AHLA's Speaking of Health Law

After Dobbs: Six Months Later

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Six months after the Supreme Court released its decision on Dobbs, the health law landscape remains as complex as ever. In this follow up to their August 2022 podcast, Delphine O’Rourke, Partner, Goodwin Procter LLP, and Melissa Scott, Managing Director, The Claro Group, discuss how the health care system continues to evolve and some of the significant legal and policy issues at play. They discuss state legal and policy developments, enforcement activity, reproductive health, reproductive apps and privacy, innovations in contraception, and impacts on underserved communities and women’s health. Sponsored by The Claro Group - A Stout Business.

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

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Speaker 1:

Support for A H L A comes from the Claro Group, which is now part of Stout. Stout is a global investment bank and advisory firm specializing in corporate finance, transaction advisory, valuation, financial disputes, claims, and investigations. For more information, visit the claro group.com.

Speaker 2:

Welcome to After Dobbs, six months later. Thank you to h l A and the Claro Group for continuing this podcast series on the impact of Dobbs across the health industry. I'm Delano Rourke. I'm a partner with Goodwin, an adjunct professor at Columbia Law School. And I'm thrilled that we're touching base to see what has transpired since June 24th. And to be having this conversation with Melissa Scott is, you may recall, Melissa and I joined for the first podcast on Dobbs and where we looked at the healthcare landscape, and it's just fantastic to come together again. Thank you, Melissa.

Speaker 3:

Thanks, Delphine. My name is Melissa Scott, and I'm a managing director with the Disputes, compliance and Investigations practice at the Claro Group, which is now part of Stout. With my focus being on the healthcare industry, spanning the provider and payer continuum, Dobbs has significant impacts on my clients. I'm grateful for the opportunity to collaborate once again with Delphine to provide an update on our earlier conversation post Dobbs. And now that we're six months post ruling, take a look at how actual and anticipated impacts continue to evolve. So, Delphine, are there any significant legal updates or developments on the matter that you're watching?

Speaker 2:

