Trump’s Actions on Healthcare to Date

Medscape offered a good review of Trump’s initial executive orders regarding healthcare.  ben_franklinI’m not going to repeat the article word-for-word here — just recap the basic points and what they might mean for you:

  • They are largely non-specific recommendations, leaving actual implementation to each agency.  Since most of the new Cabinet heads aren’t confirmed as yet, this is going to play out over time.
  • The executive order could end penalties for not having health insurance.  That sounds good until you realize that it will drive up the cost of health insurance for everyone else.  The notion of risk pool is that healthy people balance out the ill.  If you allow people who don’t use much health services to withdraw from the pool, the cost burden is born by the smaller number of people remaining.  It’s simple math.
    • On notion starting to be discussed is the idea of a “high risk” insurance pool for people with chronic health conditions.  This was tried in a number of states in the past for both health and auto insurance and failed in both areas.  States discovered that they were on the hook for budget-breaking sums and the cost to individuals soared.  (See Politz article, in sources, below.)
  • States will be given greater latitude to determine who qualifies for Medicare and CHIP assistance and what assistance these programs actually provide.  That’s OK if you live in the Northeast or West Coast, and not so good elsewhere.
  • Health insurance will be sold across state lines.  That’s a questionable benefit:
    • It reduces the power of state insurance commissioners, which could be a good thing.
    • The impact on the actual cost of insurance is questionable.  Take New Jersey, for example.  Residents will have more policy choices available, but those policies now sold in Pennsylvania and New York have higher prices than New Jersey allows.  It seems unlikely that a carrier that sells in both NJ and PA will bring a lower priced policy from NJ to consumers in PA.
  • It will repeal taxes imposed on pharmaceutical companies and insurance carriers.

Bottom line:  The initial actions favor insurers and pharmaceutical companies at the expense of consumers. Health insurance prices will increase this year.  The Congressional Budget Office estimated that Trump’s actions would double the cost of health insurance over the next 10 years.  That may be an underestimate.

However, I don’t suggest running out to buy stock in these companies.  The theme over the last decade is that draining consumer wallets is a good way to bring the economy to a halt and, eventually, crash the stock markets.  It’s been done before.

It’s time to cut your expenses and save as much as you can.


Sources:

What you can do to improve your healthcare

Have you ever left a doctor’s office somewhat disappointed with your visit? Maybe you just spoke to a physician, but instead of having all your concerns addressed, you find yourself with even more questions? Do you ever wonder what doctors secretly wished patients would do that would make caring for you a smoother process? My purpose in writing this post is to do two things: to provide practical tips that you can use today that will 1) help prepare you for encounters you might have with the health care system in the future…whether it’s a routine doctor’s visit or an unexpected trip to the ER, and 2) help you make the most out of your interactions with your physicians. Therefore, without further ado…

via 5 Things Doctors Wish You Knew (that will empower you) — Musings of PuppyDoc

ACA Reform: the newest wrinkle

OK, it’s widely understood that “ethical Congressman” is an oxymoron if not an entirely extinct species.

Georgia Representative Tom Price is a Congressman.  He also invests iskunksn medical technology and pharmaceutical companies to the tune of about $300,000.  He also introduces bills and writes letters to regulators to help the companies whose stock he owns — boosting the value of  his own investment.   In turn, the companies donate to his re-election campaigns. (The Wall Street Journal first broke this story in December; CNN added new information today.)

Basically Tom Price is a poster child for “conflict-of-interest.”  Government is supposed to be “for the people”, not for your own wallet.

Price is also Trumps nominee for Health and Human Services Secretary and Trump’s designated leader on ACA reform.

If he’s leading the charge, just who is the real beneficiary of ACA reform going to be? 

In fairness, Price says that if he gets this new job, he will get rid of all of his stocks within 90 days.  However, he’s been in Congress for 11 years, with a consistent pattern of behavior.  That’s going to change overnight?? Plus ACA repeal reportedly will occur before he has liquidated his stocks, if it happens as promised.

