Today, Explained - Health care’s post-Roe nightmare

Episode Date: August 25, 2022

The Supreme Court’s decision to overturn Roe has implications far beyond abortion; it complicates access to vital drugs and delays essential care for pregnant people. The president of the American Medical Association explains how the chaos is hurting health care providers and their patients. This episode was produced by Victoria Chamberlin, fact-checked by Laura Bullard with help from Victoria Dominguez, engineered by Paul Robert Mounsey, and edited by Matt Collette and Noel King, who also hosted. Transcript at vox.com/todayexplained  Support Today, Explained by making a financial contribution to Vox! bit.ly/givepodcasts Learn more about your ad choices. Visit podcastchoices.com/adchoices

Lots of healthcare professionals, doctors, nurses, pharmacists, predicted that there would be chaos in their field if Roe v. Wade was overturned. Here's what the president of the American Medical Association, Jack Resnick, has spent the past weeks hearing from some of those people. Physicians are literally having to call their hospital attorneys and ask questions like, is a 30% chance of this patient dying enough to meet our state's new criteria? Is the risk of losing one kidney enough to count as the health of the mother? The health of the mother? Under these new laws, it doesn't count so much because it can't. We're also seeing patients with new cancer diagnoses, life-threatening cancers, where they can't start their chemotherapy until they terminate their pregnancy.

And they can't terminate their pregnancy, so they can't get chemo. Coming up, the unintended consequences, the things we didn't predict, the people trying to get through this on Today Explained. This NFL season, get in on all the hard-hitting action with FanDuel, North America's number one sportsbook. You can bet on anything from money lines to spreads and player props, or combine your bets in a same-game parlay for a shot at an even bigger payout. Plus, with super-simple live betting, lightning-fast bet settlement,

and instant withdrawals, FanDuel makes betting on the NFL easier than ever before. So make the most of this football season and download FanDuel today. 19-plus and physically located in Ontario. Gambling problem? Call 1-866-531-2600 or visit connectsontario.ca. It's Today Explained. I'm Noelle King. After Roe was overturned, Francis Steed Sellers, a senior writer at The Washington Post, started looking into these stories about confusion among medical professionals. Early on in my reporting, I talked to a doctor I remember in Kansas City, Missouri,

who said that once the laws came through, she found herself going to the lawyers who work in the hospital, describing the various scenarios that come in the regular treatment of people who are pregnant. There has been an awful lot of uncertainty, and that's not only for patients, but also for doctors and pharmacists who've been trying to navigate their way through what seem like very murky laws. How sick does she have to be before the staff felt comfortable delivering her because of this law hanging over our head. We're calling the lawyer first, saying,

hey, we need to do this. Is it okay if I proceed? People can start having miscarriages and then their miscarriage may not complete and they need to use the same drugs. Or people's waters break early. That can be very dangerous. The pregnancy may end on its own or there may be

a remaining heartbeat, but they develop sepsis. They can go into a very extreme situation very quickly. There can be ectopic pregnancies. These are never viable. And women need to terminate those pregnancies very, very quickly. They're life-threatening. But none of these scenarios, I think, did the lawyer fully understand until this doctor sat down and tried to explain to her the kinds of complications that come with regular treatment of obstetric care there are those kinds of complications but then many others with medications as well the medications that are used to treat miscarriages are the same ones as for abortions. And also many medications have many uses and can damage fetuses. So there's a whole enormously complicated sphere

of issues that have come up for doctors and for pharmacists and as I said as well, for patients themselves. What's going on with pharmacists? Many of the drugs that are used, and particularly one called methotrexate, which is used to end ectopic pregnancies, these pregnancies that occur outside the uterus, have other uses. Methotrexate is used for cancer. It's also used very commonly and very effectively to treat rheumatoid arthritis.

In fact, it's the first line of treatment for most people after they're diagnosed, and it serves as the gold standard against which other treatments are evaluated. But in these states that have very restrictive laws, pharmacists need to be sure for their own safety, for their own sake, that when they hand out methotrexate, they're doing so for people who are taking it for rheumatoid arthritis, not to stop a pregnancy. Now, I think a lot of these things, these issues are actually going to settle out eventually. But still, in this moment of

confusion, pharmacies are asking pharmacists to make sure they know exactly what the drugs are being used for. And that can mean asking for diagnosis codes or it can mean contacting the patient's physician. Annie England-Nobland is a long-term user of methotrexate for rheumatoid arthritis, but says a pharmacy recently put her refill on hold. They needed to make sure that my rheumatologist actually prescribed me methotrexate for my RA and not so that I could, you know, abort a fetus. Now, let me add a little wrinkle to that. These drugs, many of these drugs can also damage fetuses. Women who are pregnant are at increased risk for death of the baby and for birth defects.