Thanks, Melissa. And it's crazy to think that it's been six months. I mean, on one hand it feels like it's been a lot longer. Um, you know, it doesn't, day doesn't go by that I'm not advising a client on some aspect of the Dobbs decision and the impact. And there's so much that's happened just from policy and, you know, sort of social, social movement perspective. And the significant legal updates, and I'll say these sort of in broad strokes because they're evolving daily, is we first had the trigger states. So we know the trigger laws in the states that were had laws on. The books were ready to go. Once the decision dropped, then we had laws that were in the works and then went into effect. So mostly in states that were re restricting abortion compared to the laws that had been in place previously. Um, and then we've seen a trickling of additional restrictions on abortion rights. And I'm starting with, with the restrictive states. Then I'll go to the states that actually expanded access to abortion. So there were two major waves. And then what we saw over the summer is the beginning of litigation around, um, around the laws that had been put in place. We sought challenges to, through the judicial system, we saw appeals, we saw propositions that were put forward. And that's been going on in multiple states, um, since, since, um, June one of the latest being Georgia, where in the matter of weeks the restrictive abortion laws were struck down and then put back in place. So one of the key lessons there is it is complex and it is constantly changing. So it is an area, you know, sometimes there are analogies made to telehealth that in telehealth there are 50 states with 50 different regulations that are in flux. Yes. But this is like, you know, stooped up or on, on high caffeine because the changes are much more frequent, so critical. And there's some great sites and law firms, including Goodwin, that have collaborated through nonprofits to conduct 50 state surveys, to have a baseline and then continue to monitor. Um, and then we saw the same thing in states that were, um, increasing access and securing access to abortion. Um, not just in strengthening legislation, but also, um, expanding the scope of legislation, putting in protections on the aiding and abetting side. And California and New York are great examples of states that really came down and said, we are going to be not just, um, encouraging access in our states, but we are going to also be harbor states or safe states for others. And, and that just continued with the midterm elections. And think going up the way midterm elections, there were several states, Pennsylvania is one of them, where there were governor, um, races where, you know, legislation c or where, where the governor was vocally and running on a campaign to restrict abortion. I'll use the Pennsylvania example where, um, the Republican candidate was very outspoken about, you know, petting, um, you know, complete, complete, um, um, complete ban of abortion, Pennsylvania, and then prosecuting women who obtained abortions for murder. So very aggressive stance. Um, he was one of maybe a dozen races where the outcome of of the midterm elections were gonna be determinative. And in, in, in Pennsylvania, for example, Josh Shapiro, the Democratic candidate won. And he is a supporter of choice. Uh, but California is another great example to watch. And California generally on, on social issues is at the forefront. And not only did California reinforce the right to access abortion, but interestingly also ac uh, secured the right to access contraception. That's something that we can talk more about generally in the midterm elections, what you saw was sort of a strengthening of the existing positions. And then some of these states were that were in flux, but we've also seen are a variety of different, whether it's fetal heartbeat laws that are defining, cuz it's, you know, a lot of these statutes were really vague and didn't get into fetal heartbeat. No fetal heartbeat. Um, you know, which gets complicated when you have atopic pregnancies, for example. So laws that started to drill down even further into the scope of the restrictions. So when you're looking at the statutes, when you're looking on the laws that are on the books, really important to look at these various categories. What's the timing? What are the carve outs? How are those carve out, uh, defined? And this is gonna continue. And we're gonna see, I mean, these are being played out in courts across the country. And then we have the 2024 elections. And, you know, uh, Dobbs ended up being on, depending on which study, you know, report, you look at the number three issue for, for most boarders in the midterm election or health in general. Um, so that is gonna continue in 2024. Um, so this is an area that needs to be monitored constantly and important for, you know, members of the audience who are accessing legal counsel to really be working with somebody who has their finger on the pulse because it is such a fluid area.

Speaker 3:

That's really interesting. When we had spoken last, we discussed potential impacts to care delivery in certain state's reactions, which were suggestion of punitive legal posturing. Can you talk about any escalations related to post-ops enforcement activity?

Speaker 2:

That's a great question because there was all of this concern. I mean, this aiding and abetting, you know mm-hmm.<affirmative>, how far could it be taken? Um, who could be considered to be aiding and abetting? Um, that concern continues. I mean, hotels remain concerned. I mean, we get these questions about, you know, how broad is the scope. Um, could, could a landlord, you know, who, who rents space to a provider who may be performing abortions? Could the landlord be aiding in abetting? We saw very aggressive communication from Texas, uh, the Texas, uh, legislators against Lyft and a large law firm at the outset. But to date, and, you know, knock on wood, we haven't seen very aggressive enforcement of, of of restrictive abortion laws. We haven't seen a state really single out a woman or a woman and, you know, potentially her provider. Cuz that's the big fear among the, among the, uh, healthcare community. Um, that doesn't mean it can't happen. We just haven't seen it yet. So it's still a A T B D. What it has done though, is had a chilling effect because providers, um, you know, patients, ancillary contractors are really concerned about the enforcement activity. And if you're a provider and you're already dealing with, you know, malpractice generally, and now it's okay, could I have civil penalties? Could I have criminal penalties? Could I be, you know, excluded from Medicaid? I mean, the impacts are tremendous. Could this be the end of my employment? So it has created real fear and, and a chilling effect among patients.

Speaker 3:

It's scary just thinking about it, not knowing where that's gonna go, that's for sure.

Speaker 2:

Right? I mean, if you're treating a patient who comes through the emergency room and there's been a lot of focus of tala, you know, so you're fulfilling your tala obligations, but what if you're violating a state law? Do you, you know, federal versus state, um, you know, do you end up in jail? So it's, it's, it's already, as we know, physicians burnt out. Um, the, the stress and pressure, this is yet another level which relates to the shortage of physicians, you know, shortage of physicians in, in the OB G Y N space, which was already there are really exacerbating and just to general physician burnout and anxiety,

Speaker 3:

And also contributing to that practice of defensive medicine, right? Where traditionally we've been worried just about malpractice, but this adds a whole nother layer.