Of course, the voters of Georgia share the blame for this mess. You elected someone five times who has consistently violated ethics rules.  How exactly does that work?   

Price’s original proposals for ACA repeal included the following five elements (quoted from NPR article cited below):

  1. Price’s plan offers fixed tax credits so people can buy their own insurance on the private market. The credit starts at $1,200 a year and rises with age, but isn’t adjusted for income. Everyone receives the same credit whether they are rich or poor. People on Medicaid, Medicare, the military health plan known as Tricare, or the Veterans Affairs’ health plan could opt instead for the tax credit to buy private insurance.
  2. Price advocates for expansion of health savings accounts, which allow people to save money before taxes to pay for health care. This includes allowing people who are covered by government health programs including Medicare and the VA to contribute to health savings accounts to pay for premiums and copayments. These proposals are included in Ryan’s plan.
  3. People with existing medical conditions couldn’t be denied coverage under Price’s plan as long as they had continuous insurance for 18 months prior to selecting a new policy. If they didn’t, then they could be denied coverage for that condition for up to 18 months after buying a new plan.
  4. The Price proposal limits the amount of money companies can deduct from their taxes for employee health insurance expenses. Companies can deduct up to $20,000 for a family health insurance plan and $8,000 for an individual. The goal is to discourage companies from offering overly generous insurance benefits to their workers. Ryan’s plan proposes a cap on the employer tax deduction but doesn’t specify the level of the cap.
  5. States would get federal money to create so-called high-risk pools under Price’s plan. These are government-run health plans for people with existing medical conditions who can’t get affordable health insurance on the private market. Critics say high-risk pools have been tried in as many as 34 states and largely failed because they were routinely underfunded.

Given that a Silver level ACA plan in NJ can cost upwards of $900 per month, a $1,200 annual credit doesn’t amount to much. And why should the credit be the same for a millionaire as for someone making minimum wage?  The pre-existing condition rule means that some people with long term health issues will be excluded from coverage. 

Finally, do Price’s ethics issues have anything to do with GOP efforts earlier this month to reduce or eliminate the independent Congressional Ethics Office? 

The Affordable Care Act (aka Obamacare) repeal is turning into a circus.  I’m sure there are more acts to follow.


Sources:

  • http://www.cnn.com/2017/01/16/politics/tom-price-bill-aiding-company/index.html
  • http://www.npr.org/sections/health-shots/2016/11/29/503720671/5-things-to-know-about-rep-tom-prices-health-care-ideas
  • http://ktla.com/2017/01/16/trumps-hhs-nominee-introduced-legislation-to-help-company-soon-after-investing-in-it-house-records/
  • http://www.msnbc.com/rachel-maddow/watch/ethics-questions-loom-over-trump-hhs-pick-rep-tom-price-839983683992
  • http://www.wsj.com/articles/donald-trumps-pick-for-health-secretary-traded-medical-stocks-while-in-house-1482451061

Healthcare: what you do need to do now

Donald Trump promised today that there will be “healthcare for everyone” after repeal of the ACA. He can actually do that very easily and cheaply, by cutting back the healthcare provided to “catastrophic” coverage. This category of plan exists today, but almost no one actively sells it because if provides very little value to the […]

via Healthcare: what you do need to do — CRAIN’S COMMENTS

Older Men and the Women Who Love Them, More — CRAIN’S COMMENTS

Cleaning out my mailbox, there was an article on this in Science Daily from earlier this year that’s important for older men and the women who love them to know. Low testosterone levels complicate recovery from hospital stays, according to a study from the University of Texas. Testosterone levels fall in men after age 40 […]

via Older Men and the Women Who Love Them, More — CRAIN’S COMMENTS

You are what you’re feeling, so feel happy!!! – The Effects of Negative Emotions on our Health — Be Like Water

Humans experience an array of emotions, anything from happiness, to sadness to extreme joy and depression. Each one of these emotions creates a different feeling within the body. After all, our body releases different chemicals when we experience various things that make us happy and each chemical works to create a different environment within the body. […]

via You are what you’re feeling, so feel happy!!! – The Effects of Negative Emotions on our Health — Be Like Water

Insurance for the disabled

This is a subject I’m working on now.

