Category: Blog

It Depends on Dobbs: The Uncertain Future of Abortion in the United States

The right to choose to have an abortion has been recognized as a constitutional right in the United States for nearly fifty years since Roe v. Wade. However, states have the right to impose restrictions on abortions until the vague point of “viability,” as long as the restriction does not present an undue burden to those seeking an abortion. For as long as the right to choose has been established, many states have persisted in efforts to chip away at abortion access by imposing a variety of restrictions. Since Roe, more than 1,000 restrictive laws have been enacted across the United States to limit abortion access. These efforts are gaining momentum, and more than a quarter of abortion-restrictive laws were enacted between 2010 and 2015. The trend has continued, and 2021 was the most restrictive year on abortion in American history. 

Abortion access has a long history of being weaponized as a political tool in the United States, and with increasing political pressures, more abortion restrictions than ever, and a conservative majority in the Supreme Court, this trend continues today. At the center of the current fight is Dobbs v. Jackson Women’s Health Organization, a case that was argued before the Supreme Court in December 2021. The case is regarding a Mississippi ban on abortions prior to 15 weeks of pregnancy, and will be the first case since Roe in which the court will determine the constitutionality of pre-viability abortion restrictions. The ruling, which is anticipated by the end of the Court’s term in June 2022, has the dangerous potential to overturn Roe and establish that there is no constitutional right to abortion in the United States. 

The consequences of the Dobbs ruling will be severe, whether Roe is overturned entirely, or if states are permitted to expand restrictions to abortion access. Approximately half of states are considered likely to completely outlaw abortion, or limit access to the point that abortions would be virtually inaccessible, following the ruling in Dobbs. Only fourteen states and the District of Columbia protect the right to abortion in their state laws or constitutions, and just five states protect both the right to abortion and have policies in place to enhance access to abortion. The stark contrast between states that will ban abortion and the few that will protect the right will create barriers to access in the nation where approximately 1 in 4 *women will have an abortion by age 45. It is important to acknowledge that lack of access to abortion has a disproportionate impact on low-income individuals and People of Color.  

In recognition of the importance of abortion access and the increasing threats to the right to choose, recent attempts to protect abortion at the federal level have made it farther than ever before. The Women’s Health Protection Act of 2021 would have enshrined the right to abortion in national law; however, after it passed in the House it failed to pass a Senate vote in March 2022. While this outcome is disappointing at a time when abortion rights are more at risk than ever, it is encouraging that the majority of American voters supported the WHPA, and marks important progress as the first time the Senate voted on legislation for the federal right to abortion

The right to abortion in the United States faces some of its most challenging obstacles to date. While the depth of the hill we continue to climb is to be determined by the outcome of Dobbs, regardless we must persist until abortion access for all is realized. 

*This post refers to “women” when the data being referenced refers specifically to women. It is important to acknowledge that abortion access impacts all people who may become pregnant, including trans and non-binary individuals. 

Taking Aim at the Threat of Bioweapons

It is an unfortunate enough reality that the world is concerned about the threat of naturally occurring biological hazards, but now there is a real fear that terrible biological weapons may make a reappearance. While many may consider the Covid-19 pandemic to be a “once in a lifetime” tragedy, there is reasonable concern that a lack of preparedness may give rise to another pandemic sooner than we may think. Although, we may not have time to focus on preventing another naturally occurring biological disaster because there is a serious concern that Russia may employ biological weapons in their invasion of Ukraine.

A biological weapon specifically involves using a living organism to inflict harm on others. The classic example would be depictions of Roman or Mongol armies throwing dead animals in an enemy’s water supply to ensure that disease would spread through the ranks. Since the Classical age, humans have only grown uncomfortably more efficient in all aspects of warfare and biological weapons have undergone terrifying advancement. Since 2008, more than 20 countrieshave maintained a biological weapons department and the former Soviet Union extensively researched the subject.

In October of 2021, NATO acknowledged the possibility of another devastating pandemic then began to ring the alarm bells that certain countries have the capability and motive to unleash devastating biological weapons that many would be unprepared to counter. Barely a month later, and likely in response to the then escalating tension between Russia and Ukraine, the Biden administration formally voiced their concern about the proliferation and potential use of biological weapons. The administration agreed with NATO that there needs to be a united global stance against the development of biological weapons and thorough cooperative strategies to prevent the threat of another pandemic. Thankfully, there are indications that Congress is willing to support President Biden in this area.