Speaker 2:

Oh yeah. And I've heard, I mean, physicians have told me like, there's an atopic pregnancy and there's a fetal heartbeat, and they're like, do we wait until there's no more heartbeat? But then the woman could be at risk. Like it's, it's also getting, you know, they say, now we have the law that's deciding how we should be providing medicine. And even though it's supposed to be their own medical judgment, and you know, contracts with hospitals and whoever always say it's your own medical judgment, they, if they think that the law is dictating what they need to be doing, that's really problematic.

Speaker 3:

Another area we'd spoken about previously was the fertility market and impacts to embryo storage, postops. Have you seen this play out and have there been any new developments in this market?

Speaker 2:

So that's an area where, you know, right after the decision and you know, which, which dropped on a Friday, there were embryos that were being transferred across state lines. I mean, you know, and, and we actually did a podcast, a Dobbs podcast, um, with Dr. Brian Levine, who is a world renowned fertility specialist. And we touched on that. So I also refer our, our audience back to that podcast, but request by patients who are saying, you know, ship my embryos, make sure that my embryos are in, in states that are not restrictive. And the, the focus on embryos and the destruction of embryos hasn't been as strong as anticipated. You know, what we have seen is that there are certain markets, let's say in New York or California that are where we're seeing an increase in, in a, in demand for fertility treatments from patients, um, or expected parents from different states because they think that there's more protection, um, in those states. So that's just increasing the, the demand and the access was already low and increasing the, the cost. But what we haven't seen is this front a frontal sort attack on embryos that are currently in storage. That may be because operationally, like how do you resolve that? There are bioethical considerations. You know, there are estimates of more than 1 million frozen embryos in the United States. If those embryos are not going to be used, what happens to them? Who's gonna pay for it? Where is, and and the current restrictions on, on abortion don't provide any, any guidance. So, you know, I wouldn't, you know, we might see legislation specifically focused on stored embryos. Yet to date, we haven't seen the Dobbs decision pushed to the point of really impacting embryo storage. What we are seeing though is that it's increasing, you know, pre pre dobs there was a big focus on equity in access to fertility. And that fertility really remained because costs were so high, um, for, for couples who had significant disposable income or who could find a way to finance it. And you know, this pressure on the fertility market is only increasing the cost. Um, so decreasing access, what I do think is interesting is, is focus on, well, what are the other options pre I V F and investment in those pre IVF may, whether it's intrauterine insemination or, you know, supplements or lifestyle changes or, you know, um, weight loss, whatever it is to try to, to increase fertility success, uh, without having to go to I V F for the reasons we we discussed because of the cost and access issues.

Speaker 3:

That's an interesting spin on, um, another means of innovation resulting from dogs for sure. We had also spoken regarding impacts to reproductive apps and the sensitivity to sharing and gathering fertility related information post-ops. Have there been any changes or impacts in this area that have surprised you?

Speaker 2:

