Tag: health care

A Foot in the Door: Virginia’s New Doula Law, S.B. 1384, Guarantees Their Presence, but not Their Access

Virginia has taken a critical step to address its maternal health crisis with a new law guaranteeing a birthing person’s right to have both a doula and a partner (or other support person) present during labor and childbirth. This legislation is a direct response to the state’s alarming maternal mortality rates, which disproportionately affect Black mothers who are nearly three times more likely to die from pregnancy-related causes than their White counterparts. A doula is a trained, often community-based professional who provides physical, emotional, and informational guidance to an individual before, during, and after childbirth.  Research indicates that continuous doula support improves birth outcomes, reduces the need for C-sections, and enhances patient satisfaction. For Black and other minority women, doulas serve as important advocates, familiar with their communities and bodies, and able to communicate their needs and birth preferences to doctors who may lack the same understanding. Previously, and especially during the COVID-19 pandemic, many hospitals limited patients to a single support person, forcing birthing individuals to choose between their visitors. The new law rectifies this by legally defining a doula as a member of the essential care team—a foundational step that grants legal protection to a patient’s right to their full support system. However, while this law codifies a crucial right, its promise is diluted by significant systemic barriers that prevent equitable access.

A major implementation gap exists between the law’s text and lived reality in Virginia hospitals. The legislation grants “discretion to the treating physician” to override the patient’s right to a doula. This clause is used to enforce restrictive institutional polices, most notably banning doulas from operating rooms during C-sections, even though the law explicitly includes cesarean births in its definition of “birth.” Many hospitals lack clear, updated protocols, creating a confusing and inconsistent environment where a birthing person’s rights depend on their location and provider. This institutional gatekeeping maintains the status quo, leaving families without vital support during vulnerable moments and undermining the law’s core intent.

For many Virginians, a primary obstacle to hiring a doula is financial. Private doulas can range from $800 to $2,500, placing this essential support out of reach for low and middle income families. While Virginia’s Medicaid program now covers doula services, its design creates a new set of challenges. The reimbursement rate of approximately $859 is significantly below market rate and fails to provide a living wage, especially considering the on-call nature of the work. Furthermore, doulas face a costly process to become certified and enrolled with multiple managed care organizations. These financial disincentives limit the number of participating doulas, particularly in rural maternity care deserts, where support is already scarce, perpetuating a two-tiered system of access.

Senate Bill 1384 is a legislative victory for maternal health in Virginia. Yet, a right on paper is not a right in practice. To truly realize the law’s life-saving potential, policymakers, hospitals, and state agencies must work to dismantle the deep-seated institutional and economic barriers that continue to deny so many families the support they deserve and are now legally guaranteed.

Destination Unknown: Navigating Abortion Training in Post-Dobbs America

Abortion is not only common but an essential component of comprehensive care, with one in four pregnant people accessing abortion care in the United States. During my annual physical this summer, I reflected on what challenges people seeking abortion care in my home state of Georgia – and across the Southeast – now face. As the conversation drifted from lab results to my research in reproductive rights law, my doctor posed a question I hadn’t considered: What happens if the next generation of physicians is denied the right to train in abortion care?

On June 24, 2022, the Supreme Court’s decision in Dobbs v. Jackson Women’s Health signaled a seismic shift in reproductive care, affecting not only patients, but physicians in training. The fight to preserve abortion care has moved far beyond the operating room, and now extends to fellowship and residency programs, where trainees do not know if they will ever receive abortion care experience. In a nation where abortion is no longer a constitutional right, medical students, residents, and fellows in states with restrictive abortion laws are being forced to seek training across state lines, and even abroad. One fourth-year medical student planning to pursue a specialty involving family planning, was forced to independently find a rotation that would provide abortion care training, and had to travel as far as London after her school’s reproductive health clinic shut down. 

Training in abortion care for medical students and resident physicians already had significant limitations pre-Dobbs in states with restrictive abortion laws. Along with barriers associated with geographic location or having the resources to travel, patients must now face the additional challenge of finding a physician with enough training to provide an abortion.