Insurers have no problem writing life and disability policies for healththlx3t6c8yy people.

However, getting insurance for someone who starts as disabled (e.g., autism, brain injury) is a challenge.  Certain states make that even more difficult.  For example (thank you Governor Christie), it’s illegal in NJ to write certain types of insurance for people on Medicaid.  If you’re poor, the state makes it harder to dig yourself out.

thzaeabdiqHowever, there are solutions.  As an agent, I have to dig to find them.  Most consumers wouldn’t know where to look.

Happily, I’ve always enjoyed doing research.  It’s my calling.

By the way, there are people who invest in life insurance at age 18, before there’s an opportunity for much to happen to them.  They’re smarter than I was.  If healthy, they have more options and policies are very low cost.

This is an insurance/health focused blog.  I have a related blog at “Crain’s Comments” (vlcrain17.wordpress.com) that addresses a range of additional topics in writing, finance, technology, science and medicine. 

Age and Perception

“I just can’t proof my own work.  My mind fills in what’s suppose to be there instead of seeing what is actually on the page.”

Have you ever heard anyone say that?  My guess is you probably have.  Heck, I’ve said that.

It turns out, there’s a physiological reason for this problem.  According to a new research report from the University of Arizona, the mind “inhibits” itself from auto-filling what one sees.  However, the ability to do this declines with age (1).

There are probably other factors that affect this ability to inhibit thoughts.  We just don’t know what they are.

Understanding this inhibitor and what affects its operation may explain a lot more than proofing mistakes:

  • The elderly have a very high incidence of slip and falls.  Is that because they don’t recognize obstructions when they see them?
  • The elderly are more prone to fall for scams.  Is that because they are slower to recognize signs of dishonesty?

What we have is a slowing of mental acuity independent of diseases like Alzheimer’s.  This slowing may have dramatic implications for healthcare costs for the elderly and for quality of life.  How we can slow or stop this decline requires further research because of its potential to affect so many households around the globe.

 


Sources:

(1) “Research shows how visual perception slows with age,” Science Daily, June 21, 2016.  https://www.sciencedaily.com/releases/2016/06/160621155010.htm

Choosing Doctors

This is an excellent article, which appeared in Medscape Week in Review on 24 May 2016.  It’s reprinted here in its entirety.  If even doctors are challenged in selecting a doc, how should the consumer feel?

—-

Choosing Between Two Doctors: One Physician’s Experience

Andrew N. Wilner, MD

|May 19, 2016

Introduction

Recently, a close family member—let’s call her “the patient” —needed a complex elective surgery. Her medical doctor gave us a few surgical referrals. We picked the one at the top of the list.

Luxury of Choice

The ability to choose one’s medical doctor is a luxury. Often, an accident or sudden severe symptom such as syncope or chest pain results in emergency transport to the nearest healthcare facility, where one is greeted by the duly assigned healthcare provider of the day. The relationship is forged on the basis of urgency and need, and both patient and doctor accommodate accordingly.

How to Choose?

But sometimes, one has the luxury of choice. Before entering into the sacrosanct patient-physician relationship, a patient can do due diligence regarding the physician’s training, experience, standing among his or her peers, as well as online reviews such as Yelp, where doctors are rated “like restaurants.” It’s not clear how useful all of this research is except to weed out the few bad apples who failed their boards and consistently receive one-star online reviews. But bad reviews tend to be based on long waiting times and snarky staff, not the doctor’s performance. A doctor’s competence, except in the most flagrant cases, is exceedingly hard to judge. Even a surgeon’s track record of successes and failures will be affected by the age, stage of illness, and comorbidities of the patients. A surgeon who only operates on “easy” cases might have a great track record. A more proficient surgeon who takes all comers would have a much worse record. Most doctors are capable, competent, responsible, and get the job done. But even capable, competent, and responsible doctors are not interchangeable.

