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After Dobbs: The Impact on Underserved Communities

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The Dobbs decision has impacted communities that have historically been underserved by the U.S. health care system in particularly challenging ways. Delphine O’Rourke, Partner, Goodwin Procter LLP, speaks with Priya Bathija, Founder and CEO, Nyoo Health, about who these underserved communities are, how they are being impacted, and how legal counsel can advise clients who are working with these communities. Priya founded Nyoo Health to find new ways to deliver health care to women by providing strategic and advisory support, developing educational forums, and making critical investments in women.

Listen to all of the episodes in AHLA's "After Dobbs" series here. 

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Speaker 1:

This episode of ala Speaking of Health Law is brought to you by ALA members and donors like you. For more information, visit American health law.org.

Speaker 2:

Welcome to the a HLA podcast. After Dobs. In this session, we're gonna be focusing on the impact of the DOB decision on underserved communities. And it is my privilege to introduce Prya Batia, uh, to all of you. Although she is a very well known name in the HLA community, having, um, been with the American Hospital Association for many years before launching her new platform in October of this year, new Health. And I'd love to just jump over, jump and turn it over to, to Priya right away, to explain the meaning of new health. Um, what made her, you know, wanna become a founder and ceo, what new health is gonna be doing, because I'm sure many of us are gonna wanna call her and ask her for her, uh, advice both on the legal and consulting side, and the significance of the launch date sore. I am throwing a lot at you right at the beginning. I'm just so excited about it, and I think many, uh, members of our audience are going to be as well.

Speaker 3:

Thank you so much, Delphine, and I'm really excited about it too. And I'm looking forward to the conversation that we're gonna have today about Health Equity and dos. Um, and just wanna say a quick thank you to a l a as well for hosting this series, um, and allowing us to share some of the real implications of this decision. Um, so Delphine to, to your question, I launched New Health at the end of October, um, and I did it on Diwali, which is an Aus auspicious day for, um, new beginnings in my religion and culture. And new, which is spelled n y o o, is the phonetic spelling of the word new, um, which I chose for two reasons. Um, first, this is the new experience for me. Um, I have nearly 20 years of experience in healthcare. I've worked in with and four hospitals from so many different angles. But being an entrepreneur is a whole different kind of adventure. A um, and then more importantly, um, new Health's mission is to help find new ways to deliver healthcare and health to women. And I, you know, news, hoping to do that in three different ways. Um, first by providing strategic and advisory support, um, to startups, investors, providers, and anyone else that wants to grow and scale new approaches, um, to care delivery for women. And then secondly, by developing educational forums and thought leadership to really change the narrative around women's health. Um, and then last, um, new health will be making critical investments in women, um, as they advocate for themselves in the healthcare system.

Speaker 2:

Can you expand on critical investments? Are these gonna be financial investments? What are you thinking?

Speaker 3:

Yeah, so I'm really hoping to be able to develop education series and to work with other non-profits that are already doing great work in this space to help women have the tools and resources they need when they actually engage with the healthcare system so that they know, you know, what questions to ask, what information to bring, and really to address some of the medical gaslighting we've heard a lot about recently.

Speaker 2:

Thank you for that overview. And, you know, just coming from, from my perspective, so I'm a, a partner with Goodwin in our healthcare practice and lead of our women's health and women. If women's health and wellness industry practice and, you know, the strategic advisory supports so needed, particularly from your perspective, having been in health systems and really bridging that gap between innovation and health systems. And there is such a need for education. And this brings us to dos where I don't think a day goes by, I say other than Sundays with my family where I'm not advising on jobs and the impact in one way or the other. I mean, there are the obvious impacts of, um, restrictions on abortion, but the roof will effect has been much greater than that. We are, you know, six month in. And we've already seen how it has had an impact on our, our, you know, on, on access to care by both men and women, um, on attempts to find alternative solutions on concerns about primary care. It, it's the unintended consequences or unanticipated consequences have been vast. It really is an area of a lot of, a lot of confusion mm-hmm.<affirmative> for people who are in the space. And what we are going to talk about today really focus on is, you know, those patients, not lawyers, not experts in health, but really patients in underserved communities, which, you know, tangentially are discussed. You know, I read a, a quote recently that said, simply put, it will have a far reaching and devastating impact on equity and the wellbeing of women and families in underserved communities and those living with economic instability. You know, and what I liked about it is it's direct enough. I mean, it is going to be far reaching and devastating, um, not just for six months, for a year. Um, this is a long term obstacle. 75% of women who seek abortions have low incomes. 67% are women of color. And nearly 60% already have children that are trying to support abortions are one of the primary causes of maternal death in countries where they are illegal. And we know that we are ready in a maternal health crisis. Um, so we are, this crisis has only been exacerbated and, you know, love to dive into what we are seeing to help you mentioned educational opportunities and love to hear more about those during our time together in the future because there is such a need. So, you know, if you would start, you know, what is your impression? You are really deep into the impacts on underserved communities and what can you share with us to what you are seeing already and advising clients around?