You know, it's been widespread and so first it was, you know, period apps, fertility apps, and, you know, it's, and, and the data supports that, that so many users just dumped their data. And, um, even Dr. Levine suggested, why don't you just put it in your calendar? And if you're trying to track, you know, track your menstrual cycle, just stick it in your calendar as a, as a more with a different code name, um, as a quote, safer way to share information. But those, you know, the, the pregnancy and the fertility apps provide more than just tracking. So there's been a lot of focus on, okay, well how do we continue to serve that need of women needing more than just writing it in a calendar without compromising their information. So what has, I don't know if it necessarily surprised me, but the extent maybe so is that it's really alerted consumers and I think there's a lot op an opportunity for a lot more education ownership could, privacy in general on your apps. So there's been a proliferation of third party apps that don't have a direct connection to your provider. So it's not, you know, the health system that has an app to have conversations with your provider that could be protected by hipaa. These are apps that are developed and you as a consumer user upload or type in your information. Maybe you download it from your electronic health record and even then, then it, you know, is no longer protected by HIPAA generally. And what sort of surprised me is this outcry of, now because of Dobbs, my information on this third party app is no longer protected by hipaa. Well it wasn't protected by HIPAA to begin with. So there's a massive misunderstanding and sense of security just because it's health information, regardless of who it's going to or how it got there that it's sort of magically is protected by hipaa. You know, you can say, okay, well it's really the consumer's obligation to, to really dig deeper into this. But the reality is, you know, how many people read the terms of service, how many repeat?

Speaker 3:

I was just thinking that, right?

Speaker 2:

I mean, it's like even

Speaker 3:

The notice of privacy practices that are, are so long, how many of us actually sit and read through those every year when we sign that annual notice?

Speaker 2:

Exactly. Or when you sign up for something, you know, you're like, okay, I wanna, you know, lose some weight for the holidays and you sign up to a weight loss app or whatever it is, or exercise more and, and you're loading your, you know, your prior medical history, et cetera, et cetera. You most people are not reading the terms of service, you know, and, and my team spends a lot of time drafting those terms of service and we're not delusional. Um, so then the question is, you know, many companies that weren't even in women's health said, okay, well A, we wanna make sure that our consumers know where they stand and that we are doing everything possible to protect their information, but that it's not ironclad, you know, you have a valid subpoena, there's a need. Um, and then also thinking about, okay, how do we support our consumers to protect their information? So for example, clue, which is a, a pregnancy tra pr, uh, pregnancy tracking app, um, said consumers are okay, you can turn off opt in for a location of G P s tracking, but it's not gonna be the default. You know, and you might ask yourself, well why does a pregnancy tracking app need to know where I am anyways? So that consumers a companies can do more to really limit the information that they really need to just that. Okay. And then for also the consumers to think about, okay, well if I have my, you know, whatever it is, TikTok or Snapchat or on, and it tracks my location, you know, do I really want that my app that's tracking, you know, how much I exercise? Does it really need to know where I am? Okay, what information am I sharing? And to appreciate that once I share that information, it is not protected by hipaa. And even HIPAA has exceptions. So when you're thinking about, okay, a crime, so if and under, you know, certain states it is a crime to perform an abortion and law enforcement is saying, okay, we need this information because it is going to help us solve this crime. Um, and they have a valid subpoena, not just from the individual. Cause that's arguably not the most cost effective way of gathering information, but going to a third party that has that information and saying, okay, we want information on all your users who were in this location, in that location is an abortion clinic. Okay. Or you're a telepsychiatry provider and we want information, even not just a provider, but even just a biller. Uh, we want information on all free form notes that referenced abortion. Maybe maybe someone's struggling with depression after abortion. So really, you know, and, and I've gotten this question, so how are we gonna protect P H I? And I think that's where we're gonna see more innovation are privacy. You know, whether it's gonna be an add-on to an app, you know, what the tech component is going to be, I don't know, uh, but something that's going to add additional security to these apps and make them more secure than regular information, um, because they are open and not just, you know, there's a lot of focus on, on law enforcement, but healthcare generally is probably at this point the most hacked industry. So to think about more globally, it's not just the government in the context of enforcement action, but what else can people hack and information that they gain about you? Um, so real focus on privacy and, and not just sort of the mechanical, yes, we have privacy practices in place, but what can we do from a practical perspective and as a differentiator for products, you say, you know, um, you know, uh, meta has had a big campaign I know in New York and there's a big sign in sort of Times Square and it's something along the lines of, you know, communicate as though no one is watching you. And really that focus on, we are doing everything we can to ensure your privacy.

