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Blog Post

The No. 1 reason why abortion bans will make inequities worse

By Darby Sullivan

August 9, 2022

    There is no shortage of coverage on the direct clinical implications of the Dobbs v. Jackson decision, for good reason. According to a recent Advisory Board analysis, over 100,000 patients will be denied an abortion in their home state each year. Our analyses, in combination with academic evidence, highlights two ways abortion bans will worsen gender and racial health disparities in the short term:

    • Being pregnant in the U.S. is already risky—but not equally so. In the U.S., giving birth is 14 times more deadly than having an abortion. The United States has the highest maternal mortality rate across industrialized nations, with mortality and morbidity rates increasing over the past 20 years. Though all U.S. racial groups are impacted, Black, American Indian, and Alaska Native pregnant people are two to three times more likely to die from pregnancy-related causes than white pregnant people.
    • Abortion bans are dangerous for pregnant people and their children—and they will disproportionately impact historically marginalized people. Countries with more abortion restrictions have more unsafe abortions. An Advisory Board analysis shows how Black and low-income patients are disproportionately represented in states with abortion bans. Unsafe abortions are associated with infertility, chronic pain, and pelvic inflammatory disease, and 40% of patients who have unsafe abortions require hospitalization. One study estimates that, if the U.S. were to face a total abortion ban, maternal mortality would increase by 24%. And a 2021 study found that abortion legalization actually reduced maternal mortality among Black women by 30-40%.

    These two examples are only the start of the direct clinical implications of the reversal of Roe v. Wade. Experts also expect to see exacerbated behavioral health needs from the stress of trying to secure an abortion or the reality of carrying an unwanted pregnancy.

    But as serious as the clinical implications of abortion bans will be (and we're just beginning to understand them), these near-term effects are not the full story of how this decision will impact health equity. And when we don't know the full story, we can't sufficiently prepare for the future.

    Our hypothesis: The long-term socioeconomic implications of this decision will be bigger than the short-term clinical impact—and they will be felt for generations

    We predict that the biggest impact abortion bans will have on health equity will be the negative socioeconomic impact that additional unwanted pregnancies will have for generations to come for pregnant people, their families, and their communities. And that's because:

    • Denied abortions worsen poverty. To state the obvious, raising children costs a lot of money. Families who have been denied access to an abortion are four times more likely to be living below the Federal Poverty Line. Pregnant people who are denied abortions routinely experience more debt, lower credit scores, and worse financial security post-pregnancy than those who secure a wanted abortion. They are also 44% less likely to complete a post-secondary degree, stunting educational attainment and long-term earning potential.
    • Poverty is the common link among the social determinants of health, which impact up to 50% of health outcomes. Poverty limits one's ability to live in a safe neighborhood, afford quality housing, and access healthy food. It determines which schools are available to children and to what extent people can access broadband and digital tools. Once an individual or family slips into poverty, it's incredibly difficult to emerge from it—including for the generations that follow. In fact, Advisory Board has published extensively on how intergenerational poverty along with structural inequities (like racism) are the two root causes of health disparities.

    Of course, poverty impacts all clinical outcomes, not just obstetrics. The entirety of health care delivery will feel the ripple effect of this decision.

    When poverty gets worse, every single health equity initiative will suffer

    We can't overestimate the importance of that last point. Abortion bans will lead to higher poverty rates. The health care leaders we work with well know how poverty can stand directly in the way of their most elemental strategic goals: improving patient outcomes and reducing total cost of care.

    Life sciences companies see how poverty limits medication adherence. Service line and physician leaders under both fee-for-service and value-based care contracts contend with how poverty complicates care plan adherence and quality goals. Health plan leaders increasingly quantify the impact poverty has on avoidable high-cost utilization.

    In response, cross-industry leaders have made public commitments toward advancing equity and have made significant investments in the social determinants of health. There's growing consensus that, to make progress, the industry must address the root causes of disparities.

    But the fall of Roe v. Wade will make every effort to advance equity—no matter its focus—more difficult. And let's not forget that these effects are compounded by the Covid-19 pandemic, which laid the greatest clinical, emotional, and socioeconomic burden on the same populations most at risk after Dobbs v. Jackson.

    The pandemic was our industry's health equity wake-up call. Dobbs v. Jackson is the first major test of our commitment

    We've spoken with many health care leaders across the C-suite who have described 2020 as their wake-up call for health equity. That mental shift led to marked changes in how executives across the industry set strategic goals and allocated funding.

    The overturning of Roe v. Wade should inspire a similar reckoning for health care leaders. If our hypothesis comes to pass, the ripple effects of this decision could mark one of the greatest setbacks for health equity in modern memory. And it's the first major test of the industry's proclaimed commitment to advancing equitable outcomes.

    This moment likely feels deeply overwhelming for health care leaders—and for good reason. In many ways, you may feel as though the starting line for advancing health equity has been yanked backward. But the good news is that you're not starting from scratch anymore.

    The industry has made real strides toward advancing health equity in the past few years, and our guidance today is the same as it ever was. Here's how to start building a health equity infrastructure that cements equity as a need-to-have, not a nice-to-have:

    • Incorporate health equity into the strategic functioning of your business—rather than defaulting to press releases or passion projects. This requires a comprehensive approach that addresses your workforce needs, patient outcomes, and community conditions.
    • Track granular data on your progress and be transparent about where you're falling short—and you may increasingly fall short as the ripple effects of Dobbs takes shape.
    • Orient all work toward a longer-term vision of addressing the root causes of disparities—poverty and racism, which may now seem all the more intractable. This can take the form of cross-industry partnerships or policy advocacy aimed at advancing structural change in our industry, or serving as an "anchor" institution to uplift the economic outcomes of your community.

    Now, let's get to work.

    Rachel Woods, Alex Polyak, and Sarah Hostetter contributed to this post. 

    Roe v. Wade has fallen: Here’s what’s next for health care leaders

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    The Dobbs v. Jackson ruling has triggered a cascade of consequences for health care leaders and the people they serve, and has introduced unprecedented complexity to organizations operating across state lines.

    Advisory Board has been working to understand the implications for all stakeholders since the draft opinion was leaked in May. Our research will not provide moral guidance, policy advocacy, or political prognostication. Rather, our goal is to provide practical guidance to you as a health care leader—to help your organization adapt to change by distilling the most likely scenarios in this moment of heightened uncertainty, and by pointing you towards actions that will improve outcomes for your organization, people, and patients.

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