Speaker 3:

Yeah, so Delphine, you know, from, just from a practical perspective, since the Dobbs decision, we've seen at least 13 states implement restrictions that make abortion access essentially non-existent. And then even more states have applied extreme limits. So, you know, just from a practical perspective, people, um, who are seeking abortion care in those states need to travel to other states or figure out how to obtain a medication abortion through the mail. Um, we're also seeing healthcare providers struggle to determine what pregnancy emergency care they can provide without violating newly enacted abortion bans. Um, and we're seeing this situation be exasperated by hospitals that don't provide comprehensive reproductive and pregnancy care across the country. And because of all of this, individuals aren't able to overcome all the hurdles that are being, um, put in front of them to get the care that they need. So experts, you know, have long predicted that, you know, this decision would have a tremendous impact on women's health across the country. And that includes things like a surge and unplanned pregnancies that may result in inadequate care, um, elevates elevated rates of pregnancy complications, um, and increased rates of preterm births and infant and maternal mortality. Um, so those are some of the predicted outcomes that we are probably gonna start seeing playing out in front of us. Um, but that's just a starting point. Um, research has also shown us that women who aren't able to obtain, um, abortions fair worse in their overall physical and mental health. Um, they're also economic considerations. Um, they're more likely to be unemployed or experience economic hardship and insecurity. Um, and those, those challenges aren't just impacting them. They're impacting them and their children and others that may be depending on them. Um, so what's happening here in the aftermath of the Dobbs decision really has the potential to widen our country's health, wealth, and opportunity gaps. And you mentioned this, and I know we're gonna dive more into this in the podcast, but, um, the DOS decision really is having a devastating impact on equity, um, and the wellbeing of women and families in underserved communities, um, and those that are low income or living with economic instability. So just, you know, I was gonna refer many to many of the statistics that you already touched about, um, who are seeking abortions now. And, um, we can, we can talk a little bit more about that later.

Speaker 2:

A lot of conversation around employers and employers providing, you know, access for reimbursement, for travel for, but the reality is that for millions of women in the United States, that's not even part of a conversation. I mean, going to another state, even if their employers are, are, are not paying for it. It's just not an option. So as much as its a, a challenge for many, um, and, you know, it's their, you know, women with means can travel to another state, can take the time off, and it's just not an option for millions of women. So as much as, you know, I hear that and, and people propose that as one of the solutions, it really is a solution for a very small percentage of women in the United States. You know, what are women doing? Um, the idea that women are just not having abortions is, is frankly unrealistic. Mm-hmm.<affirmative>, um, you know, are you seeing groups of women trying to go to other states? What are you hearing about?

Speaker 3:

Yeah. So Delphine, if it's okay with you, I'd just like to maybe take a step back to what you were talking about before the question in terms of, you know, women with means are still gonna be able to get the abortions they need and the women who don't, will not. Right. And so I think what we will see in the aftermath of this decision is that the people who are most hurt by the decision are those individuals that already face barriers to accessing abortion care. So that includes black, indigenous and other people of color. Um, those who are low income and struggling to make ends meet, um, the LGBTQ plus community, um, immigrants, young people, um, those living in rural communities and, um, people with disabilities. And I can dive into each of those a little bit more to talk specifically about, um, you know, how it's impacting them. But I think when you want, you know, when you look at what women are doing, um, there are women that just are not going to be able to get, um, access to abortion care because of the limitations that are placed against them. Um, but there are a lot of organizations that are working together in partnership to help ensure that women have access to reproductive care. Um, and I'll just use Illinois as an example, right? Um, we are the only state in this area that allows abortions to take place. Um, so every state that borders Illinois has either banned abortion or is expected to ban it soon. Um, and so people are traveling across straight lines to access care in Illinois. And you know, I read a lot of news articles about this, you know, living in Chicago and people are referring to Illinois as an abortion oasis. Um, there's one clinic in southern Illinois that has become a destination for people from all over the country. So they're getting people from neighboring states like Missouri and Indiana, but they're also seeing patients come from Ohio, Arkansas, Louisiana, Mississippi, Alabama, Kentucky, and Texas. Right. And Planned Parenthood of Illinois has estimated that there will be an additional 20 to 30,000 more abortion patients that will annually cross the state lines into Illinois. And Illinois has already shown a 28% increase in abortions, which is one of the largest increases across the country since dobs. And it's unfortunate because a lot of these women face hardship in being able to travel to other states to access abortion care.