Women who are pregnant or who plan to become pregnant must not take a Trexep. So there's an added risk for doctors who may be prescribing a drug like methotrexate. So there's an added risk for doctors who may be prescribing a drug like methotrexate who then worry that the patient may accidentally become pregnant. Now they can cancel patients, but we all know that accidental pregnancies can happen. Then there's a whole ethical question, right? Women in the past with these accidental pregnancies might have had to resort to terminating the pregnancy. Instead, now, will they have to carry a fetus and potentially a very severely damaged fetus to town? We should note there were people who said when Roe versus Wade is overturned, everything will be fine. Abortion has been illegal in many states, you know, prior to the overturning. What gave you

the hunch that actually there might be chaos? Why did you start looking? Well, we saw an awful lot of reaction on Twitter. People were very worried. A lot of people talked about delays and denials and getting their drugs. We also saw stories of women beginning to bleed out before their ectopic pregnancies were being treated. Some of these stories seemed extreme. We also heard from patient advocacy organizations who said they were hearing from a lot of people who were having trouble getting their drugs. Those advocacy organizations are checking up and verifying the stories. And we spent a lot of time. We didn't rush these stories

in any way. We followed up with people. And there were some legitimate misunderstandings we found. I talked to a woman in a blue state who said she was being denied or delayed her methotrexate. It turned out when I called the pharmacy and went back to her and talked about the time she went, she turned up during the pharmacist's lunch hour. So the woman had made an understandable assumption, a wrong assumption. She was relieved when we found out what had happened. But in this very heightened political atmosphere, there are delays and denials happening. There are definitely problems happening that we're able to track. But there's also a lot

of anxiety that is allowing people sometimes to overstate the problems. One of my colleagues actually spoke to a woman who had decided to be sterilized because her doctor would no longer prescribe her methotrexate because of the risk of her becoming pregnant. Now, she was a somebody with a history of infertility. She didn't think it was a big risk herself, but that was the decision she made. I've talked to other women, another woman who decided to have a hysterectomy because she couldn't risk a pregnancy because she had a very dangerous condition called preeclampsia, when your blood pressure goes very high during two previous pregnancies and actually had had

strokes. So some women have been forced to take very extreme steps in order to prevent unwanted pregnancies. Right now, we're in a very, very confusing situation for women, and it is causing enormous emotional distress. Are patients forced to have these conversations with pharmacists at the pharmacy window in front of other customers? We've heard of that happening. I was embarrassed because I was in a pharmacy line and I said, okay, do you also need to know the first date of my last period as well? There are some very distressing situations where women need another drug to complete a miscarriage and then are asked at a pharmacy window, are you sure this is for a miscarriage and not to have an abortion? And that can be very, very distressing. I think one of the other things that's happened is we're just coming out of the most extreme moments with COVID and there's lots of turmoil anyway in the medical system.

So pharmacies are realigning their needs. Doctors as well have been under extreme pressure. And I think this coming on top of that, this kind of massive rethinking of how they go about their jobs, this caution, because, you know, OBGYNs have always faced very high rates of malpractice allegations. But these are felonies. And suddenly that changes the calculus for doctors. So, this is a situation of immense change that's coming just as people are emerging from COVID with all the stresses that is put on the system. How is pregnancy care changing? You know, some of these laws came into effect immediately after the Supreme Court's Dobbs

decision. I talked to some doctors in Ohio who treat high-risk pregnancies who had had to cancel planned abortions for the following week for women who had come to the very, very difficult decision to terminate pregnancies when they realized that their fetuses had extreme abnormalities. They were then told they had to travel out of state. So, in all these areas, these complex areas, as the laws change, doctors are having to get advice about what it means for them and for their continued treatment of patients. And patients are having to learn on the fly what they need to do if they do feel they need to terminate a pregnancy. Did you speak to doctors who said, once upon a time, I would make a decision,

I'm a professional. Now I go and talk to a lawyer, I go and talk to a colleague, I make sure there are complications with ectopic pregnancies. Sometimes when the cells settle either on a uterine scar from a cesarean section or cannot be seen. And so the doctor is left in a sort of gray area trying to figure out exactly where it is and worrying it might be inside the uterus, which would then put them at risk. And they've had to consult other people before moving ahead with a procedure that should be done expeditiously because it is a life-saving procedure. But many have resisted hospital ethics boards because those people are not experts in the way their fellow doctors are, and it may delay the treatment to go outside to external ethics boards. The doctors who are resisting going to ethics boards, what reasons do they give?

