Darby Sullivan

There were many unknowns when Dobbs v. Jackson was introduced last year, but we were quite certain about the impact on clinical outcomes. Being pregnant in the United States was already riskier than in similar nations, especially for Black, American Indian, and Alaska Native people. And earlier studies showed that abortion bans lead to more unsafe abortions, which carry consequences such as risks of infertility, chronic pain, pelvic inflammatory disease, and worsened behavioral health.

We also predicted another impact that Dobbs would have on health equity: higher poverty rates. Raising children is expensive, and data shows that those denied abortions are more likely to live below the federal poverty line and experience worse financial security than those who can secure a wanted abortion. The increase in poverty would be even more impactful on health equity than the short-term clinical impacts — not only for patients themselves, but also for every healthcare organization that’s made investments and proclamations for advancing health equity. The impact on healthcare organizations would be felt because fewer abortions and rising poverty would lead to worse health outcomes and higher healthcare costs. And for purchasers, we thought it was difficult to predict how those costs would change in the immediate aftermath of Dobbs.

New data shows that the Dobbs ruling has impacted clinical outcomes—where 64% of ob/gyns say that the ruling has worsened pregnancy-related mortality. We can also look at states that already had abortion restrictions before Dobbs to get a sense of how this ruling will  decrease access to maternity care — which we know increases maternal mortality and infant death. These are difficult outcomes to list so bluntly, but they are realities stakeholders have dealt with and will continue to navigate for the foreseeable future.

When it comes to poverty, we won’t know if our hypothesis was right for many years, given the compounding effect that poverty has on clinical outcomes over time (and generations). The good news here is that this situation means the healthcare industry still has time to intervene and address the root causes of social determinants of health – including those other than poverty—in their communities.

In the wake of Dobbs, it is more important than ever for leaders to build a health equity infrastructure that cements equity as a need-to-have, not a nice-to-have. The good news is, our guidance on health equity is unchanged—though leaders should stay on top of shifts in clinical outcomes in their state. To start, leaders must incorporate health equity into the strategic functioning of their business, rather than defaulting to press releases or passion projects. This requires a comprehensive approach that addresses workforce needs, patient outcomes, and community conditions. Then, leaders must track data and be transparent about where they’re falling short. Finally, they should orient all work toward a longer-term vision of addressing the root causes of disparities — poverty and racism. This can take the form of cross-industry partnerships or policy advocacy aimed at advancing structural change in the healthcare industry, or leaders can make their organizations serve as "anchor" institutions to uplift the economic outcomes of their communities.

Gaby Marmolejos

This time last year, we knew that people residing in states with trigger bans would be immediately impacted by the newly limited access to abortion, and we anticipated this number would grow as other states considered abortion restrictions. We predicted that there would be more live births and more telehealth visits for patients seeking medication abortions, as well as a rise in preventive measures like vasectomies and tubal ligations. And we predicted that restricted abortion access would lead to three alternatives for women denied the procedure, all of which carry a unique set of health risks: traveling out of state for abortion services; attempting unsafe, self-induced abortions; and ordering “extralegal” abortion medications by mail. But even as we named these shifts, we were quick to call out that any volume change would be small. Despite the small numbers, we suggested that all organizations prepare themselves for situations where new restrictions would impact care delivery, like a patient arriving in the ED with signs of a self-induced abortion or the number of requests for out-of-state visits.

In the year since Dobbs, the breakdown of abortion restrictions has only gotten more complex. While only a handful of states have abortion bans early in gestation – most states have at least one abortion-related restriction—whether it’s determined by viability, waiting periods, ultrasound requirements, care team requirements, limits on telehealth, or parental notification. Navigating these restrictions is only going to get harder as more states move to limit abortion access and more methods are put under scrutiny. We are still watching as court rulings threaten access to mifepristone — a pill used alongside misoprostol for medication abortions. While restrictions to-date have been at the state level, mifepristone is at risk of becoming unavailable nationwide — and therefore impacting all healthcare stakeholders. Ultimately, we expect  that of the Americans who seek abortions each year, 91,000 will shift how they access abortion care.

At least in the short term, patient preferences for reproductive health services shifted after Dobbs. Many hospitals and health systems have reported increases in volumes for permanent contraception services. One health system reported a 35% increase in new vasectomy consultation requests and a 22.4% increase in vasectomy consultation visits compared to one year prior to Dobbs. With the future of medication abortions in question, health leaders tell us some patients are opting for surgical abortions even when medication options are available. We have seen increases in out-of-state travel for abortion services and increased use of “extralegal” medication abortion by mail — though as we predicted, the overall numbers are small.

We don’t yet have good data on how many more patients have arrived at hospitals with complications from self-administered abortions or how many have received delayed care for miscarriages. Because those figures can be hard to parse out of the data, we may never know. But experts — including those at Advisory Board — are urging health leaders to prepare for this reality and adapt clinical and communication protocols to prepare their workforce to address health risks associated with abortion restrictions.

