Trauma Amid Roe v. Wade Despair 

Amid my concern of the massive societal impact from overturning Roe v. Wade, lies the intersection of this decision’s havoc with every iteration of trauma.

Roe v. Wade has been overturned, and like many, I’m devastated. There will be mass impact of this decision across systems and sectors for generations to come. As I pondered a unique way to approach this blog post, one chronic theme came to mind. Amid my concern for all populations, lies the intersection of this decision’s havoc with every iteration of trauma.

Here are the facts: There is Pervasive Trauma

  • Vulnerable and marginalized populations live with rampant access to care obstacles; historical, experiential, and medical trauma are embedded within in the DNA of each person. 
  • The Turnaway Study released last Spring revealed stark facts of trauma’s wrath for women denied an abortion.
    • They are 4X as likely to end up living in poverty, stay with abusive partners, suffer from poor physical and mental health, plus have decreased aspirations. 
  • Collective Occupational Trauma for practitioners will further escalate as they reconcile:

There Will be More Trauma to Come

We can also expect:

  • Thousands of unplanned births and the potential for increased maternal morbidity and mortalityThere will be trauma.
  • Increased mental health challenges for persons dealing with unwanted pregnancies; There will be trauma.
  • High rates of suicidal ideation, gestures, and action for victims of rape, sexual assault, and interpersonal violence who are forced to carry a pregnancy to full-term; There will be trauma.
  • A ripple effect for college-aged students facing an unwanted pregnancy, and forced to raise children on college campuses, delay, or give up hopes of earning a degree; There will be trauma.
  • Persons with chronic conditions, medical, psychiatric, and intellectual disabilities often face often life-threatening conditions when forced to maintain a pregnancy. “Abortion restrictions do not only endanger people who don’t wish to be pregnant. Many people who want biological children have conditions that put them at higher risk of adverse outcomes and miscarriages…this poses clear psychological risks, as well as physical ones”; There will be trauma
  • A rise in adverse childhood experiences scores for children born of unintended pregnancies, and for persons exposed to adverse life experiencesThere will be trauma.
  • Threats to other rights and freedoms of ALL vulnerable and marginalized populations across the diversity, equity and cultural inclusion landscape; There will be trauma.

Moving Forward

Many associations and entities have already published position statements opposing the overturning of Roe V. Wade. This list of resources will fuel your advocacy energies:

ACLU

Center for Reproductive Rights

Center for Trauma-informed Policy and Practice

Guttmacher Institute

Human Rights Campaign

International Partners for Reproductive Justice (Ipas)

Keep Our Clinics

NARAL Pro-Choice America

National Abortion Federation

National Black Women’s Reproductive Agenda

National Latina Institute for Reproductive Justice

National Network of Abortion Funds

PACEs Connection

Planned Parenthood

Rape, Abuse, Incest National Network (RAINN)

Women Have Options

There are other countless other resources, and I invite all to add resources to this list. In the meantime, seek support by reaching out to each other: family, friends, colleagues, and counseling. Stay fierce, advocate, and ensure appropriate care for those in need. There will be ongoing emotions to reconcile as society contends with the new reality. We must be ready to ensure necessary health and mental health intervention, and for every person. After all, There will be trauma.

What Good Is Health Plan Cost-Sharing When Persons Can’t Afford to Access Care?

Increasing numbers of persons challenged by cost-sharing options only adds to the growing tally of persons struggling with social determinants of health and mental health; this counters efforts to attain wholistic health equity.

Outcomes
Researchers analyzed data from the 2019 Survey of Consumer Finances with telling results:
• High percentages of non-elderly households lack sufficient assets to meet typical plan cost-sharing amounts.
-45% of single-person non-elderly households unable to pay average cost-sharing amounts of $2,000 annually; low income households were in the same boat
-63% could not pay over the higher plan amounts of $6,000.
• Available liquid assets for single-person non-elderly households with incomes <150% of the federal poverty level (FPL) were limited; available assets averaged $577 vs $1,753 for those between 150% and 400% of FPL, and $13,243 for those above 400% of FPL.
• Median available liquid assets among multi-person households were $698 for those below 150% of poverty compared to $2,996 for households between 150% and 400% of poverty, and $23,439 for households with incomes of 400% of poverty or more.
• 84% of multi-person households with incomes <150% of the FPL lack $4,000 in liquid assets
• 50% of households could not afford a basic employer insurance plan deductible ($2000)
• 2:3 households lacked funds to covered a high-end deductible ( $6000)

Deductibles, co-pays, co-insurance are common means of health plan cost-sharing. However, what happens when healthcare consumers are unable to pay them? A recent study by the Kaiser Family Foundation revealed the sorry truth: health plan enrollees are too often unable to access the care they need, or forced into medical debt and bankruptcy to do so. In a time when strong efforts are in play to bridge healthcare disparities and ease access to care, that reality remains an elusive butterfly for too many individuals.

Most households lack sufficient liquid assets to meet an out-of-pocket maximum. Some might recall that the Affordable Care Act limited out-of-pocket maximums for most private health insurance plans: $8700 for single coverage, $17,400 for family coverage. This is appalling considering the Affordable Care Act set out-of-pocket minimums, yet the average out-of-pocket maximum for single coverage in 2021 was $4272.

Rising Medical Debt
Amid the pandemic, high numbers of persons faced emergency medical bills from care, whether related to COVID-related costs, or deferred health and behavioral issues. Roughly 62% of households with incomes between 150% and 400% of the poverty level were unable to afford care or access the approximately $3000 needed to cover urgent care costs.