Critics of widespread access to abortion care often argue that medical exception laws are enough to prevent maternal mortality or morbidity. However, these “exceptions,” often written into law by people without medical training, using nonmedical language, have resulted in mass confusion for clinicians who, when faced with split-second decisions, are forced to deny or delay care for their patients. Post-Dobbs, there is scant opportunity for doctors in training to have hands-on abortion care experience in states that operate on medical exception laws.

Within Family Medicine and Obstetrics and Gynecology, some family planning program directors have already expressed concerns about the ability to attract residents and fellows to programs in states with abortion bans. These concerns are not without basis, with a cross-sectional study of 2,436 OB-GYN residency programs revealing a small but significant decrease in the number of applicants to residency programs in states with strict abortion laws. According to the study, state-specific abortion restrictions are impacting the training of around 44% of OB-Gyn residents in the U.S. Even though OB-GYN residency programs were also completely full in 2023, there was a statistically significant decrease in applications compared to 2022, and years pre-Dobbs.

While the long-term on the OB-GYN workforce may not be visible just yet three years out from the Dobbs decision, should the trend continue, maternal mortality and morbidity may rise, especially in maternal care deserts. Maternal care deserts are defined as counties where hospitals lack obstetric services, birth centers, obstetricians, gynecologists, or certified nurse-midwives. Maternal care deserts are often found in rural areas, with most rural countries having maternal mortality rates close to two times higher than rates in urban counties.

The future of abortion care training in OB-Gyn and Family Medicine residency programs in states with restrictions is uncertain, with no clear path forward. While some states with restrictive laws may offer medical exceptions, these may not provide enough opportunities for medical students and residents to gain enough training to confidently perform these procedures, impacting the standard of care nationwide.

The Affordable Care Act’s Impact in Reducing the Uninsured Rate in America & the Upcoming Health Insurance Cliff

In March 2010, President Barack Obama signed the Patient Protection & Affordable Care Act, commonly known as the ACA or Obamacare, into law. One of the legislation’s main goals was to reduce the number of Americans lacking health insurance coverage. Between the law’s passage in 2010 and 2023, the number of uninsured Americans fell from 46.5 million to 25.3 million.

The ACA sought to increase health insurance coverage for Americans through two main mechanisms: Medicaid expansion and subsidies for Americans to buy insurance through the health insurance marketplaces administered by the federal government and many states. The ACA sought to expand the number of adults under the age of 65 eligible for Medicaid, a jointly funded federal and state program, which traditionally provided coverage to the lowest income Americans. Specifically, the maximum income eligibility threshold for most Medicaid members effectively increased from 100 to 138% of the federal poverty level. However, the Supreme Court, in National Federation of Independent Business v. Sebelius, ruled that states could choose whether to expand Medicaid in their states. As of 2025, 10 states, including populous states such as Texas and Florida, have still not expanded Medicaid.

For Americans ineligible for Medicaid and earning less than 400% of the federal poverty level annually, the Affordable Care Act provides subsidies in the form of a tax credit, the Advanced Premium Tax Credit (APTC), to help people afford their health insurance premiums. By 2019, the number of uninsured Americans had fallen to 28.9 million.

In 2021, President Joe Biden signed the American Rescue Plan Act (ARPA) into law. The legislation provided enhanced subsidies, known as the Enhanced Premium Tax Credit (EPTC), which expanded assistance to Americans seeking to purchase health insurance through the ACA marketplaces. Specifically, ARPA removed the cap on premium tax credits for those making more than 400% of the federal poverty level, providing subsidies for middle-income Americans for the first time. The EPTCs have been successful in increasing health insurance coverage through the ACA marketplaces, as a record 21 million Americans purchased insurance coverage through the marketplace in 2024. Bolstered by these subsidies, a low unemployment rate, and pandemic-era policies protecting Medicaid coverage, the nation’s uninsured rate reached a record low 7.9% in early 2023.

The EPTCs are currently set to expire at the end of 2025, as they were not extended in the One Big Beautiful Bill Act signed into law by President Donald Trump in July. In fact, the EPTCs have become more important in the health safety net because of the impact of the One Beautiful Bill Act’s cuts to Medicaid and other assistance for low- and middle-income Americans, which are estimated by the nonpartisan Congressional Budget Office (CBO) to increase the number of uninsured Americans by 10 million through 2034. The CBO also predicts that the expiration of the EPTCs would increase the number of uninsured Americans by an additional 3.8 million people by 2034, with 2 million Americans losing their insurance next year alone.

