Given the current political debate about healthcare coverage in the United States, the topic has been on the minds of many patients and providers, including mine.
I was one of the many providers who enthusiastically welcomed the Affordable Care Act‘s expansion of insurance coverage to millions of patients in the US. Despite the ACA bringing the uninsured rate to a historically low, about 9% of Americans remain uninsured, most of whom are members of low-income families.1 While we are still struggling to insure all Americans and at the same time are considering policy changes that would take insurance away from many, Mexico has achieved universal health insurance coverage with the implementation of Seguro Popular, a public insurance option.
However, in places like rural Chiapas, one of the poorest states in the nation, many barriers to care make the promise of true universal healthcare access difficult to achieve. Compañeros En Salud (CES), the organization I have worked with for the past six months, is committed to filling in these gaps between coverage and care.
One patient that highlighted the barriers to care in rural Chiapas was a 49-year-old woman pregnant with her ninth child. She received prenatal care at the CES clinic in Plan de la Libertad where I was working as a supervisor to the pasante (a physician completing the mandatory year of social service) in that community. This patient was severely anemic and, given her many prior births, had a high risk of complications including hemorrhage, which is the highest cause of maternal mortality worldwide.2 While lay midwives work with women in several communities, their experience and capacity is variable; in the case of an emergency in this rural setting, they often lack the materials and training needed to save the lives of a mother and her baby.
Under Seguro Popular, this patient should be able to deliver her baby in a hospital, which would greatly reduce her risk of complications. However, the reality is that for our patients, the journey to a hospital is blocked by often insurmountable barriers: lack of food for the patient and her family during their stay, few transportation options to a hospital many hours away, lack of funds to pay for lodging near the hospital prior to delivery, and mistrust of healthcare facilities due to historic mistreatment of women.
CES has worked hard to understand and overcome the many gaps that exist between health care coverage and true access to care. The Salud Materna (Maternal Health) program specifically addresses the barriers that exist for expectant mothers trying to reach maternity care through multiple interventions. The Salud Materna program provides vouchers for food and transportation for a patient and a support person, as well as free lodging in a maternal house attached to the hospital. They provide training in patient-centered, dignified health care to pasantes in an obstetric and perinatal nursing program to make patients’ birthing experiences positive. Finally, they support improved communication between providers in the community with those in the hospital.
CES is continually working to overcome barriers to care in the communities they serve in rural Chiapas, and have seen great success in terms of the number of women choosing to deliver in a hospital and being able to successfully travel there for delivery. While the barriers faced by patients in the communities CES serves highlight the fact that health insurance coverage does not equal healthcare access, universal health insurance is an important starting point that opens doors for patients. I hope that as our country continues to debate healthcare policy, we think critically about ways to increase health care insurance coverage as well as overcome barriers to improve access to care.
Say L, Chou D, Gemmill A, Tunçalp Ö, Moller AB, Daniels J, Gülmezoglu AM, Temmerman M, Alkema L. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health. 2014 Jun;2(6):e323-33.