Republican Senator, James Risch, introduced bill 2912 last year that directly addresses the devastation of the Covid-19 pandemic and the actions the United States must take to prevent another natural, or weaponized, biological disaster. The bill calls on the government to make assessments of foreign countries, specifically Russia and China, and potentially ban all cooperative research funding if those countries are found to not be compliant with the Biological Weapons Convention. Additionally, the bill would call upon the United States to actively use its leverage within the United Nations to condemn the offending countries and prevent them from seeking any position of power within the sphere of global health.

The threat of these weapons cannot be understated. Even Russia is spreading obvious misinformation that their justification for invading Ukraine was because of alleged bio-labs within the now besieged nation. As the conflict in Ukraine continues, the likelihood of Russia resorting to utilizing biological weapons among its many other war crimesonly increases. Congress has shown initiative in recognizing that the United States needs to be proactive in its defense against biological hazards, so there is hope that the often-divided institution will come together to condemn any use of such a weapon and react accordingly. 

Racial Disparities in Opioid Use Disorder Treatment

Over the past twenty-five years, the United States has experienced an increasingly devastating opioid crisis.  According to the Department of Health and Human Services (HHS), in the late 1990s, pharmaceutical companies offered reassurance to the medical community that patients would not become addicted to opioid pain relievers, leading healthcare providers to begin prescribing them at greater rates.  Increased prescription of opioid medications led to widespread misuse of both prescription and non-prescription opioids before it became clear that these medications could indeed be highly addictive.  

The Centers for Disease Control and Prevention (CDC) outlines the rise in opioid overdose deaths in three distinct waves.  The first wave began with increased prescribing of opioids in the 1990s, with overdose deaths involving prescription opioids increasing since at least 1999.  The second wave began in 2010, with rapid increases in overdose deaths involving heroin.  The third wave began in 2013, with significant increases in overdose deaths involving synthetic opioids, particularly those involving illicitly manufactured fentanyl.  The market for illicitly manufactured fentanyl continues to change, and it can be found in combination with heroin, counterfeit pills, and cocaine.  In 2017, HHS declared a public health emergency to address the national opioid crisis and announced a five-point strategy with the following priorities: improve access to prevention, treatment, and recovery support services; target the availability and distribution of overdose-reversing drugs; strengthen public health data reporting and collection; support cutting-edge research on addiction and pain; advance the practice of pain management. 

The COVID-19 pandemic has created a devastating public health crisis and has posed significant challenges for health care delivery, including opioid use disorder (OUD) treatment.  Like the opioid crisis, the COVID-19 pandemic has had a disproportionate impact on racial and ethnic minority groups, particularly those who use drugs.  For example, one recent study showed that Black people with OUD are not only at significantly increased risk for COVID-19, but also have greater odds of hospitalization and mortality.  This reflects how Black communities have been subjected to the dual burden of disproportionate COVID-19 deaths and rising overdose mortality.

Methadone has been successfully used for over forty years to treat OUD and must be dispensed through specialized opioid treatment programs.  To receive the treatment, individuals have to show up every day for ninety days to receive their dose.  Only after that, are they able to take home a weekly bottle.  To get a full month’s worth of take-home methadone, individuals need to have been going to the clinic for two years.

Buprenorphine reduces cravings without becoming addictive itself and has been found to have similar effectiveness as methadone for treating OUD when given at a sufficient dose and for sufficient duration.  However, unlike methadone, buprenorphine can be prescribed by certified health care providers.  This eliminates the need to visit specialized treatment clinics, thus expanding access and providing an option for individuals with OUD who are unwilling or unable to attend a licensed methadone treatment program.

While both methadone and buprenorphine have been shown to reduce opioid misuse compared to abstinence-only interventions, buprenorphine has the greatest potential for widespread dissemination due to its relative ease of use and safety.  However, findings from several studies suggest buprenorphine and methadone treatment rates are correlated with race and ethnicity.

The following recommendations have been proposed by public health professionals and, if adopted, could help address the racial disparities in access to medications for OUD.  First, the requirement that a health care provider must complete a course before they are able to prescribe buprenorphine should be lifted. Second, newly diagnosed OUD patients should be offered both buprenorphine and methadone as treatment options.  Furthermore, patients currently receiving methadone should be offered the option to transition to buprenorphine.  Third, policies and regulations should be changed to allow pharmacy-led methadone dispensing.  Steps such as these must be taken to ensure all Americans, regardless of race or ethnicity, have equal access to health care.  Otherwise, this would be a missed opportunity to improve public health. 