One doctor we spoke to, for example, talked to a colleague and a radiologist who had examined the patient themselves. They were right there, and they were able to work as quickly as they can. Another doctor I spoke to who had a patient who was developing sepsis after their waters broke early consulted a lawyer, but that doctor said to me this was a very black and white case. She still felt she needed to call her lawyer as she went in just to explain what she was doing. This was in the immediate days after the Dobbs decision. How often and how serious are the delays now? I mean, what you're talking about is essentially a thing that used to happen with some amount of immediacy. How serious is the problem of slowdown?

On every individual case, it's immensely serious, right? We're talking about life-saving procedures. Documenting this across the country is very, very hard. Doctors have always had to respect patients' privacy. This is through the HIPAA regulations. In addition to that, now many women in this very heightened political atmosphere don't particularly want to talk about their cases or put their names out there. So reporting this, discovering the numbers, figuring this all out is going to take a long time.

Coming up on Today Explained, it's not just reporters like Frances Steed Sellers who are hearing about post-Roe chaos, the president of the American Medical Association is going to tell us about the calls he's been getting from doctors. Thank you. wire cutter. AuraFrames make it easy to share unlimited photos and videos directly from your phone to the frame. When you give an AuraFrame as a gift, you can personalize it, you can preload it with a thoughtful message, maybe your favorite photos. Our colleague Andrew tried an AuraFrame for himself. So setup was super simple. In my case, we were celebrating my grandmother's birthday and she's very fortunate. She's got 10 grandkids. And so we wanted to surprise her with the Aura Frame. And because she's a little bit older, it was just easier for us to source all the images together and have them uploaded to the frame itself. And because we're all connected

over text message, it was just so easy to send a link to everybody. You can save on the perfect gift by visiting aururaFrames.com to get $35 off Aura's best-selling Carvermat frames with promo code EXPLAINED at checkout. That's A-U-R-A-Frames.com, promo code EXPLAINED. This deal is exclusive to listeners and available just in time for the holidays. Terms and conditions do apply.

The all-new FanDuel Sportsbook and Casino is bringing you more action than ever. Want more ways to follow your faves? We'll see you next time. and secure withdrawals. Get more everything with FanDuel Sportsbook and Casino. Gambling problem? Call 1-866-531-2600. Visit connectsontario.ca. It's Today Explained. I'm Noelle King, and we are back with Jack Resnick. I'm a dermatologist at UCSF in San Francisco, California, and president of the American Medical

Association. The AMA's job? The American Medical Association represents physicians and works to make sure that doctors around the country have the tools they need to take care of patients in the United States. It seems like dermatology, Jack's area of expertise, would be unaffected by Roe being overturned. That is not the case, it turns out. Even dermatologists in a lot of these states are now running into several things they prescribe where pharmacists won't fill them. You know, even kids getting Accutane for severe acne or a variety of psoriasis or skin cancer drugs where pharmacists are now demanding diagnoses and demanding pregnancy tests and demanding other things because they're scared of being prosecuted. Kids getting Accutane, that's one that never would have occurred to me, in all honesty.

What's the main thing that doctors are afraid of? Well, there's tremendous fear, frankly, about prosecution. In many of these states, violating these restrictive laws is a level five felony. So physicians face going to prison for taking care of the patient that's right in front of them. What are we supposed to do? Do we wait until it's too late and get sued by the family, and rightly so?

Or do we do, you know, our job, what we're trained to do, and have to defend that in court? We're worried about patients being prosecuted. We're worrying about patients' friends and family being prosecuted. We've even seen instances where people's social media posts and messages are being gathered by law enforcement. So I just can't sugarcoat what a dangerous time this is. And so I guess this brings us to the question of what can the AMA do about all of this? The Supreme Court has really cut off a major legal avenue

that we typically used in the courts to push back when state governments stepped in and tried to insert themselves into healthcare decisions that really should be between doctors and patients. when state governments stepped in and tried to insert themselves into health care decisions that really should be between doctors and patients. But we're doing everything we can to try to mitigate the downsides that we're facing and protect our patients as best we can. There's actually a federal law called EMTALA, and that's a law that's been on the books for many, many years. But it basically says that when you have a dying or unstable patient right there in front of you in an

emergency department, that you have to take care of them regardless of their insurance or any other issues. So for example, we worked with the White House and the U.S. Department of Health and Human Services to ensure that there was clarity from the federal government that that requirement really supersedes state laws, which might get in the way of a doctor being able to provide care for that unstable or dying patient. And we're thinking about other things that maybe haven't had as much coverage, like, for example, medical education. What's going to happen to the next generation of physicians that we train in medical schools and residency programs