Speaker 3:

I'm so glad that you brought up the app permissions, cuz that's something that I always makes me scratch my head when you get those popups asking about tracking. Um, so yeah, tracking,

Speaker 2:

Can

Speaker 3:

You definitely my hits near to home<laugh>,

Speaker 2:

Can you, you know, can you access all my contacts? Can you access this? And you're like, well, what else are they automatically? Well,

Speaker 3:

Why would you need that? I don't understand the relationship between the question and the app. Well,

Speaker 2:

Definitely, and that's the other piece of it is, you know, what, what is, when you set up for an app, what are they doing with your data? Are they selling it to a third party? Are you agreeing to be part of, you know, a clinical trial? Um, are they sharing it with third parties? You know, most of us don't really focus on what's happening, um, to, I mean obviously there, there are exceptions, uh, but to our data, when it's casual apps, people might think about it when they're sharing information on their health portal. But when it is more of a, oh, you know, I need to get my cholesterol down, so I'm gonna give a bunch of information including my name, my address, um, my, my date of birth, um, et cetera, et cetera, so that I can have this friendly app help me. Well, a lot of that information is p h i, right? So let's be less casual about it and, and really think about where, where it's going. And, you know, we're gonna see more consolidation in the space, in digital health generally, and in women's health because there are so many single point solutions and it's like, okay, how many apps can I enter my information into? You know, so consumers are saying, well, I want my, let's, you know, my high cholesterol app to sync with my weight loss app, to sync with my exercise app and only have one location. Well, as these apps consolidate and have more and more data, you know, then you're, you're really sort of exponential. Um, you know, it, it's a data play in a lot of ways. So that information becomes more and more valuable as there is more aggregated data.

Speaker 3:

Sure. So shifting gears a little bit from fertility and reproduction, um, innovation and advances in contraception methods was another area we sur might, might see some renewed investment activity postops, particularly in the area of birth control options for men. Can you describe how you've seen Dobbs open new doors to contraception?

Speaker 2:

That's an interesting question because I mean, in large part, because what we saw in the data is that, you know, the Dobbs decision pushed to the forefront. A lot of data on who's getting abortions, um, what, you know, behavior, um, which types of groups are getting abortion, just this data around abortion services. And it turns out, I think it was roughly 40% of, um, of people who accessed abortion services were on some type of contraception.

Speaker 3:

That's interesting.

Speaker 2:

Yeah. So there's this view of, well, you know, okay, particularly when there's sort of a negative view, it's okay, well, you know, they weren't even trying, well, yeah, 40% were trying to use contraception and something happened. So it could be user error, it could be, you know, the contraception wasn't the right prescription for them. I mean, there's so many, um, you know, variations in what can impact the efficacy of, let's say a birth control pill. Everything from, you know, from, from weight to, although it's, you know, most pills now are, are sort of weight adjusted. But anyways, there can be outliers to other medication that that impacts the efficacy. So it's okay, you've got at least 40% of people who are saying I'm trying something. Um, so education, you know, so it's really been interesting is this real push on, well, what can we do to increase education on contraception? There's a prior view that, hey, at this point, you know, they teach health in high school and most people must just, you know, have figured it out by now, but clearly not. So what are the avenues to really target, you know, again, drilling down on the data, where could, you know, from a public policy, public health perspective, where could education have the greatest impact? And then, okay, birth control, you know, focused on, on women, uh, generally other than condoms. And, you know, the F D A lists, I think it's 16 different types of, of contraception, and only two are for men, and those are vasectomies and condoms. So a lot of interest in contraceptive methods that are focused on men. And it also gives men more control. Cuz there is this anxiety of, oh, well, if I don't have this backstop of abortion, which men have, you know, been the beneficiaries of, um, what can I do to control it? Uh, one, I think one notable example is Contraline. Um, they have a reversible birth control for, for men and raised, um, I think about 7.1 million, um, in November. And some pretty significant investors consider including, you know, gv, Google Ventures, who, you know, that's, that's an indicator when Google Ventures is looking at something and investing that they think there's going to be a lot of traction beyond IUDs, beyond oral contraceptives for women, um, beyond the methodologies that we're already aware of and that are mainstream. You know, the total addressable market, and it's not just in the United States, is, is obviously significant. And we have seen, there have been studies done by the w by World Health Organization that the increase in, you know, the more restrictive laws are abortion laws or abortion access laws, the higher the rate of, of, of maternal death. Now, you know, for a variety of reasons, anything that's irreversible can be challenging to socialize for both men and women. But the data supports that mostly for men. So any innovation that's reversible has, has great potential. So a lot more interest in male contraceptives and investment in the area,