For Americans able to still afford their health insurance coverage, their premiums may skyrocket. According to a 2024 analysis, EPTCs saved the average subsidized health insurance plan enrollee more than $700 on their monthly premium. In anticipation of the expiration of these enhanced subsidies, insurers on the ACA marketplace are raising premiums by roughly 20% for 2026.

Health insurance coverage is important for two main reasons. First, it allows Americans to utilize health care services without paying exorbitant out of pocket costs. Secondly, the reimbursement hospitals and other health care facilities receive from insurance companies for services provided to insured patients provide needed financial support to help allow these facilities to stay open. In an time with rising economic headwinds for both Americans and for health care providers, a rise in the health uninsurance rate caused by the expiration of the Enhanced Premium Tax Credits would add to economic challenges faced by patients and health care providers alike.

Blockchain’s Promise for the Future of Healthcare

In the winter of 2017, the world was captivated by the rise
and fall of Bitcoin. Every night during its historic rise, local
news ran rags-to-riches
stories of basement investors who had cashed out at the right time.
Every day, bloggers, tech journalists, and finance journalists tried to diagnose
the market and divine what portents this fluctuation may hold for
the future. Even before Bitcoin hit its fever pitch in December of 2017, the
national conversation focused on the technology powering it – Blockchain. Intrigued
by the success of Bitcoin, industry leaders sought to understand Blockchain’s structure,
potential, and capabilities. Although the Bitcoin craze eventually came to an
end, the conversation over Blockchain continues and it is now positioned to
make inroads into the healthcare industry.

Blockchain, in its modern form, was
created in the fallout of the 2008 financial crises. It is “[a] digital
record or ledger [mini database] that is structured as a series of blocks that
are strung together in a chain. Each block—a digital expression of a
transaction or an event—is validated by multiple computers on the internet.”
Blockchain is also highly secure by distributing “blockchains” to millions
of computers, creating a decentralized
database.

This combined ability to both secure and share files
simultaneously makes Blockchain an attractive new frontier for the healthcare industry.
Large
healthcare providers such as Cigna, Aetna, and Sentara Health have
signed onto Blockchain pilot programs; even Apple
signaled interest in Blockchain applications. In
2018, 45% of the healthcare industry experimented with Blockchain
applications and 11% of the industry deployed Blockchain applications for use
in business. By 2025, it is projected that 55%
“of healthcare applications will have adopted Blockchain for commercial
deployment.”

This growing trend of Blockchain’s presence in healthcare is
due to the enormous benefits the system presents. Cognizant’s
2017 report, “Healthcare: Blockchain’s Curative Potential for
Healthcare Efficiency and Quality,” identifies top benefits that healthcare
organizations could gain through its implementation, such as strengthened data
security and improved interoperability. As Cognizant’s
report states, “Blockchain technology enhances privacy through
modern public key encryption techniques, reinforces data integrity with its
properties of immutability, and improves security with its decentralized data
model” allowing for improved patient care through data interoperability between
different care providers. Deloitte’s 2018 global Blockchain
survey also identifies areas where Blockchain will provide
significant value, such as disintermediation, transparency and auditability,
and industry collaboration.

These advantages present
solutions to long-standing problems that have plagued the industry’s
ability to modernize, specifically the ability to digitize
patient records into Electronic Health Records. Blockchain’s decentralized
data also provides a single authoritative source for patient records resulting
in lower cost for patients, better collaboration between professionals, and
increased efficiency for providers. Full realization of these benefits has the
potential to revolutionize and modernize the healthcare industry and drastically
increase the quality of care that patients receive.

Yet Blockchain’s real world implementation highlighted some operational hurdles. The Mayor’s office of Austin, Texas undertook a project called the “MyPass Initiative” to utilize Blockchain technology to improve the city’s homeless services by replacing paper records with “electronic encrypted records that would be more reliable and secure.” The initiative aims to “consolidate the identity and vital records of each homeless person in a safe and confidential way while providing a means for service providers to access that information.” Yet the program faces difficulties such as social buy-in and a reliable way to connect a person with an identity, which can hamper full implementation and in turn preclude the complete realization of the initiative’s benefits. These challenges are not insurmountable and overcoming them will pave the way for larger implementation of Blockchain technology in fields such as healthcare.