Doctor #1

Our trusted doctor’s referral was sufficient endorsement, but I still did a background check that revealed an impressive website that included education materials, a patient portal, patient approbations, and boasted an affiliation with a nationally respected medical center. We made an appointment.

It was all uphill from there.

A few days later, the doctor’s office called requesting that we change the appointment. The secretary explained that she was using new scheduling software and had made a mistake. Could we come the following day instead? We were able to change our busy schedules to accommodate. No harm, no foul.

We were told to register ahead of time on the patient portal. We tried, but the passwords didn’t work. This was frustrating and took days to fix.

The Visit

We faxed records several days ahead of time and even brought hard copies with us. I had already made several calls to the doctor’s office to ensure that we were “in network.” We arrived early, as instructed, completed registration paperwork, consents, record releases, and more, then handed the records to the secretary. The doctor saw us on time, listened intently, and suggested further testing. These results would guide his final decision regarding which procedure to do. Upon review, his recommendations included many of the blood tests we already had. When I pointed this out, he seemed irritated and said that he didn’t have access to these. This was incredulous, as I had faxed them days ago and handed hard copies to his secretary just minutes before. He just shrugged and indicated that the consultation was over.

Who’s On First?

We went to another office where an LPN printed lab slips for the blood tests. I saw that there were new tests as well as some we already had. Perhaps the doctor wanted the same ones repeated? Even though this surgery was outside my realm of expertise, I observed that an entire panel of blood tests had no bearing on the problem at hand. When I pointed this out, the LPN filling out the forms agreed, cheerfully admitting that she had clicked the wrong box on the computer screen.

The blood tests had become a comedy of errors. The doctor had ordered additional tests that needed to be done, which were mixed with orders for blood tests that had already been done, combined with tests the LPN had mistakenly ordered. Sorting out this mess took more than an hour. That extra hour meant that we missed the 3 PM closing time of the blood lab and had to make another trip, resulting in more time off from work, frustration, etc.

A few days later, when we checked the results on the now functioning portal (the office never called), I saw that despite my arduous efforts, the same blood tests had been repeated anyway. In this era of high insurance deductibles that can run into the thousands and, indeed, tens of thousands of dollars, these errors would result in hundreds of dollars of out-of-pocket costs. To make matters worse, one of the original routine tests that had been normal was inexplicably abnormal on the unnecessary repeat testing. A third “tie-breaker” would now be required, inflicting more discomfort on the patient and consuming more time and resources.

It’s Up to You

When we returned for consultation, the doctor gave us the low down on the surgery. There were several options, all with varied degrees of success and risk, including death. He seemed loathe to make a recommendation. He insisted that it was up to us. This position was infuriating. Of course it was up to us. But it was up to him to make a recommendation. After I insisted, he reluctantly chose one procedure and said that if it was his family member, that’s what he would do. Based on the patient’s age, history, comorbidities, and testing, he estimated that there was only a 75% chance of success. I asked what we could do to improve the odds. He said, “nothing, it’s just luck.” When I added that as a physician it was very difficult for me to be on this side of the desk, he just smiled and nodded. He offered no words of encouragement or advice.

No More Questions

Immediately after we left the consultation room, I remembered an important question and tried to stop the doctor as he strode down the hall. He glared at me as if I should know that the consultation was officially over. Now, it appeared, I was invading his personal space and time. Perhaps I was, but I didn’t appreciate the glare.

Safety or Convenience?

The office assistant explained that the procedure would be done at the outpatient surgicenter at the nearby hospital, although often the doctor did the same procedure in his office. When I asked why we needed to go to the hospital, yet another foreign facility we would have to navigate, she explained that the doctor preferred operating there because they “turned over the room quickly.” (The answer I was hoping for was that the hospital setting provided better facilities and proximity to emergency services, should they be required, but that didn’t seem to be the doctor’s priority.)

