The Impact of the Affordable Care Act on Women’s Health, Broad Impact Health Careers, and HMS Course “Social Change and the Practice of Medicine”: A Conversation with Dr. Lois Lee

Interview by Minsoo Kwon

HHPR Associate Editor Minsoo Kwon interviewed Dr. Lois Lee. Dr. Lee MD, MPH, is a Senior Associate in Medicine at the Boston Children's Hospital Division of Emergency Medicine. Upon attending the Perelman School of Medicine at the University of Pennsylvania and the Harvard School of Public Health, she completed her residency and fellowship years at the Children’s Hospital of Philadelphia and Boston Children’s Hospital, respectively. She is now one of the leading public health and health policy researchers in the areas of injury prevention, particularly firearm-related mortalities, and women’s health. Dr. Lee is also a co-director of the Harvard Medical School Course, ‘Social Change and the Practice of Medicine.’ Dr. Lee continues to advocate for powerful social and public health policy change.

Most recently, Dr. Lois Lee published her perspective titled “Crossing Lines– A Change in the Leading Cause of Death among U.S. Children” in the New England Journal of Medicine. Readers can access this article for free from the NEJM site and also listen to an audio interview with Dr. Lee by visiting NEJM.org.

Minsoo Kwon (MK): During your journey to becoming a pediatric and emergency medicine doctor, was there a particular moment that piqued your interest in health policy research and inspired you to pursue your master's in public health?

Dr. Lois Lee (LL): I knew from around the age of eight that I wanted to be a doctor. I imagined being a doctor to be what most people think. You go to the doctor's office, and you see your doctor. It was only after I went to medical school at the University of Pennsylvania, where I met my medical school professors, that I realized, in addition to taking care of patients, you can also have a job where you teach and do research. So by the end of medical school, I decided I wanted to stay involved in the academic side. During my pediatrics residency at the Children's Hospital in Philadelphia, I was located in West Philadelphia, which is an area that is quite socio-economically depressed. Back then, children in Pennsylvania were not guaranteed health insurance. So we actually cared for a large population of children who had no health insurance. That was really my first time taking care of children who had acute health needs, because their parents could not afford for health care. And although I didn't realize it back then, it was those experiences that really influenced my ultimate interest in policy effects on health outcomes.

There's one story that particularly comes to mind. I was a resident working in the emergency department. A mother came in with her child who was very sick with asthma and was having a very hard time breathing. It turns out, the child had been breathing like this for a couple of days, but they had not come to the hospital. Although the child was prescribed an Albuterol inhaler (which is a common treatment for asthma), the mother had not given it to her. I didn't know at that moment, but I later found out that the mother had asked the social worker if there was a way for them to get free food. It turns out that the family did not have enough money to pay for both food and medicine. They had chosen food. You could imagine, maybe if she had been able to start her medicine the first day she got sick, she wouldn't have been hospitalized.

When I came to Boston to do a fellowship in pediatric emergency medicine, it was a very different climate because Massachusetts had actually passed legislation so that all children could have health insurance, regardless of parent parental income. I immediately noticed two big differences in the families I was caring for: 1) Families knew their pediatricians, and 2) patients didn't present to the emergency department because they didn’t have access to health care and medicine.

At that time, I had yet to launch my health policy career. However, I was really interested in injuries and injury prevention. And that's how I got into firearm injury prevention work that I do now. But as I was studying injury prevention, I realized that one big part of that is legislation. So, we were studying how legislation affects motor vehicle crash deaths and firearms. And this connection is what made me interested in how legislation can affect health outcomes on a much broader scale.

Even though I was about 15 years into my career, I decided I wanted to have more training on health policy. So I took a sabbatical year, and it was during that time that I did a Health Policy Fellowship and took more courses in health policy. I had already gotten a Master's in Public Health and Quantitative Methods, so I could do research. During this sabbatical year, I worked for Senator Sheldon Whitehouse, one of the Democratic Rhode Island Senators, as part of the health policy staff. It was during this Fellowship that I had the time to write my papers about the effects of the Affordable Care Act on women's health. Now, my interests are more broadly how health policy legislation affects health, not just for children, but also for adults.

MK: In your review titled “Women’s Coverage, Utilization, Affordability, and Health after the ACA,” you examined the effects of the Affordable Care Act on women’s health specifically. Could you briefly explain for readers why you chose to focus on the policy’s impacts on women specifically? Are there key contrasting factors between women and men who are seeking health care and access?

LL: Absolutely. This is definitely a topic that is very close to my heart. As a woman, I know how important women's health is–not just for the individual woman, but also for her children and family. As a pediatrician, I acknowledge that it's women who give birth to children, obviously, and women are very important in raising the child. And in many households, women are the sole provider and caregiver, especially in many single parent households.