Blockchain’s utilization in healthcare is nowhere near complete, but its capabilities and potential operational effectiveness are becoming clear to industry leaders. Its promise to improve patient care through better interoperability, heightened data security, and lower cost is a benefit that the healthcare industry has long been looking to provide to patients. With growing industry engagement with Blockchain technologies and continued innovative pilot programs, such as Austin’s MyPass Initiative, we move ever closer to realizing Blockchain’s promise for the future of healthcare.

Electronic Health Records: The Dark Side of Digitizing Health Data in the Online Era

The Electronic Health Record (EHR) is permeating the healthcare industry. Easily accessible “minute clinics” and mobile apps providing diagnostic services are all fortuitous results of the increasing digitization of our medical history. While there are many clear benefits to having an EHR—providing accurate and better healthcare, better clinical decision making, and lower healthcare costs—there are numerous privacy risks associated with EHR utilization.

The EHR was a little-known concept when President George W. Bush broached the idea of computerizing health records in his 2004 State of the Union Address. Since then, the healthcare industry has seen a national push to become 100% EHR-dependent; a mission bolstered by President Obama promoting the use of EHRs in both the American Recovery and Reinvestment Act as part of the Health Information Technology for Economic and Clinical Health Act (HITECH) of 2009 and the Affordable Care Act (ACA) of 2010.

Private industries and the general public are increasingly buying into the idea of EHRs as well; according to the Agency for Healthcare Research and Quality, there has been an upward trend in the percentage of patients who find the implementation of EHRs important. There has also been a year-over-year increase in the percentage of healthcare providers who have adopted EHRs, reaching 67% in 2017.

However, this progress toward 100% EHR utilization has also caused increased privacy concerns as EHRs contain a patient’s most sensitive data. These medical records are valuable on the black market as they include a wide range of personal information such as medical history, social security numbers, and insurance details. The permanency of this information provides criminals enough data to completely steal an individual’s identity as well as the ability to commit a wide array of other crimes.

In the summer of 2016, a rogue online actor known as “thedarkoverlord,” stole 655,000 health records from three healthcare providers in the United States. The hacker quickly put the stolen records up for sale on the dark web for an asking price of $700,000. The anonymous hacker told Vice’s Motherboard publication that “[t]he data could be used for anything from getting lines of credit to opening bank accounts to carrying out loan fraud and much more.” This data breach represented a mere 2.4% of all stolen electronic health records in 2016.

More often than not, the burden to resolve the theft of medical records—such as in the case of “thedarkoverlord”—rests with the patient. According to Ponenom Institute’s Fifth Annual Study on Medical Identity Theft, “[s]ixty-five percent of medical identity theft victims […] had to pay an average of $13,500 to resolve the crime.” The heavy financial burden and continued attacks directly affect the public’s concern for its privacy. In 2015, 68% of patients were not confident that their healthcare providers could protect their medical records from loss or theft.

To prevent and combat security concerns, lawmakers have enacted regulations “to protect the privacy of individuals’ health information while allowing covered entities to adopt new technologies to improve the quality and efficiency of patient care.” These competing interests have become more difficult to balance with the increasing reliance on EHRs and thus the increasing opportunity to steal data.

The Health Insurance Portability and Accountability Act (HIPAA) has been the cornerstone legislation on health-data privacy and holds organizations responsible for breaches of data it protects, yet major data breaches still occur through company oversight. In an attempt to incentivize private entities to keep cybersecurity frameworks up to date, Ohio recently passed a law that creates a safe harbor against tort claims for companies who are victims of a data breach. In order to take advantage of this law, companies must comply with the strict state-mandated security framework criteria. Ohio’s innovative approach to cybersecurity enforcement aims to encourage all businesses to implement cybersecurity programs tailored to protect sensitive information while still allowing for technologies to improve.

When President Bush called for implementing EHRs in 2004, he—nor anyone—could have predicted the scale of the current data breaches. A healthcare system reliant upon EHRs is new territory for the health industry and will continue to draw in those who wish to steal its data. However, with continued reliance upon the protections of our regulations such as HIPPA and innovative methods to incentivize a high level of cybersecurity in the private sector, we can feel secure in our progress towards the future that EHRs can provide.

