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July 28, 2022 | Volume 26, No. 6| Archives
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| Discussions of Reproductive Care, Guns, and Budgets (continued)
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| In This Issue:
- The Administration and Reproductive Care
- Congress and the Bipartisan Safer Communities Act
- Congress and Reconciliation Budget Negotiations
- COVID Corner
- What We're Reading
Three big policy areas are dominating the conversation right now: reproductive care, guns and violence, and ongoing negotiations on the former “Build Back Better” proposal, now referred to as budget reconciliation. Read more on each topic below to find out how these issues impact the HCH community.
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The Administration and Reproductive Care
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After the June 24, 2022, Dobbs v. Jackson Women’s Health Organization Supreme Court ruling, the Biden Administration has been searching for ways to protect reproductive rights across the country. President Biden issued an executive order to marshal coordination between federal agencies in order to protect abortion access and health care privacy.
In response to these mandates, CMS (Centers for Medicare and Medicaid Services), issued guidance that pregnant people presenting at emergency rooms for lifesaving abortion-related care were protected by EMTALA (Emergency Medical Treatment and Labor Act). Under the law, physicians must provide emergency medical care including abortions to stabilize patients. CMS made it clear that EMTALA pre-empts any state law regarding the procedure.
Disregarding the likely increase in self-managed abortion-related injuries, pregnant people may need abortion care after natural pregnancy loss, a cancer diagnosis, extreme hypertension, preeclampsia, and for an ectopic pregnancy. After the Dobbs decision, research from the University of Colorado-Boulder indicates that pregnancy-related deaths will rise by 24%. Clinicians in states where abortion is illegal are likely to get less or no training in abortion care, and women needing related care are at higher risk of mortality.
The CMS guidance intends to reduce maternal mortality through emergency care, but states that have criminalized abortion already are fighting back. Texas Attorney General Ken Paxton has brought a lawsuit challenging the guidance as “unlawful” and an attempt to make emergency rooms “walk-in abortion clinics.”
At the direction of the executive order, the Department of Health and Human Services issued its own guidance regarding pharmacies and abortion medication. The guidance cites Civil Rights laws and forbids pharmacies from refusing to carry abortion medication such as misoprostol. Citing related concerns regarding miscarriages, HHS says refusing to fill these prescriptions is discrimination based on sex and disability.
Both CMS and HHS are using fines as enforcement. CMS also is so threatening to rescind Medicare and Medicaid provider agreements from non-compliant health care facilities. The U.S. has the worst maternal mortality rate among developed countries; the Administration is taking steps to prevent these statistics from getting worse.
The Biden Administration's executive order, issued on July 8, attempts to curb the impact of the Dobbs decision. It directs the HHS Secretary to submit a report to the President in one month regarding expanding and protecting access to abortion care, and enhancing access to family planning and emergency contraception. HHS is directed to promote information about places to receive free reproductive services and comprehensive contraceptive counseling (and specifically calls out the role of FQHCs). The order mandates coordination between government agencies and advancing legal remedies to protect patient privacy, especially for those traveling across state lines for abortion care.
Moving Forward: CDC data for 2020 shows that maternal mortality for Black women is two to three times higher than for White women. Instead of improvement, there has been a significant increase in maternal mortality between 2018 and 2020 for Black and Hispanic women. Research reported in Duke University Press regarding the criminalization of abortion indicates that pregnancy-related death not tied to self-managed abortion will rise by 7% in the first year after the Dobbs decision and an estimated 21% in subsequent years.
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ACTION STEPS: It is more important than ever to provide education and offer comprehensive contraceptive counseling. Long-Acting Reversible Contraceptives (LARCs) are especially important to the HCH community and technical assistance should be provided to clinics to increase services. Title X and other funding streams should be accessed to remove cost barriers to LARC, and referrals should be made to clinics offering insertion services.
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Congress and the Bipartisan Safer Communities Act
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False conclusions about the dangerousness of mental illness prompted, in large part, funding for State Crisis Intervention Orders. These programs received $750 million in funding. Members of Congress emphasized the use of funds to establish and maintain “Red Flag Laws” to confiscate guns on an emergency basis from people thought to pose a danger to themselves or others.