The VAWA, Medical Forensic Examinations, and Assumptions about Victims of Sexual Violence 

In 2000, the National Institute of Justice (NIJ) came together with the Center for Disease Control and Prevention (CDC) to perform a study to better understand the breadth of abuse, stalking, and other violent behaviors on women in the US. Previously, other studies showed that arrests of abusers upon report tended to have a positive effect in reducing future violence. However, research hadn’t yet captured the sheer extent and magnitude of abuse directed against women in the United States. 

In the study performed by the CDC and the NIJ, researchers surveyed 8,000 women and 8,005 men through a process of randomly selecting phone numbers of households across the US. Of the women that responded to the survey questions, 17.6% had been victims of rape, 8.1% had been victims of stalking, and 22.1% had been assaulted by an intimate partner. But while these statistics were significant in and of themselves, the most surprising finding of the study was the primary source of violence against women: intimate partner violence. “64.0% of the women who reported being raped, physically assaulted, and/or stalked since age 18 were victimized by a current or former husband, cohabiting partner, boyfriend, or date” compared to only 16.2% of men.” 

Additional studies have been conducted that also demonstrate the endemic nature of intimate partner violence and the need to classify it as a major public health crisis. In the wake of this kind of research, various lawmakers in Congress, including then Senator Joe Biden, pioneered the passage of the “Violence Against Women Act” (VAWA) in 1994 and since renewed and strengthened in 2000, 2005, and 2013. On Wednesday, March 16 2022, President Joe Biden signed the fourth reauthorization of the law, which provides a variety of further enhancements to the bill: increased resources and support for survivors of underserved and marginalized communities, establishing a federal cause of action for individuals whose intimate images are disclosed without their consent, increasing support for the Rape Prevention and Education Program, implementing trauma-informed policies for law enforcement responding to domestic violence reports, among others.

Of these various updates, the bill also specifically provides for strengthening the healthcare system’s response to domestic violence and sexual assault. Title V of the bill provides various grants to states for conducting surveys of healthcare systems with the intent to gauge the effectiveness and availability of medical forensic examination. Medical forensic examination is the process whereby a health care provider examines a victim of sexual assault to address any of the victim’s immediate injuries but mainly to collect any bodily evidence that may assist in a future prosecution of an abuser. The bill’s prompting of further research about the effectiveness of these tests is purposed to result in states forming specific action items to improve the process in their jurisdictions. 

Studies have demonstrated that victims receiving these examinations feel roughly handled. Other studies, often conducted on a somewhat small scale, have demonstrated that victim-blaming mentalities actually pervade many forensic examiners’ approaches to conducting examinations. In an article titled, “‘Silly Girls’ and ‘Nice Young Lads’: Vilification and Vindication in the Perceptions of Medico-Legal Practitioners in Rape Cases,” authors Lesley McMillan and Deborah White discuss the findings of surveys they performed of various practitioners. Strikingly, of the various responses recorded to questions about the different rape cases practitioners had dealt with, many repeatedly echoed the idea that they had dealt with some “real” rape cases, often referencing rapes by a stranger, and other less real cases of “silly girls getting drunk and getting caught by their boyfriends” (285). As the authors highlight, these ideas about rape stand in violent contrast to the reality of how most rapes of women occur—at the hands of intimate partners. Hopefully, the funding provided in the reauthorization of the VAWA will result in meaningful changes to the process of conducting forensic medical examinations so that victims are better dealt with and just convictions are more common.

How the Unvaccinated Raise Insurance Premiums for the Rest of Us

Under the Affordable Care Act (ACA), private health insurers cannot deny a person coverage or charge them a higher premium because of a pre-existing condition or because of their health status. 

Is being unvaccinated for Covid-19 a pre-existing condition? If it isn’t, the unvaccinated could be denied healthcare coverage, but perhaps they should be. 

The health care market is characterized by a significant cost-shifting problem. Right now, healthy, vaccinated individuals are paying the collective cost of the unvaccinated population’s Covid-19 related healthcare. The Covid-19 vaccine has been widely available for almost a year and has proven to be highly effective for preventing costly hospitalization and for mitigating “long-covid” symptoms, which can be very costly. It is so effective that while the unvaccinated population represents only 15% of adults in the U.S., it incurs more than 90% of the nation’s Covid-19-related healthcare costs. It is widely understood that those who remain unvaccinated are far more likely to be hospitalized for Covid-19, and require more specialized – and thus, more expensive – medical care. 

Even before the Covid-19 pandemic, there was a major cost-shifting problem burdening the healthcare system. Before the passage of the ACA, the insured population was essentially carrying the cost of the uninsured. While the ACA’s individual mandate has helped mitigate the issue, another ACA provision poses a new problem in the context of Covid-19. Because insurers cannot deny coverage based on a pre-existing condition, they have been unable to deny coverage to the unvaccinated. 