The ACA Twilight Zone

Death by a thousand cuts has been the Trump Administration’s approach to the Affordable Care Act (ACA).  To be sure, President Trump  tweeted on April 23, 2017 that “ObamaCare is in serious trouble.”  On October 13, 2017, he tweeted, “ObamaCare is a broken mess. Piece by piece we will now begin the process of giving America the great HealthCare it deserves!”  On May 30, 2018, he stated: “For the most part, we will have gotten rid of a majority of Obamacare.”  And on June 4, 2018, he tweeted, “We had Repeal & Replace done (and the saving to our country of one trillion dollars) except for one person, but it is getting done anyway. Individual Mandate is gone and great, less expensive plans will be announced this month.”

In the courts, the ACA has certainly been no stranger to the artful attack.  But two lawsuits, one filed in Texas and the other in Maryland, have gained nationwide traction and hold nationwide consequences.  The first suit, Texas v. US, made its way to U.S. District Court Judge Reed O’Connor’s bench in the Northern District of Texas.  The 20-state GOP led suit was filed on February 26, 2018 by Texas Attorney General Ken Paxton.  It argues that since the ACA was only upheld by the Supreme Court in NFIB v. Sebelius because the individual mandate was a tax, and now that the Tax Cut and Jobs Act of 2017 (TCJA) zeroed-out the individual mandate penalty, the entire ACA is unconstitutional.  The Plaintiff-states also argue that since the ACA does not have a severability clause – a clause that would allow the rest of the statute to live if one part is stricken – the ACA as a whole must fall.

Under Attorney General Jeff Sessions direction, the government will not defend the ACA’s constitutionality.  Defending the ACA, and its patient protections like the prohibition on insurers from discriminating against patients with pre-existing conditions, are 17 Democratic attorneys general representing their respective states as Intervenor-Defendants.  A slew of patient groups and scholars filed amicus briefs in support of the Intervenor-Defendants, but only Citizens United filed as amicus in favor of the Plaintiff-States.  The American Cancer Society Cancer Action Network filed as amicus, urging the court to uphold the ACA and to “recognize Congress’s clear intent to improve access to lifesaving health care for millions of Americans.”  A bipartisan group of law professors filed as amicus, arguing that “[t]he arguments of both the plaintiff States and the United States on the severability of the insurance mandate from the other provisions of the ACA are inconsistent with settled law.”  On July 19, 2018, Senate Democrats introduced a Senate resolution that would authorize Senate Legal Counsel to intervene in Texas v. US to defend the ACA’s patient protections for people with pre-existing conditions.

The second suit, City of Columbus v. Trump, filed on August 2, 2018 by the Cities of Baltimore, Chicago, Columbus, and Cincinnati in the U.S. District Court for the District of Maryland alleges that the Trump Administration’s actions over the last several years amount to an unconstitutional sabotage of the law the President is required to faithfully execute.  The suit makes two claims: the first claim that the Administration is acting arbitrarily and capriciously, and the second that President Trump is violating the “Take Care” Clause of the Constitution.  Under the Take Care Clause of the U.S. Constitution, the President and his or her Administration must “take care that the laws be faithfully executed.” U.S. Const. art. II, § 3.  The suit cites a range of administrative actions taken to sabotage the ACA and have the aim and effect of weakening ACA exchanges, driving up premiums, and driving out issuers, ultimately increasing the rate of the uninsured and underinsured.

Judge O’Connor, after first announcing that oral arguments in Texas v. US would take place on Monday, September 10, moved up oral arguments to Wednesday, September 5, at 9:30 a.m.  At the same time in Washington, D.C., Supreme Court nominee Brett Kavanaugh will be testifying before the Senate Judiciary Committee for potential confirmation.  As some have noted, the fate of the ACA could turn on Kavanaugh’s appointment to the Supreme Court.  Kavanaugh’s preeminent views on separation of powers and his textualist-meets-originalist approach to statutory interpretation is consistent and can be expected to appear in his opinions, but is alarming to health care advocates and patients.  Kavanaugh’s jurisprudence shows that he cares deeply about administrative law and is unlikely to “deconstruct the administrative state,” but he is likely to “put a tighter leash on the regulatory state.”  In all, the fate of the ACA remains to be seen.