Speaker 3:

The education piece and the 40% stat on contraception is really fascinating. I, I had not realized, but it makes sense, right? When you see there's always those percentages, right? 99.3 or, or whatever they advertise for efficacy rates, that what happens to those point however many that are using contraception that end up one of the statistics.

Speaker 2:

Exactly. Or there could be another medications decreasing it, you know, it's the sure, sure. 93 or whatever that number is without any other, um, other variables, but there may be another variable, you know, um, so that when I saw that statistic, that really surprised me. And that's, you know, when you're looking at, at any type of engagement for a or or adapter rate, you know, say you have your early adopters and then you have those people that you, you know, who might, who might jump in and, and or jump on. And then you have those that you really have to convince, well, there you have a 40% that you probably don't have to, you know, they, they're already buying into the idea of contraception. Sure. It's just drilling down into why isn't it working and, and what can be done to, if it's user error, if it's education at, at whatever level. But clearly there's a need.

Speaker 3:

Absolutely. So have there been any other surprises for you post-ops, including opportunities created as well as negative impacts that weren't immediately obvious?

Speaker 2:

Well, I'll start with the negative. I mean, we know, um, I, I like to get the negative out of the way first, just in general,<laugh>, which people say good news or bad news, I say, gimme the bad news and we know what it is and, you know, let's focus on, on, on making it into good news. Um, not, not by, um, rose colored glasses, but saying, okay, well, so what can we do about it? I mean, the negative impacts, um, and we, uh, did podcast, uh, with Priya Bethea on the impacts of Dobbs on underserved and, and BIPO and L G B T Q communities that, you know, I would encourage our audience to listen to. We knew the impact was gonna be disproportionate on communities of color. You know, the, and, and then communities that are already marginalized, um, you know, living, living in poverty, it's, you know, for, for so many different reasons, the number of women who are already having abortions, um, then access to care, you know, for, for many women, the employer option is now really positive that employers will pay for access to abortion services if they have to travel outta state. Goldman Sachs, you know, they ca all came out, um, on the first day at saying, we're gonna pay for this. Many women do not have jobs where, um, you know, with a Goldman Sachs type company that is providing the services, they can't afford to go outta state. They might not even be able to afford to go to the next town over. Um, you know, the majority already have other children already living in poverty. So that is, it's, it's devastating in rural areas as well. And you know, what I think we didn't focus on before to the extent that, that we needed to, and also going forward is you might have insurance, you might, um, be able to travel some, but there's certain states where there's just, you know, few, very few ob GYNs period, much less, um, providers who are providing abortion services. So it, it really becomes a moot point, you know, and then there were statistics that were cited several months out that abortions had gone down 6%. But the reality is, okay, that's what's been recorded. And what, you know, always worries, and this is historic, is well, what happens, what's happening with all the women who are not going to obtain services in a medical facility, um, are not, you know, it's sort of that gray market of abortion. And, and that's a, that's a really scary place, and we're not going to have statistics on that unless they then come through the, the emergency room and it's a, you know, a vicious cycle concerned with restrictive abortion laws that if they do come through the emergency room, then you know, they could be subject to prosecution, the physicians that help them. So, you know, again, is who is gonna be disproportionately impacted, you know, I'm calling it the legal determinants of health. We have the social determinants of health where you now live and the laws in that state will directly impact your, and they did before. I mean, this isn't, you know, this isn't due. I mean, we saw Medicaid expansion in certain states and not in other states, but will directly impact your access to care. We already had a maternal health crisis, so this is only going to add to it. So that's, you know, chilling effect across the board. I'm hearing from physicians that, you know, men of color are more reluctant to come in, in person to get care because there's, you know, already a distrust, already a concern about