Recent reports show dismal results for persons dealing with psychosocial challenges, as well as rising medical debt:
• >50% of Americans experience medical debt
• >57% owed over $1000
• 40% had problems paying medical bills or affording premiums
• 65% who earned <$40,000 and 51% earning $40,000 to $75,000 could not afford premiums despite having employer-sponsored coverage.

• >51% of persons with employer-sponsored plans reported someone in their household delayed or skipped care, or filling a prescription due to the associated expense
• 26% of adults with an employer-sponsored plan had to cut spending on food, clothes, or other household items to pay their health-related expenses.
• 20% took on an additional credit card debt to pay their expenses

The rising numbers of persons challenged by cost-sharing options must be resolved. This reality only adds to the growing tally of persons struggling with social determinants of health and mental health, countering efforts to attain health equity. More must be done to enhance access to care for every person across the wholistic health landscape of physical, behavioral, and psychosocial health.

The Impact of Trauma and Systemic Racism on Wholistic Health Equity

Abundant data on wholistic health disparities mandates intentional, sustainable quality improvement action. Will the next generation of metrics account for this reality?

There is an industry priority to right the societal wrongs associated with historical trauma and systematic racism. These long-standing realities are key drivers of wholistic health disparities: physical, behavioral, and psychosocial health.. A fluid stream of outcomes mandate concordant approaches to racial, ethnic, and other cultural contexts of treatment (e.g., disability, familial choice, gender orientation, regional influences). Yet, despite research to validate data wholistic health outcomes, reflective quality metrics have not been developed.

What Are We Talking About?

            Abundant data assesses the impact of historical, racial, and other types of trauma on health and behavioral health outcomes. Increased healthcare utilization has been identified for survivors of physical and sexual trauma, primarily minority women. Campbell et al. (2002) studied 2,355 females, 21-25 years old, enrolled in a large health maintenance organization (HMO). Patients who experienced intimate partner violence had a far higher prevalence (>50%-70%) of gynecological and central nervous system complaints (e.g., back and pelvic pain, fainting, headaches, seizures), plus other stress-related health issues (e.g., hypertension, insomnia, susceptibility to viral/bacterial infections). Purkey et al. (2020)identified trauma survivors as frequent users of primary, urgent, and emergency care for acute and chronic symptoms. Clarke et al., (2019) discussed the presence of vague somatic complaints by patients who endured traumatic experiences (e.g., ACEs, bulling, pressures to excel in school and career). Costly emergency department visits and ambulatory diagnostic tests are frequently used to identify etiology for chronic and diffuse pain, digestive problems, headaches accompanied chronic illness exacerbation, yet to no avail.    

Another vital dyad for attention involves chronic pain management and stigma experienced by patients from marginalized communities. Wallace et al. (2021) completed a recent study; participants were trauma survivors (e.g., historical, racial, sexual) and members of indigenous, LGBTQIA+, or refugee communities. The results were telling. When physical and emotional pain were expressed to providers, they was minimized or dismissed. If acknowledged by providers, short-term prescriptions were given versus referrals to behavioral health and other specialists.

What Does it Imply?

Data mandates the need for intentional, sustainable quality improvement in this arena. Will the next generation of metrics account for this reality? Racism remains a major factor to drive racial and ethnic inequities in health and mental health, though fails to be addressed in healthcare’s quality proposition. Of the articles reviewed for this blog post, trauma-informed quality analysis of care remained elusive. 2021 saw a fresh generation of industry health equity measures, yet few addressed integrated care, let alone assesses wholistic health equity. Existing metrics continue to silo health or behavioral health. Insufficient focus has been on industry-vetted quality models addressing population-focused, concordant, trauma and equity-focused interventions. 

Where Will Health Equity’s Quality Compass Point?

This author is developing a Quintile Aim for consideration, which adds the pivotal domain of Wholistic Health Equity to the industry’s seminal quality compass. NCQA continues to push this agenda in evolving new metrics. Public comment is open (until 3/11/22) for new HEDIS measures targeting the SDoH. Wyatt et al. (2016) posed a 5-step quality model for organizations to advance health equity delivery to the communities they served, addressed in Figure 1. 

Figure 1: A Framework for Healthcare Organizations to Achieve Health Equity (Wyatt et al., 2016) 

Wyatt R, Laderman M, Botwinick L, Mate K, Whittington J (2016). Achieving Health Equity: A Guide for Health Care Organizations. IHI White Paper: Institute for Healthcare Improvement 

The model was well-intended though had limited substance or strategic action to leverage the intent. This effort was reminiscent of the Quadruple Aim; little data drove the model and obstructed full industry acceptance. By contrast, Dover and Belon’s (2019) Health Equity Measurement Framework (HEMF) is worthy of exploration. Based on the World Health Organization’s Social Determinants of Health model, HEMF vast evaluation areas to measure health equity at macro, meso, and micro levels, as shown in Figure 2. 

Figure 2: HEMF Framework Elements (Dover & Belon, 2019)

Dover, D.C. and Belon, A.P.  (2019. The health equity measurement framework: a comprehensive model to measure social inequities in health. Int J Equity Health 18,36 https://doi.org/10.1186/s12939-019-0935-0

The HEMF model is worthy of a test drive to gauge its true merit. Use of the wide-scope of theoretical and evidence-based industry elements is an asset. Population diversity and complexity are accounted for through power-related and disparity measures. Health beliefs, behaviors, and values are acknowledged with stress factored in; the traumatic-response across circumstances is embedded. My desire to keep this post brief limits further elaboration on the HEMF model. However, know it poses strong value as a robust quality model to address health, behavioral, and racial health disparities across populations exposed to trauma’s diverse lens.  

Have other integrated care quality models that account for wholistic health equity? Add your considerations and comments below!

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