Speaker 2:

Well, I'd like to unpack that, um, two ways. The first is we're assuming, lemme say, you know, they'll, they'll travel too, that they can even access, um, reproductive care when they reach whatever state it may be. Mm-hmm.<affirmative>. Um, there are, you know, care zones, uh, care deserts, um, across the United States for any type of care, whether it's like Thea or, or oncology or reproductive care that in abortion context existed and was acute prior to dogs. Mm-hmm.<affirmative>. And we're already seeing that dogs is creating a chilling effect even in states where it is legal for positions to, to perform, um, surgical abortions. So in a state like Illinois, it might not be the only one. You know, even if women are able to travel, there's great concern that the care just won't be available. So, you know, in pulling out more broadly, that's a concern for all access to healthcare in the us We can talk about greater insurance for telepsychiatry, but if there are no telepsychiatrist, it really becomes moot in, in, in practice. So any thoughts there? And then I'd like to turn back to your comment about the different groups.

Speaker 3:

Yeah. Going to your point about care providers, Delphine, I just, you know, we've already seen such a strain on safety net providers in the post dos and even before the DOS decision, right? But since June, um, 60 reproductive health clinics have closed for, um, cause services across the country. And so these closures are impacting access to all reproductive healthcare, um, including contraception. And for the most part, they're take, they're happening in communities with, um, lower resources and that are already facing poor maternal health outcomes, right? So they're happening in the places that have already been challenged. Um, there's also been to the point that you made a decline in the number of healthcare providers who are performing abortions. And that's a trend that happened, um, before this decision. And as a result of all of this, um, safety net providers, like community health centers or public hospitals or family planning clinics, um, that are located in and serve vulnerable populations have to pick up the load. And right now, these safety net providers don't have the resources they need in order to do that. Um, so, you know, one of the things as we think through what comes next is making sure that we're funding and staffing these providers appropriately, because they're gonna play sort of an even bigger role for these vulnerable communities as we move forward.

Speaker 2:

So let's talk about those communities and you know, there is a tendency, and I'd love to hear how you'd like to change the conversation or suggestions on messaging sort of group, all underserved mm-hmm.<affirmative>, you know, group all, and you know, LGBTQ rural, white urban. Not everybody's gonna be impacted the same way. Could you give us some initial thoughts on, you know, both impact and approaches for various communities? And you mentioned, you know, rural health and that's again, an area that's not getting as much attention as I think it needs to receive.

Speaker 3:

Yeah. So, you know, I think if you want to break down sort of the groups, and there are so many groups that are impacted when you consider marginalized communities, right? So I'll just start with the first one that's sort of on my list with it, which is black, indigenous and other people of color. And you know, Delphine, you and I have talked about this a lot and I, I pretty sure I've talked about this on an ALA podcast before, but compared to other countries, the United States is already has the highest rate of dead, deadly pregnancy related complications, um, during or within 12 months after the end of pregnancy, right? And when we look at maternal health in our country, we see racial, gender, geographic, and generational in inequities all over the place, right? And so, just as an example, black American Indian and Alaskan native women are three to four times more likely to die of pregnancy complications than white women. And births involving unintended pregnancies are more likely to result in adverse health outcomes for women, including death, which means the risk is even higher for women of color than it is for white women. Those with low incomes are really negatively impacted by this as well. Um, as you mentioned, 75% of individuals seeking abortions are low income. And to some degree for them accessing abortion has always been a challenge. Um, there's been, you know, we have a long history of having limits on public funding for abortion, which has always made it hard, if not impossible, um, for women who are on Medicaid or to access abortions. And so now, as a result of jobs, if these women live in states with abortion bans, they not only have to figure out how to gain access to an abortion and to fund that abortion or find someone to fund that abortion for them, they also have to take into account travel, food and lodging, um, that's necessary in order to access an abortion. And then when you consider that many women that are getting abortions are already mothers, they also have to factor in childcare and the cost that comes with that. Um, so it has just become an even larger burden, um, for that population. Um, you mentioned rural communities. Um, people living in rural communities are far less likely to have access to the right medical providers. Um, and that's gonna become even more challenging, um, with restrictions on abortion access. Um, another group that I don't, I don't think we talk about enough when it comes to this issue are young people. Um, and they're uniquely affected by abortion restrictions. Um, they're less likely to become pregnant, but when they do, they're more likely to characterize their pregnancy as unintended. Um, they tend to show up later in pregnancy for care. Um, they have difficulty traveling, um, making, you know, the fact that they may have to get to another state more challenging. Um, and then there are all kinds of laws requiring parental involvement, um, to make those reproductive decisions. Um, you know, another group within the underserved, um, community are immigrant populations, right? So if there are immigrants without documentation, they may be disproportionately impacted. Um, and one that, you know, I didn't list before that I'll just throw in here before we move on, is, you know, those who are facing domestic violence, right? So domestic violence is all about power and control, and many abusers choose to weaponize a partner's bodily autonomy and reproductive choices as tools of violence. So they may prevent a partner from having an abortion as an abuse tactic, um, and force them to stay, right? And so this decision really impacts a whole lot of subsets of populations across the country.

Speaker 2:

What are, from your perspective, key legal issues that attorneys should be thinking about when advising clients in underserved communities are more likely than not clients who are serving patients in under underserved communities? Even if the attorneys can't solve the issue, what should they be thinking about in terms of issue spotting that would be different from providing guidance to, um, a client that provides services to, you know, for sake of conversation, let's call them fully insured?

Speaker 3:

You know, and I, and I come at this, you know, from an attorney that has spent a lot of time in the hospital space and, and working with providers. And I think one of the things that attorneys should be cautious of, and it's not a legal issue, it's more just a practical issue, um, and I touched on it before, which is sort of the burden that's gonna fall on safety net providers and the need to ensure that those providers have access to the resources they need, the clinicians they need, um, to be able to continue functioning and serving the communities that they, they serve today. Um, and I think that's just something that is helpful for attorneys to have sort of in the back of their mind as they're thinking through advice and counsel. Um, and I think there's a huge role, and I talk about this a lot with my law students for lawyers to play in sort of the policy piece around this. Um, I touched on, you know, Illinois becoming an abortion oasis, and there's a reason for that. Um, Illinois has a lot of policies in place that make it a place where abortions are being performed, right? So obviously the Illinois Supreme Court recognizes the right to abortion under the state's constitution, right? Illinois was a second state in the United States to enact a statutory protection for abortion as a fundamental right. Um, but state Medicaid within the state also funds abortion. Um, private insurance is required to cover abortion. And, um, qualified healthcare providers outside of physicians have the ability to perform abortions, right? There are are, um, in 2021, the state repealed the parental notice of Abortion Act, um, which ended the parental consent requirement within the state. And so I think it's helpful for attorneys to understand the types of policies that can be implemented that will help alleviate some of the pressure points for these underserved communities. Um, and Illinois's not done, right? So they have all of these policies in place that have allowed it to become an abortion oasis, but they're still advocating for more that would continue to improve access and, um, the availability of reproductive care within the state, right? They're moving forward with, you know, policies that could improve Medicaid reimbursement. There are advocates that are trying to amend state rules so that nurse practitioners and advanced practice providers can provide abortion care. Um, so there are all of these things from a policy perspective, um, that I think attorneys should be aware of. And if they're interested in, you know, help advocate for those policies within their states and communities that would allow the pressures on underserved communities to be alleviated and allow them to get the reproductive care that they need

Speaker 2:

And the have of ala. Um, and I just wanna thank you, Priya, for this, this fantastic conversation and hope that we can dive deeper so that we are moving away from framing the conversation as underserved communities in a block and really breaking down what those solutions could be, whether they're educational or policy or legal. So thanks again and look forward to everyone joining us for our next after dos.

Speaker 3:

Thanks Delphine.

Speaker 1:

Thank you for listening. If you enjoy this episode, be sure to subscribe to ALA speaking of Health Law wherever you get your podcasts. To learn more about ALA and the educational resources available to the health law community, visit American health law.org.