in these states where they might not even get adequately trained in miscarriage or ectopic pregnancy management because those things are so limited in their states. That's extraordinary. That seems to be almost deliberately taking us back in time medically. It's very scary. And it's something we've been facing for some time as we've had That seems to be almost deliberately taking us back in time medically. It's very scary. And it's something we've been facing for some time as we've had physicians training in certain hospitals, for example, that might have policies where, depending on the ownership structure of the hospital, some of the full spectrum of reproductive health care, including abortions, might not be offered. But now to have entire states where that's happening really just adds to this crisis. If they're not getting exposed to the full spectrum of reproductive health care, that threatens their ability to take care of patients in the decades to come. I think it's a pretty well understood fact that there are disparities in treatment in the United States. If you have more money, it's easier to get health care. If you live in certain areas, it's easier to get health care. When Roe versus Wade was overturned, do you think there was an immediate effect on how equitable health care in this country is? I'm worried about the impact that it's going to have. I think these

kinds of restrictive laws, we know that they fall hardest on historically marginalized populations, especially those without the resources to travel to other states or to miss several days of work. And we already have a maternal mortality crisis in this country. The maternal mortality rates in the U.S. are far higher than in any country on the globe with our level of resources. And that crisis is worse, for example, among Black women. It's a problem that we need to solve and a problem that I'm fearful that this restriction in access to reproductive health care is going to make worse. So getting back to some of the dangerous medical situations we talked about before, like ectopic pregnancies, not properly cared for, those can threaten the

life of a pregnant person. And I also think once you take away access to full-spectrum reproductive health care, which includes physicians taking care of patients with desired pregnancies all the way through to delivery, and also sometimes includes abortion, what's going to happen in these states, particularly to marginalized populations, as these laws go into effect? Well, we know some things that are going to happen. We're going to see some patients turning to self-managed abortions without engagement of a healthcare team, and we know that's less safe. We know that patients who have to travel for abortions are going to get them later in pregnancy as they find the time and resources to travel and then wait in longer lines in those states that are still providing access to that

care. And then we also know there's a large body of evidence in the medical literature that shows us that those patients who are turned away and carry unwanted pregnancies all the way to term end up with more physical and mental health struggles over the course of their lives. They end up with worse economic outcomes and even a higher risk of intimate partner violence in their lives. So again, all of these things fall hardest on Black, Latino, Indigenous, transgender, and other populations. And I am worried that that's going to get worse as we see the fallout from this decision. We are two plus years into a pandemic, and for much of the past two plus years, we've been hearing about burnout being a problem among doctors. What has the overturning of Roe meant for doctors' mental health?

You've described people who are genuinely scared for their careers, people who are scared of being prosecuted. How is this affecting mental health? What have you heard? When I talk to physicians about burnout, it's largely about those things that get in the way of what drew them to medicine in the first place, right? This is about obstacles to providing the care that they wanna provide and that they know is best for their patients after informed consent and a process of engaging with patients and talking about the values that those patients also bring to the table.

So this is yet another thing, I think, that will add to physician stress and worries me about making sure that we have the workforce we need to take care of the health of the nation in the decade to come. And we are seeing substantial burnout, as you mentioned. I think physicians have been holding together a healthcare system these last few years that is stretched far too thin. And something like 20% of them now say that they're going to retire in the next two years.

And lastly, I wonder about you. You're a dermatologist by trade and by training? That's right. Do you ever have moments where you think, oh man, I just want to go back to being a dermatologist? You know, I love getting to take care of patients and I still do that as part of my life. And the privilege of getting to sit down one-to-one with a patient in an exam room and have them share their problems and their concerns with you and try to solve the puzzle or the mystery of what's wrong with them and talk through ways to make them better is really one of the most fun things we get to do as physicians. But I equally love my work

as president of the American Medical Association and getting to advocate for physicians and patients. It's not an easy time for so many reasons with assaults by governments really trying to insert themselves in the exam room and into that doctor-patient relationship. But if anything, it motivates me even more as to the importance of doing this job. I get to work with incredible colleagues.

I'm proud of the people and the profession that I represent. And I've certainly learned in my time in this career that one can never predict in any given year what the crises are going to be. But I'm glad I'm here and have the opportunity to try and make a difference. Today's show was produced by Victoria Chamberlain. It was edited by Matthew Collette and fact-checked by Laura Bullard. It was engineered by Paul Robert Mounsey. I'm Noelle King. It's Today Explained. Thank you.