The unvaccinated population is incurring billions of dollars in healthcare costs, and insurance companies spread these costs evenly among policy-holders, whether they are vaccinated or not. Why should a policyholder who makes the responsible choice to get vaccinated have to pay the price of the unvaccinated patient’s bad decision through higher premiums?

Health insurers in the individual marketplace have interpreted the pre-existing condition provision of the ACA to mean that they can’t impose penalties for not being vaccinated, but some private and public employers have taken the step of penalizing unvaccinated employees to address this cost-shifting problem. 

Delta Airlines, rather than imposing a vaccine mandate, took the usual step of charging unvaccinated employees a $200 monthly penalty, essentially a higher insurance premium, to address the expectation of higher healthcare costs. 

Insurers themselves have also re-instated copays and deductibles for Covid-related costs that were waived at the beginning of the pandemic and before the widespread availability of the vaccine, but these affect both the unvaccinated and vaccinated. 

So long as vaccination status is considered a pre-existing condition for the purposes of health insurance, employer-imposed penalties seem to provide the best path forward for addressing the cost-sharing problem posed by the unvaccinated population’s disproportionately high healthcare costs. 

The Disheartening Reality of Maternal Healthcare in the United States 

Around the world, the United States is admired and followed as the globe’s leading superpower. However, the continuously high rates of maternal mortality in the United States greatly distinguishes it from its international counterparts.

The Center for Disease Control and Prevention (CDC) defines maternal mortality as “the death of a woman during pregnancy, at delivery, or soon after birth.” In the United States, about 700 women die each year as a result of pregnancy or delivery complications. While most of the complications that arise during pregnancy are preventable or treatable, the United States struggles to decrease its maternal mortality rates as women’s lives, especially women of color, are consistently put at risk. 

Throughout the country there are people, and more importantly policymakers, who believe healthcare is a privilege rather than a right. The right to healthcare is not explicitly mentioned anywhere in the United States Constitution, making policy decisions around how to access it a source of tension between political parties and lawmakers. Furthermore, access to maternal healthcare tends to suffer as a result of this political tension. The difficulty in improving maternal healthcare is further compounded by the fact that reproductive health is a subset of healthcare that predominately impacts women, making it a less funded and researched area of healthcare. 

Looking to legislative history to examine the steps taken forward to help improve these disheartening facts, the Affordable Care Act (ACA) stands out as a beacon of hope. The ACA expanded Medicaid to reduce the amount of uninsured women who are of a reproductive age and new mothers in the year after delivery. The ACA also forced insurers not to charge women higher health premiums than men, which used to be a common practice as women were expected to have more healthcare costs during their childbearing years. Additionally, reimbursement for midwives was increased to the amount physicians receive for performing the same service- an incredibly important addition for expanding access to personnel who can safely perform births. Though legislation such as this exists to improve maternal mortality rates in the U.S., devastating statistics around this issue continue to occupy the country and disproportionately impact women of color.

According to the CDC, black women are three times more likely to die from a pregnancy-related cause than their white counterparts. This is largely due to social determinants of health that historically and continuously place women of color at a disadvantage when receiving healthcare through structures of systemic racism and implicit bias. In Washington D.C., 95% of pregnancy-related deaths occurred among black women between 2013-2017. In 2017, United Medical Center’s Obstetrics unit in Washington D.C. closed due to lack of revenue and malpractice, leaving nowhere to give birth for women living in Wards 7 and 8 which are primarily occupied by black residents. Women living in these Wards are forced to travel to Maryland or cross the Anacostia River to safely deliver their babies. This reality is sadly not unique to the nation’s capital as high maternal mortality rates continue to plague the U.S. even with legislative victories like the ACA. 

Unfortunately, the hope once raised by the passage of the ACA now appears to be overshadowed by the impending United States Supreme Court decision set to overturn Roe v. Wade this summer with Dobbs v. Jackson Women’s Health Organization. This upcoming decision is bound to disproportionately impact women of color as they will be forced to carry unwanted pregnancies to term and then give birth in a system that is already causing them irreparable harm. This upcoming decision has the power not only to increase the U.S.’s maternal mortality rate, but also change the course of how women’s rights and specifically their place in the healthcare system is respected in this country. Furthermore, how do we move forward in a society where after almost fifty years of progress from Roe v. Wade, our fate rests in the hands of a court who fails to recognize how a decision regarding women’s access to abortion will inevitably have a devastating impact on women of color accessing maternal healthcare?