when things start to go bad in the situation, you don’t have a lot of time for course adjustments, and let’s go to plan B. Sometimes things happen very, very acutely, very, very quickly. I’ll be honest with you, I have not done home birth, so I’m probably not a good expert on that. I’m sure there are people who have experience with that who might feel differently. I was always on the receiving end if there were significant complications. And again, things can get very, very difficult over a very short period of time.
Certainly, at the very least make certain that all of the criteria for a healthy birth are met and you do that by a preconception or early pregnancy screening, and people need to be able to ask questions and get honest answers. Someone who brings a problem with hypertension into the pregnancy, someone who’s over or under ideal weight by a significant amount prior to the pregnancy, these would be reasons why perhaps the path of a home birth would not be the best selection.
Beverly:
And I’m going to change gears just a little bit before we let you go. I would be remiss if I didn’t ask you about the Affordable Care Act. The stat is that you have voted over 50 times to repeal the ACA, so you have strong opinions about this. I was hoping you could to give us a perspective into doctors. How have doctors navigated the past years of the ACA and what does it meant for them? And why do you, as somebody who worked for years as a doctor find that the ACA is not the direction you think that the country should go?
Rep. Burgess:
Well, let me just point out that many of those votes to repeal were actually bi-partisan votes. Most recently, the repeal of the so-called Cadillac Tax, the extra tax on employer sponsored insurance, the repeal of the tax on the medical device industry and repeal the tax on health insurance itself. Those were all bi-partisan efforts. There was creation in the Affordable Care Act of something called the Independent Payment Advisory Board, which became famous during the debates as the shorthand term was the death panel that actually got repealed and that was a bipartisan repeal.
When people do talk about the number of times that I’ve stood in opposition to the Affordable Care Act, some of those times that’s been bipartisan opposition, and I have a list of some 20 things that President Obama himself allowed to either not happen or not be enforced in the Affordable Care Act. Look, this is one of the things when you look at a big, big piece of legislation like this, it’s chutzpah to think that we’re going to get this right at the first pass is… I mean, no one really should think that. And a bill this large signed into law in March of 2010 has been altered and changed a number of times. Some by executive orders, some by just simply agency reaction and sometimes by legislation, but it would be… Again, to have the bill as passed in 2010, being rigidly enforced today would actually be unworkable.
From a physician standpoint, one of the biggest objections is the pressure for consolidation in healthcare, it’s always there. Insurance companies tend to form natural monopolies. Hospitals can have that same tendency toward consolidation and hospitals that acquiring medical practices is something that you’ve seen really increased during the time of the 12, 15 years that the Affordable Care Act has been the law.
And is this necessarily being a good thing for the practicing physician? No, not always. Has it been a good thing for the patient? No, not always. And to the extent that the Affordable Care Act was so restrictive and tended to… Chorus is too strong a word, but it certainly facilitated consolidation within the healthcare space. I don’t think that has really worked to any patients or physicians benefit. Look at the things that have had to be paused during the time of the pandemic just to get us through this. And one of the arguments I’ve made is we need to look at all of the waivers that have been given through the Center for Medicare and Medicaid Services. Waivers that allowed for reimbursement for telemedicine, for example, those things expire when the public health emergency goes away. We need to be certain that we think through that and if there’s good policy there that has developed, even in the face of something as devastating as the coronavirus pandemic, that we don’t let it expire and go back to status quo.
Let me just say this too generally, about the Affordable Care Act. Supreme Court heard the arguments, I think you’ve seen the reporting of the questions that were asked by the justices, the Supreme Court will not likely render its opinion until sometime in the next calendar year. So we’re a ways away from knowing what they actually decided, if indeed they decided anything.
My firm conviction has been that the Supreme Court is not going to be the one that changes this. And I think the court recognizes that this is a difficult task and it correctly in our system, in our system of divided government, it belongs in the hands of the legislative branch. And even some things that have been done by executive order, some of which I agreed with, but really, it belongs in the hands of the legislative branch. If they’re tough questions that we have difficulty dealing with, then constituents need to hold us accountable. But that is why our system is set up the way it is. These difficult questions and need to be handled legislatively, not through the courts. And the problem with the executive orders as we’re seeing, is those can be undone when the next executive takes office.
Beverly:
Exactly. The ACA and needing changes legislatively is something that we have talked about on this podcast. We appreciate your work on that Congressman Burgess, or should I say Dr. Burgess for the sake of this podcast, we appreciate all the valuable experience and insight you’ve brought to Capitol Hill over the years, and also for bringing that to us today on She Thinks, thank you so much for joining us.
Rep. Burgess:
Good deal. Thank you very much. I appreciate it.
Beverly:
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