accessing care in a traditional setting, and now you're adding on this additional layer of, you know, they could give your information to law enforcement. Now surprises, and, you know, we've, we've saw this rich initial, uh, what we call rage investing immediately after, and it still continues immediately after the Supreme Court decision of, you know, investors saying, well, I wanna invest in companies that are filling the gap. Um, I want invest in companies that are providing, um, you know, uh, abortion support services, or, Hey, Jane, which provides, um, abortion, medicated abortion, uh, services. And in completed a, a round recently, um, as well as from, um, family offices from, um, you know, high net worth individuals were saying, we wanna do something. And what it's done, which this has definitely been a surprise, is really shown a light. And I think this is, this is good, you know, um, there's never, never silver lining, but it's like covid when people say, well, what did we learn? And, and what can we out of tragedy? If, if that's the way you look at it, um, what can be learned? And it's the it, all of the media attention and just all the attention on dos, even just those couple weeks shown a light on women's health. And, you know, regardless of which side you are on, on the abortion conversation, shown a light much broader on maternal health, on lack of support for menopause, lack of understanding from menopause for Alzheimer's, you know, which is a condition that disproportionately impacts women osteoporosis, um, you know, w women dying of heart disease and stroke at higher rates than men. Why? Because of a lack of understanding of, of the symptoms and how the conditions present. And a lot of those areas are not politicized. You know, heart disease is, as far as I'm aware, hasn't become a political issue or a, you know, or a religious issue. Um, same with menopause, same with Alzheimer's. So easier to get alignment from because, you know, healthcare is politicized. Um, easier to get alignment on some of these issues. And then hopefully either more funding support or legislation to support research. Um, P C O S is another area, uterine Fibroids, which disproportionately impact women of color. Again, not politicized. An area where, um, people can align regardless of their political, cultural, uh, religious views. And where there's a huge need and it has shown a need, um, or has shown a spotlight on the breadth of the need, and which then shows, hey, there's a need. We need new solutions. Look at all these innovators who are coming up with new solutions and investors saying, okay, well let's support those new solutions or grants or nonprofits saying, let me support additional research in P C O S, you know, um, and, and find a way that we can increase women's quality of life. Um, GE increase, um, overall clinical outcomes, save money for the system. Same with payers. You know, if there can be, uh, increased support for abnormal menstrual bleeding and women who currently cannot be active in the workforce because there's, it's so debilitating. If there can be a change where they're out of work two days a week in two days that a month instead of two weeks, you know, that starts having economic advantages and if you can scale it and for a payer to decrease costs. So saying, what can we do to meet those needs and collaborate? So I think that's the real positive opportunity is saying, this is a need, and let's remember there are 3.9 billion women. So when, when we hear, oh, it's a niche market, you know, that sort of flies in the face of just the total addressable market, the potential consumers, and, you know, a condition, you know, something like menopause. Every woman goes through menopause unless she dies of something earlier. So we're not just looking at the US addressable market, but the global addressable market. And there aren't that many areas where you can say, okay, I could leverage this to 3.9 billion consumers. Um, so it's really invigorated the space and, you know, in the current market conditions, we're seeing, you know, certain areas are really, are really flat and healthcare continues not at the same, you know, not with the same robustness as last year because of, you know, the recession, the market conditions, and overall, you know, sort of high valuations last year. But healthcare is resilient and women's health, um, is, is incredibly resilient, um, for a variety of reasons in, you know, women have the purchasing power, um, make the ch you know, chief medical officer of the homes and are saying, this isn't just a nice to have. Um, but really a necessity and a necessity for overall health and wellness and an economic necessity. So really bullish on, on the market and, um, to continue to focus on the legal framework because the legal framework cannot be an afterthought.