Another Opinion? Really?

In the big picture, these were all small injustices; a change in appointment, a defective patient portal, some blood test errors, a receptionist’s perhaps mistaken perception of the doctor’s priorities, and my hassling perhaps an overhassled physician.

But I wasn’t happy and told our family doctor. What if the surgery didn’t go well? This doctor didn’t seem to care one way or another. Our doctor recommended another surgeon for us to try. Faced with the possibility of having to repeat tests, fill out more forms, register on another patient portal, and check benefits with our insurance company, the patient, who had been pretty tolerant of all of the above, wasn’t keen on getting another opinion. Wasn’t one opinion enough? What if the opinion was different? Would we need a third? She had a point. Nonetheless, I insisted.

Doctor #2

The second doctor had no opening in her schedule for months. However, out of professional courtesy, she would see us after normal office hours. I wasn’t enthusiastic about getting a complex consultation at the end of a physician’s busy day, but I appreciated the gesture. (A word of advice: If ever you need an appointment with me, first thing in the morning is best.)

The Doctor Did Her Homework

A few days before our appointment, the office called to say that the doctor couldn’t read a few of the many fax pages we had sent. I was impressed. Not only had Doctor #2 reviewed the records, she wanted to ensure that they were complete.

A Clear Recommendation

The day of the appointment, we arrived early as usual and filled out paperwork. We were told that the doctor was running behind. She didn’t see us until almost 6 PM. We were happy to wait, but I was concerned that the late hour might mute her interest in our case. Not in the least. Our consultation lasted until 7 PM. She patiently listened and reviewed the now voluminous records and blood tests. Nothing needed to be repeated. She acknowledged that there were several options but, without hesitation, made a clear recommendation. She would do the procedure in her office where she had everything arranged as she wanted it, including an anesthesiologist on site. It was true that there was risk for injury and death, but she had never seen these rare complications. She positively glowed as she advised that 3 out of 4 patients with this problem would do well.

Conclusions

The relationship between doctor and patient (and family) is intensely personal. Doctor #1’s office was disorganized with poorly trained staff who made many small mistakes. This did not inspire confidence. Nor did the doctor. He was professional but cold and dismissive. On the other hand, perhaps his technical skills, arguably a surgeon’s most important attribute, were superior to Doctor #2. We had no way of knowing. When it came down to it, the recommended procedure, risk for complications, and chance of success were the same with either doctor. No doubt Doctor #1 was correct—it would all come down to luck. But if we didn’t have luck, I knew which doctor I’d rather have at the bedside. Thank you, Doctor #2.

Note: Minor alterations in the details of the above true story have been made to protect privacy.

Drug Price Reform — When, Not If

Brand name drugs are expensive.  They’re more expensive in the US than elsewhere, but they’re still expensive, regardless.

Prices are based on a number of factors, including what manufacturers think they can get insurance companies and governments to accept.  List prices are paid by consumers without health insurance.  Insurers and government programs pay negotiated rates often substantially below list.

Prices are supported by patent and exclusivity laws that protect original manufacturers.(2)  The US is the leader in this, to the point that drug companies will discard work on promising medicines if they believe they cannot obtain patents for them.(1)  For US consumers, it means they pay higher prices than people in other countries for the same drugs from the same manufacturers.  Congress has also made it illegal for US consumers to buy drugs elsewhere and bring them into the US.

“The current model for cancer drug pricing is not sustainable and harms patients and families as well as our health care system.” (5)

“Americans with cancer pay 50 percent to 100 percent more for the same patented drug than patients in other countries. As oncologists we have a moral obligation to advocate for affordable cancer drugs for our patients.”(6)

Take GSK’s Advair inhaler as an example.  The cash price of the 500/50 version of the inhaler for a consumer without insurance in the US is between $560 and $600 for a one-month supply.(3)  The price for the same product in Canada is $84.00.(4)  Some US consumers with insurance will pay a higher copay than the cash price in Canada.  With Horizon Omnia, I was quoted a price of over $300 for this drug by the pharmacy department at Wegman’s.

