After T. went to sleep, I did some more reading on the VBAC Facts blog and it seems to be engaging in brownian motion with the policy theory in the medicare book. The author makes a number of points (sleep inducing, despite how interesting they are) about the interaction of the structure of policy and politics in the US and the changes (or rather conspicuous lack thereof) in Medicare over the decades since 1965. A big chunk of his thesis is that Congress is a policy making body in a way that is not the case in European states, and in a way that's deceptively hard for policy theorists to get a handle on. While Medicare is popular, it is poorly understood, so widespread political opinion and even interest groups in the public don't necessarily have a ton of influence year-to-year on Medicare policy, which means the "pros" wind up making a lot of relatively low-visibility decisions.
This is great analysis. Our rhetoric of "choice" by "informed" consumers/stakeholders/wtf is a fucking poor model for what happens with health care policy. I don't care whether you're talking about reproductive issues, screening tests, end of life care etc. Most people don't really know anything at all about these things. Even the people who are personally touched by these things (pregnant women, people going in for "annual" checkups, people trying to decide whether to buy long term care insurance and if so how much, people trying to find a nursing home for their aging relations, etc.) face a very NOT transparent industry and a steep learning curve.
I'm not arguing that justifies paternalism. Quite the contrary. What I am arguing is that we can certainly collect from stakeholders what their values are, assign a bunch of really smart people (ETA: including representatives of stakeholders) to spend all their time trying to find out everything they can about what the hell is going on in the industry, and then thrash out a compromise that does a decent job serving the respective groups. Which is to say, regulate the heck out of it. There are a wide variety of ways to do it (including NGOs, senate sub-committees, bureaucracies, etc.). We're trying some of them.
So when I see a post over on BlogHer justifiably complaining about a woman who was apparently denied health insurance because she had a c-section (particularly given the overly slice happy OB-GYN community in this country), followed up with comments about how maybe this will ultimately motivate women to fight harder to avoid c-section, I just want to smack someone -- and I'm not entirely certain who. Altho the MD who claims that homebirths don't reduce complications rates seems like a Real Good Candidate. I'm at this point old enough to strongly suspect that that MD (who, incidentally, is presenting as a woman) honestly believes the crap she is depositing -- just like ACOG's justification for their policy and attempts to legislate it in the face of resistance is probably not _consciously_ driven by a desire to have a stable and predictable schedule for their members with Christmas, Thanksgiving and regular weekends off.
I might be discouraged. After all, I can't tell whether the AMA's model legislation efforts against homebirths and cosleeping are an example of an ascendant power over-reaching itself and about to fall precipitously -- or an embattled interest group thrashing in its death throes (possibly prior to a phoenix-like rise from the ashes). I don't have any strong sense of whether things are about to get a whole lot better or a whole lot worse -- or go sideways in a conflicted and chaotic way, not unlike oil prices during this hurricane season. But I'm actually not discouraged. If the insurers and a lot of the customers are getting really peeved at the doctors, and there are legal action groups looking for people who got stuck with a section they didn't want looking to _sue hospitals and providers for banning VBACs_ (and there are -- I am not making this up), we could very well be looking at an effective counter to that particularly ill-judged ACOG policy against VBACs. _Especially_ since Healthy People 2010 is coming down hard on the pro-VBAC side, thus making the docs look like they've been completely isolated on this issue. If other countries did things the way we do, and midwives etc. didn't exist, this might not be enough. But our reproductive stats suck and other people do cheaper and better.
The OB gravy train has a few more years in it for sure, possibly even a decade or more. But I'm thinking ACOG must be feeling at least a _little_ embattled at this point.