To prepare for future changes in volume of reproductive health services, health leaders should continue monitoring mifepristone court rulings, even in states where abortion is not restricted. We’ve already seen how legal battles can spur an increase in permanent contraceptive and surgical abortion procedure volumes, and a nationwide ban on these drugs may shift contraceptive care everywhere.

Sebastian Beckmann

While the overall volume shift associated with the Dobbs decision may be small, we predicted that changes in the legal environment would erode provider autonomy everywhere, causing anxiety among clinicians — and in some cases, changing the way physicians practice. To safeguard against legal (or public relations) risks, physicians would now have to ask themselves, “Will I get sued for performing this procedure or for not performing a procedure that might be medically necessary?” As a result, organizations would have to bulk up their legal, marketing, and communications teams to handle a rise in questions from providers, patients, and lawmakers. At the very least, those questions would slow down the care delivery process as new, often non-clinical stakeholders found themselves embedded in the patient journey.

Clinical decision-making has indeed become more complex — and legally risky.

We’re seeing that clinicians may feel insecure about treating women with miscarriages, which has led to a variety of news stories that unfold as personal tragedies. In states with exceptions that allow abortions to save the life of the birthing parent, doctors have faced repeated situations where they have to decide how close to death a patient needs to be before they proceed with an abortion. We’ve also seen examples of where fully complying with the law creates its own risks. For example, two hospitals are under federal investigation for endangering the lives of patients experiencing miscarriage by failing to provide necessary medical care.

Further, in a couple of states we are seeing attorneys general take an aggressive stance toward physicians who administer abortions, which has increased physicians’ perception of risk and the erosion of their clinical autonomy.

Legal complexities have only increased in the year since Dobbs, and leaders tell us they have even more questions as new regulations are enacted and often challenged. Despite this uncertainty, the good news is that health leaders can do a lot to support providers in search of autonomy. Importantly, leaders can take on the burden of keeping up with the shifting legal landscape. Organizations must ensure that providers and staff are constantly updated on the latest guidance for their state and the surrounding region — while never asking their workforce to take on this burden themselves. Beyond that, organizations can ensure that staff have simplified workflows that balance clinical appropriateness and legal defensibility when questions of clinical autonomy arise.

Sarah Hostetter

In the immediate wake of the Dobbs decision, we predicted that new legal risk, rising patient complexity, and reduced clinical autonomy would complicate clinical practice and increase the already alarmingly high rate of physician burnout and shift where physicians want to practice medicine.

When it comes to burnout, it is important to clarify that the loss of clinical autonomy is a new challenge — different from other root-causes of physician burnout — put on top of an already overburdened workforce. My colleague Sebastian described the impact of eroding autonomy on care delivery above, but we also predicted that the loss of autonomy would impact supply as more physicians switch employers, move states, retire early, or leave the practice of medicine altogether.

We also anticipated shifts in where physicians chose to practice. Female physicians (and employees in general) may be less interested in working in states with restricted abortion access. Ob/gyns and emergency medicine physicians may be unwilling to trade some of their clinical autonomy to practice in states with restricted abortion. We predicted that any changes in where or if physicians would practice would be significant because states that were likely to restrict abortion were the same states that already had some of the highest rates of physician shortages. These are also regions already facing difficult trade-offs for consolidating or closing reproductive services like labor and delivery. Ultimately, we feared that the areas struggling the most with shortages and pressures to close or consolidate services would be hit the hardest by shifting physician supply.

As expected, in the year since Dobbs we have seen an increase in provider burnout, though we haven’t yet seen that translate into higher rates of turnover or early retirement. What we have seen is a change in where physicians choose to practice. But even more concerning is that we’re seeing fewer medical students decide to pursue an ob/gyn residency at all — a huge problem for a specialty already facing problems with access to care. The data is already bearing this out. A recent study from the Journal of General Internal Medicine found that 82.3% of physicians want to work or train in states with preserved patient access to abortion care. Further, 76.4% of future physicians wouldn’t even apply to states with legal consequences for providing abortion access, which could have dramatic implications for the physician pipeline in states with restricted access — and ultimately impact patient outcomes.

For remaining ob/gyns, training has become more complex as residency programs scrambled to provide clinical training for things like spotting a self-induced abortion, something today’s physicians had not previously seen in their clinical lifetime. Not to mention the challenge of training physicians on how to practice under legal uncertainty, as we state above. 

Leaders should continue to focus on the drivers of burnout — whether they are the long-standing root causes like administrative burden or new factors like the perceived and real loss of autonomy in a post-Roe world.