Prices are becoming detached from research costs.  The price for insulin for the treatment of diabetes has tripled in the last decade, despite the fact that the product has been largely unchanged for decades.(7)  (Synthetic insulin was introduced in the US in 1982, following development in India.)

More increases apparently are pending.(9)

Some people are angry about pricing, and one country is finally taking action.  Colombia has ordered Novartis to lower the price of its leukemia drug, Gleevec.  If the company does not comply, Colombia has threatened to break the patent and issue licenses for production of a generic version of the product.  According to Fox News, members of the US Congress are involved in lobbying the Colombian government to protect the drug company.  US Senator Orin Hatch of Utah is one of the people named in the news report as having close ties to the pharmaceutical industry.(8)

Whether Colombia breaks the current pricing model, or it happens elsewhere, it’s just a question of time.  Current prices are artificial and based on government intervention in the markets, and not on free market economics.

However, that’s the paradox that some conservative politicians like to ignore:  one is against government controls unless the controls lead to higher profits for your friends.

 

 


Sources:

(1) Frakt, Austin. “How Patent Law Can Block Even Lifesaving Drugs,” The New York Times.  28 Sept. 2015.  http://www.nytimes.com/2015/09/29/upshot/how-patent-law-can-block-even-lifesaving-drugs.html?_r=0

(2)  “Frequently Asked Questions on Patents and Exclusivity.”  US Health and Human Services, Food and Drug Administration.  http://www.fda.gov/Drugs/DevelopmentApprovalProcess/ucm079031.htm#How%20many%20years%20is%20a%20patent%20granted%20for?

(3) GoodRX.com.  http://www.goodrx.com/advair-diskus?form=inhaler&dosage=500mcg-50mcg&quantity=1&days_supply=&label_override=Advair%20Diskus

(4) Canada Pharmacy Online.  http://www.canadapharmacyonline.com/DrugInfo.aspx?name=Advair+0042

(5) Fred Hutchinson Cancer Research Center. “Expert opinion on how to address the skyrocketing prices of cancer drugs,” Science Daily.  12 February 2016.

(6) Mayo Clinic.  “Oncologists reveal reasons for high cost of cancer drugs in U.S.”  Science Daily.  16 March 2015.

(7) University of Michigan Health System,  “Sugar shock: Insulin costs tripled in 10 years, study finds,”  Science Daily.  5 April 2016.  https://www.sciencedaily.com/releases/2016/04/160405122030.htm

(8) “Colombia battles world’s biggest drugmaker over cancer drug,” Fox News Health.  18 May 2016.  http://www.foxnews.com/health/2016/05/18/colombia-battles-worlds-biggest-drugmaker-over-cancer-drug.html

(9) Frellick, Marcia.  “17 Essential Drugs at Risk for Price Boost, Analysts Say,” Medscape. 19 May 2016.  http://www.medscape.com/viewarticle/863544?src=wnl_mdplsnews_160520_mscpedit_wir&uac=153634BV&impID=1103558&faf=1

C-Section Cons and Pros

TheVCphoto2 C-Section rate is an important criteria in selecting an obstetrician.  Neither the decision to do the procedure nor the choice of doctor are trivial, but they are related.