However, this funding can be diverted for other purposes, such as Assisted Outpatient Programs. AOPs are involuntary outpatient programs that are supposed to reduce criminal recidivism and promote independent community living. Clinicians and lawmakers are very fond of these programs; patients say they are coercive and violate their human rights.
Insidiously, people living with mental illness can be court-ordered into these programs due to prior hospitalizations, whether or not they have committed a crime. Most states have an ambiguous definition of the reasons for involuntary outpatient commitment, such as that people living with mental illness are incapable of caring for themselves or of sound decision-making. Persons are ordered into these programs with little legal recourse, essentially stripping this population of their constitutional rights under the Fourth Amendment.
Providers argue that these programs have positive outcomes for patients and promote medication adherence and reduce recidivism rates. Consumer groups argue that these programs take away patient autonomy, sever the therapeutic relationship, and damage the potential for long-term care. When consumers do not have choices about their treatment, they are less likely to form a therapeutic alliance with their clinicians. Systemic racism also is embedded in this program, as Black Americans are disproportionately forced into treatment.
Studies indicate that patients have similar and increased positive outcomes when offered voluntary Assertive Community Treatment. ACT programs offer wraparound services which address physical, behavioral, and social determinants of health from a person-centered approach. They work to improve employment outcomes, prevent or ameliorate homelessness, provide medication access, and address co-occurring substance use issues. There is no evidence that AOPs produce better outcomes than ACT programs. Studies do indicate that AOP programs are unsuccessful without the wraparound services that ACT programs include.
The complicated issues of homelessness make it more difficult for the HCH population to comply with obtaining medication and reporting to medical appointments. Transportation access and provider location are not taken into consideration as courts choose providers for consumers. Many AOPs do not provide wraparound services, and consumers will be met with demands on their time and no supports. Failure to comply results in involuntary inpatient commitment. AOPs seem to be another way to criminalize homelessness and mental illness.
AOPs violate the right to privacy and bodily autonomy. They take away a person’s right to make decisions about their own health care and future. This trend is becoming deeply rooted in our nation’s history and traditions. It is a pervasive social injustice.
Moving forward: Assisted outpatient program laws already exist in 45 states. Our community should advocate for an overhaul of these systems with the use of the State Crisis Intervention Order funds. Definitions of eligibility, due process requirements, and mandated time limits should be incorporated into these laws if the programs cannot be dismantled altogether. The focus on people living with mental illness should transition from inaccurate public concerns regarding violence and to the health, wellbeing, and autonomy of individuals.
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Congress and Reconciliation Budget Negotiations
As Congress attempts to pass the narrow version of the Build Back Better plan, the coverage gap of more than two million uninsured people in Medicaid non-expansion states goes unaddressed (see our HCH insurance coverage fact sheet). The current bill is focused on extending the premium assistance for private insurance put in place with the American Rescue Plan Act. These premium tax credits are essential, and making them permanent would cover 7.4 million Americans. While this is important work, those Americans already have more financial resources than persons in the coverage gap. We cannot afford to leave millions of uninsured people behind.
People stuck in the coverage gap include people in the postpartum period who lose their Medicaid two months after birth, children who have aged out of Medicaid at 19, parents whose children leave home, and people whose income rose enough to lose Medicaid but not enough to afford insurance on the Exchange. Health inequity and racial disparities are inherent in the coverage gap, as people of color represent 60% of those uninsured.
Closing the coverage gap in states that expanded Medicaid has advanced social justice and health equity. Reductions in food poverty, economic insecurity, and evictions were benefits of providing enhanced access to Medicaid. Racial disparities improved where the difference in uninsured rates between Black and White people has declined by 11% since 2013.
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If it seems like everyone you know has had COVID recently, that is likely due to the very highly contagious variant BA.5 which is a subvariant of Omicron. The White House is continuing to encourage those 50 years and older to get a second booster dose of an mRNA vaccine a minimum four months after their first booster dose.
The FDA and CDC recently approved the protein-based Novavax COVID vaccine, which is a more traditional vaccine type and may appeal to those skeptical of the newer mRNA technology of the Moderna and Pfizer vaccines. Meanwhile, the White House is shifting its focus on a new initiative to develop vaccines which will focus on reducing the rates of COVID infection and transmission.
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This publication and all HCH advocacy are funded by dues from Organizational Members of the Council and by private donations. Consider joining the Council to support this work.
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