Speaker 3:

Well, I love how you moved through the negative impacts into the positive and that highlighting of positive implications for women's health. So thank you for spinning that question. I

Speaker 2:

Mean, we could, we could spend, you know, 12 podcasts on the negative, just in general. Yeah. Like the opportunities in women's health, um, particularly for our most vulnerable populations, um, whether it's, you know, obesity, when you see the obesity rates that have, you know, underlying impact on so many other disease states, um, you know, decrease in screening for, from, for breast cancer. I mean, the list goes on. So I'm trying to focus on that doesn't mean we're, we're ignoring the negative, so what can we do to try to solve them or make them better?

Speaker 3:

Yeah. And if there's anything positive that we can pull from this, um, that's a, a great positive spotlight to put on women's health. So my final question for you is whether you think the dust has settled or will Dobbs continue to have an impact on legal issues for years to come?

Speaker 2:

Oh, I think conservatively 10 years conservatively. Um, and as I mentioned, we're gonna have the 2024 elections, I mean, between now and 24, it, it there, you know, it's gonna continue to play out in the courts, in in legislation. Um, we'll see some enforcement actions. We'll have a better sense of, you know, what's the impact on employers, whether, you know, if there's a large, you know, I don't know if it'd be a class action, that's not my scope, but if there's a large class action against, you know, brought by an ag against a major employer, you know, for providing support for reproductive services, be inter, you know, that that'll, that'll have an impact. Um, so definitely in the courts in legislation, how it impacts employers, you know, what we see as alternatives. And then, you know, Senator Lindsey Graham says, you know, this is, this is just the first step when he, he proposed a federal ban on abortion and, you know, and there are, or you know, certain politicians and, and current congress people who will push for that, a national federal ban. And depending on, you know, who, who's in the White House in 2024 and what congress looks like that, that might be feasible. This is, this is not a two year, three year, five year, this will continue. So, you know, whether we also see a push on using the abortion laws to restrict contraceptives and IUDs and other forms. So this is gonna go on for years. And if you're an investor looking at the space, if you are a health system saying, okay, how am I gonna continue to navigate this? You know, you're doing community outreach to be able to answer those questions. If you're a patient advocate and you're, and the patients say, well, you know, can the government get my information? Um, but it's, you know, when can they get information? How can they get my information? Do providers have an obligation to tell them? So it's going to really resonate and won't necessarily be connected to, oh, that's because of Dobbs, but just a general alert to privacy and who's controlling me in my healthcare, you know, so this is not a one and done, this is not the end of a pandemic. Um, which, you know, that's another piece once the public health emergency ends and if potentially 14 million people are no longer on Medicaid, I mean, it just goes on and on. But this will be just the way Roe v Wade was the past 40 years before, you know, Dobbs will be the next 40 years.

Speaker 3:

And I think if there's anything we can learn from the topics we covered even today is the implications are so far reaching, there's so many gray areas yet, um, that you could pull in or keep separate that we'll just have to continue, continue to watch and see how things evolve.

Speaker 2:

And that might be the biggest surprise, because when I brought up with clients, you know, when, when about the league, it was like, oh, no, you know, many, many pe many folks, you know, not just with clients, but when I would speak, would say, well, I don't provide abortion services, so this won't impact me. So, you know, that might be one of the biggest surprises is how widespread, um, sort of the, the ripple effect has been. I think you're right. So Melissa, thank you so much. Thank you to the Claro group. Thank you to ala thank you to our audience for, for tuning in and see you next time. Thanks everybody.

Speaker 4:

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