Leaders should revisit any pre-Dobbs assumptions for clinical staffing and perform new projections for physician supply, particularly for ob/gyn. Comparing residency rates in your state versus the national average may be a quick proxy for whether ob/gyns will choose to practice there in the next 5 to 10 years. Organizations that project a lower supply in the coming years should focus on non-physician staffing, like deploying advanced practice providers (APPs) autonomously or increasing the pipeline of midwives.

Organizations with their own residency programs must ensure that their educational programs match the realities on the ground, so doctors enter practice with the knowledge and skills to operate in an increasingly complex legal and clinical environment. While these action items are specific to organizations in states with restricted abortion, all providers should invest in training for clinical and non-clinical staff.

Chloe Bakst

Last year, we predicted there would be a change in demand for various life sciences products, particularly an increase in contraceptives and medication-assisted abortions. We also predicted that clinicians would need more support to feel comfortable and confident in using these products as a patchwork of state laws and restrictions took hold. We advised life sciences leaders to tune into the needs of their commercial teams, provider partners, and customers who would ultimately face newfound challenges as they navigate the new clinical and operational realities after the fall of Roe.

As predicted, the landscape for dispensing and delivering medication abortion has become more complex. State abortion bans, specific bans on telehealth for medication abortion, state-level requirements for in-person dispensation of mifepristone (a drug used in medication abortions) and for in-person counseling and ultrasounds that are not medically recommended continue to restrict abortion access in many states.

One aspect that we miscalculated was just how high the stakes would be for pharmaceutical companies. New federal court challenges to the FDA approval process are leading to new uncertainties for life science companies. As a result, life sciences leaders will need to monitor state legislation and court proceedings and prepare for a potentially seismic shift in drug approval norms and authorities.

Questions remain. In the past, manufacturers have never had to wonder, “Can I legally deliver this FDA-approved product in this state?” Having to do so now creates a huge set of uncertainties for life sciences.

My colleagues detail above what leaders need to do to protect clinicians and patients in the aftermath of Dobbs. But health leaders need to also consider the implications for manufacturers if clinical products are challenged, deeply restricted, or taken off the market years after their safety and efficacy has been shown. That would ultimately impact patient care. Health leaders should continue to monitor court challenges to mifepristone and start to prepare for similar challenges related to other reproductive health-related products, including oral contraceptives and intrauterine devices.

Life sciences companies must also evolve their understanding of the complete patient journey and provide resources for clinicians and pharmacists who may be fearful of legal repercussions when treating patients.

Alex Polyak

We predicted the healthcare industry would not necessarily see changes in the amount of Medicaid and individual market plans covering abortion. However, we did expect to see changes with employers who have more flexibility and incentive to alter benefits to meet the reproductive needs of their members and keep their employees satisfied. In fact, we said that employers would have to address the topic of abortion if they wanted to effectively engage, recruit, and retain their workforces. We predicted that employees would need more communication around how organizations would handle the changing legal environment and employee needs and desires for abortion services.

We also suggested that employers would be pressured to take a stance on the issue as part of a larger trend where employees look to work for organizations with a commitment to social justice, no longer viewing their employer as merely a pay stub.

In the last year we’ve seen many employers expand reproductive coverage that they did not previously offer, despite having to wade through significant legal complexities. The practicalities of that coverage have largely focused on transportation for employees that need to travel out of state to access abortion legally. However, what we didn’t predict was just how aggressive challenges would be — or how strong pressures would be on corporations — including for services like transportation. As a result, employer action has been largely tempered. For example, we haven’t seen businesses relocating, despite what some expected in the early aftermath of Dobbs.  

There is also little evidence to suggest that employers conducted widespread listening tours or pulse surveys to understand how their workforce was impacted by the Dobbs decision or what benefits they were looking for from their employer in the coming years.

As a result of the employer response, workforce stability may erode. Above, my colleague Sarah showed evidence that suggests that healthcare workers are already making decisions on where they train and work based on their state’s (and organization’s) approach to abortion access. We expect a similar response for non-clinical staff and for the workforce as a whole.

Most employees under the age of 40 want to work for an employer that offers abortion care coverage, but employers themselves will have to navigate between should they provide support and can they legally do it. Many employees want their employers to continue to provide — if not increase — abortion support or coverage. That can include directly providing benefits for abortions or offering clear next steps for employees seeking abortion care, including transportation support, time off, and (if necessary) legal guidance.

There is already evidence of how these services will shift in the coming years. The number of U.S. employers offering travel benefits for abortion services is expected to double over the next few years. Over a third of employers (35%) now offer travel and lodging benefits for elective and medically necessary abortions, and another 16% of employers plan to offer abortion travel benefits in 2023. Employers with fully insured plans are expected to offer coverage for elective abortions in states where permitted by law by 2023, with 93% of companies indicating that they will do so.

As more employers offer abortion care coverage, they will need help understanding the legal landscape and what their options are. They may look to partners such as lawyers, brokers/consultants, and health plans to help them navigate the changing landscape.