The C-Section is the most common surgery performed in the US.  The primary factor determining whether this procedure is performed is the doctor and hospital the woman chooses, and not medical need.(7)  The rate of Cesarean births was 4.5% when first measured in 1965; it was over 32% in 2014.  As of 2014, Louisiana and New Jersey led the US in the highest rate of C-Sections — over 38%.(7)

The increase in C-Sections hasn’t made childbirth safer for either pregnant women or the newborn.  The rate of maternal death in childbirth has doubled since 1985, from 7.4 to 17.8 per 100,000 births.(9)  However, there is a question about how much of this increase is real or do to changes in government reporting.(6)

The rate of newborn mortality in the US is slightly worse than the rate in Bosnia.  According to the CIA World Factbook, the US rate is 5.87 per 1,000 births (2015 estimate).  There are more than 50 countries with lower rates of newborn mortality, including Canada, all European countries, all Commonwealth countries, Singapore, Taiwan and South Korea.

A survey of new mothers in 2011-12 found several reasons for the increased use of C-Sections, including

  • Physician or hospital unwillingness to inform the patient about options
  • Hospital and doctor efficiency
  • Limited awareness of surgical risk
  • Blind faith in medical professionals
  • Doctors’ unwillingness to attend births in the middle of the night (4).

However, unnecessary C-Sections are expensive for insurers, resulting is a push not to do them.

In one case part of which I witnessed, a physician decided to delay a C-Section in the hope of a vaginal birth on a woman with a previous history of miscarriage.  That decision was catastrophic.  The placenta tore, the fetus died and the mother almost bled out.

Ultimately, the decision to do a C-Section should be based on medical prudence, and not on insurance, the doctor’s quality of life or hospital income.

What does birth cost?

Cost estimates vary wildly, depending on whether they focus on out-of-pocket expenses for the new parents or the total charge including what insurance pays, as well as by state.  (2)

How much the new parents pay depends on the kind of health insurance they have as well as any supplemental insurance.

What you can do?

If you are a loved one are involved in selecting an obstetrician, you need to quiz the doctor on how he/she makes decisions about doing these procedures.  If the doctor shows a clear preference for surgery in most cases, or expresses concern about insurance and costs, you need to find a different doctor.  The guiding consideration needs to be the woman’s medical condition and history, period.

Any “automatic” decision is probably wrong.  Even a carefully considered decision could be wrong.  There’s nothing trivial about these choices.

____

Sources:

(1) Almendrala, Anna.  “U.S. C-Section Rate Is Double What WHO Recommends,” Huffpost Parents.  http://www.huffingtonpost.com/2015/04/14/c-section-rate-recommendation_n_7058954.html

(2)”Average Charges for Giving Birth: State Charts.”  Transforming Maternity Care.  http://transform.childbirthconnection.org/resources/datacenter/chargeschart/statecharges/

(3)  CDC. “Births — Method of Delivery.”  http://www.cdc.gov/nchs/fastats/delivery.htm

(4) ChildbirthConnection.org.  “Cesarean Section.”  http://www.childbirthconnection.org/article.asp?ck=10456

(5) Haelle, Tara. “Your Biggest C-Section Risk May Be Your Hospital,” Consumer Reports. 13 April 2016.  http://www.consumerreports.org/doctors-hospitals/your-biggest-c-section-risk-may-be-your-hospital/

(6) Maron, Dina.  “Has Maternal Mortality Really Doubled in the U.S.?”  Scientific American.  8 June 2015.  http://www.scientificamerican.com/article/has-maternal-mortality-really-doubled-in-the-u-s/

(7) “10 states with the highest C-section rates,”  Fox News.  9 July 2014.  http://www.foxnews.com/health/2014/07/09/10-states-with-highest-c-section-rates.html

(8) Rappleye, Emily.  “The most common surgery in the world is often unnecessary — and this physician is out to fix it,” Becker’s Hospital Review.  16 May, 2016.  http://www.beckershospitalreview.com/hospital-management-administration/the-most-common-surgery-in-the-world-is-often-unnecessary-and-this-physician-is-out-to-fix-it.html

(9) Wallace, Kelly. “Why is the maternal mortality rate going up in the United States?” CNN.  11 Dec. 2015.  http://www.cnn.com/2015/12/01/health/maternal-mortality-rate-u-s-increasing-why/