Before the Affordable Care Act was passed in 2010, there were huge inequities in coverage of health insurance and health benefits for women compared to men. For example, being pregnant, and having your maternity care was not routinely covered in all health insurance policies. Sometimes they wouldn't be covered at all, or sometimes you had to pay extra money. Before the Affordable Care Act, many insurance companies could deny you coverage for pre-existing conditions. Those pre-existing conditions could include things like having been pregnant in the past, or having been a victim of domestic violence—immediately a major inequity between men and women. One of the major things is that even though you have the same insurance plan, and you're the same age, women could be charged higher premiums than men.

One of the reasons I wanted to do this study is that the early studies that looked at Medicaid expansion benefits did not particularly look at outcomes specific to women. These earlier studies would look at men and women, and they would kind of compare them in their first table, but they didn't look specifically at these outcomes for women. And so that's why I felt like the work we did was very important and kind of focusing on what were the discrepancies and specific benefits.

Now, the Affordable Care Act actually leveled the playing field for all of those factors. The ACA mandated that both private and public insurance policies had to cover maternity care. It made the premiums equal between men and women of the same age. It also prohibited denial of coverage for pre-existing conditions.

MK: Given that we've seen these very tangible, positive effects of the Affordable Care Act and its coverage expansions on women’s health, what do you think our next step should be in terms of continuing to push for insurance coverage, expansions, and improvements to healthcare access?

LL: I think the next step would be important for all states to expand Medicaid. As of January 2022, there are still 12 states, which have not expanded Medicaid. This means large healthcare disparities for lower income women, because it makes it harder for them to have access to health insurance, which is critical for access to high quality health care. Something that is being discussed in Congress is having continuous coverage postpartum for one year, after a woman gives birth. Past studies have shown there's this high degree of what we call insurance “churn.” So women who are not insured could become insured while they were pregnant. But then they only can have coverage for 60 days after the baby is born. But that's a high risk time for the mother as well as for the baby. So, key next steps include both states putting forward this legislation, but also Congress to try to mandate continuous coverage for at least one year postpartum for women. These efforts would address both potential medical complaints related to maternal morbidity and mortality, anemia, and postpartum depression.

MK: Is there anything else that you wanted to add in this conversation about women's access to and affordability of health insurance and health care?

LL: Yes, I think another important fact to point out, which you probably know, is that even though the United States spends the most money on health care among all industrialized countries, right, we have the highest infant mortality rate and the highest maternal mortality rate and our spending on social programs. We also know there are huge disparities in both infant and maternal mortality, both by race and geography. If you look at those 12 states that have not expanded Medicaid, most of them are in the Deep South. Those are the states that have the highest infant mortality and maternal mortality rates, particularly among the communities of color, especially among the black population. So I think this is a big issue that the United States is starting to grapple with. But I really do believe that expanding Medicaid, which would provide better insurance coverage and health care, is probably just one of many things that we'll need to do to try to decrease infant and maternal morbidity and mortality.

MK: Thank you. Currently, you teach a Harvard Medical School Course with Dr. Rebekah Mannix titled “Social Change and the Practice of Medicine”. And it's open to not just Harvard Medical School students, but also students at the College, Law School, or Graduate School. Could you tell us a bit about the genesis of this course?

LL: The course used to be an injury prevention and control course, and I was brought on to talk about injury prevention in children. But then the schedules actually changed at Harvard Medical School, and one year, they had a very poor enrollment and had to cancel the class.

So the following year, I asked the course directors if they were planning to revive the class, and they said no. So I was able to take over as one of the course directors with Dr. Mannix, who is very passionate about improving the lives of children through health and through policy. I knew she would be a perfect partner for this course.

In our first two years, we still focused on injuries, but we called it “Social Change, Injury Prevention, and the Practice of Medicine”. Then, during the pandemic, we realized that there is much more that we could do with this course, as there's just so many examples of how the practice of medicine and physicians have changed. That's why we broadened the focus of the course, and now call it “Social Change in the Practice of Medicine”. And because there were issues with enrollment in the earlier version of the course, when we found out that we could have students cross register, we thought, well, why not open it up to everybody?

What I’ve found that has been really interesting talking to our college students, is that many of them, like me, thought being a doctor was just taking care of one person at a time, which of course, is a very worthwhile and important career. But many students want to be able to do even more, and want to help more than just one person at a time.

To quote one college student, she said, “You know, I was thinking about going to medical school, but I didn't think that would allow me to make the larger changes that I want to in my career. Your class showed me how being a doctor, I can have a bigger influence. Now, I've definitely decided to apply to medical school.” I had not really thought about it from that angle. Hopefully, students in the course have realized that being a physician really does open up this whole world of possibility, as with that knowledge, you can drive social change.