key: cord-0851711-7uo18cjk authors: Thompson, Terri-Ann; Northcraft, Dana; Carrión, Fabiola title: Addressing Structural Inequities, a Necessary Step Toward Ensuring Equitable Access to Telehealth for Medication Abortion Care During and Post COVID-19 date: 2022-03-17 journal: Front Glob Womens Health DOI: 10.3389/fgwh.2022.805767 sha: 346b7cceee90d81ed4c6f8c959d9ab230fcb22e9 doc_id: 851711 cord_uid: 7uo18cjk Telehealth, one of the newest health innovations, has been promoted as a tool to enhance access to health care services in ways that center patient needs. However, integrating telehealth within an inequitable health system undermines its potential. This perspective highlights policies and practices that foster structural inequities and names their impact on the use and acceptability of telehealth for medication abortion among specific communities of color. Communities of color have a higher prevalence of abortion use but face many barriers, including financial and geographic barriers, to abortion access. Preliminary evidence on telehealth for medication abortion shows that it is highly acceptable, accommodating of patient needs, and may allow patients to access abortion care at earlier gestational ages. However, evidence during the COVID-19 pandemic shows that utilization of telehealth is lower among communities of color. We describe how systemic barriers, including regulations on or laws banning telehealth for medication abortion, disinvestments in digital access, and restrictions on public insurance coverage, could perpetuate lower utilization of telehealth for medication abortion care among communities of color. We call for systems changes that will remove these barriers and make this health care innovation available to all who may desire it. Telehealth, one of the newest health innovations, has been promoted as a tool to enhance access to health care services in ways that center patient needs. However, integrating telehealth within an inequitable health system undermines its potential. This perspective highlights policies and practices that foster structural inequities and names their impact on the use and acceptability of telehealth for medication abortion among specific communities of color. Communities of color have a higher prevalence of abortion use but face many barriers, including financial and geographic barriers, to abortion access. Preliminary evidence on telehealth for medication abortion shows that it is highly acceptable, accommodating of patient needs, and may allow patients to access abortion care at earlier gestational ages. However, evidence during the COVID-19 pandemic shows that utilization of telehealth is lower among communities of color. We describe how systemic barriers, including regulations on or laws banning telehealth for medication abortion, disinvestments in digital access, and restrictions on public insurance coverage, could perpetuate lower utilization of telehealth for medication abortion care among communities of color. We call for systems changes that will remove these barriers and make this health care innovation available to all who may desire it. Keywords: telehealth, telemedicine, medication abortion, equity, racial and ethnic disparities, reproductive justice, Medicaid, Every person should have the right to "decide the number, spacing, and timing of their children, to have the information and means to do so, and to attain the highest standard of sexual and reproductive health" (1) . However, for many communities of color in the United States (US), this right goes unrealized. Sociodemographic factors such as socioeconomic status, residence, race, and ethnicity, exclusively and mutually, shapes their reproductive health experience and has resulted in calls for the use of a reproductive justice framework (2) ; one that acknowledges the role of societal factors in the achievement of good sexual and reproductive health. Research indicates that health disparities based on social status and race/ethnicity exist and persist in the US. In the abortion space, Black, Latinx, and low-income individuals have higher rates of abortion (3) due to higher rates of unintended pregnancy, a consequence of reduced access to and effective use of contraceptives (4) . Simultaneously, these populations experience reduced access to abortion services (5) . Racial and ethnic differences in abortion access can be tied to a higher proportion of Black and Latinx communities being publicly insured and/or without insurance coverage (6, 7), a higher proportion being low-income (8) , and fewer abortion facilities being located in neighborhoods where more than half of the residents are Black or Latinx (9) . The results of reduced abortion access are dire, with minority groups having disproportionately higher experiences of negative health and wellbeing outcomes such as increased financial insecurity (10) , reduced aspirational life plans (11) , and increased incidence of serious pregnancy complications such as eclampsia as well as poorer physical health for years post pregnancy (12) . One strategy for reducing abortion disparities is Telehealth 1 ; the use of electronic information and telecommunications technology to facilitate health care. Telehealth has been used to provide assessment, counseling, and follow-up care for medication abortion (a safe and effective abortion method where two medications, mifepristone and misoprostol, are taken to terminate a pregnancy). It has similar rates of effectiveness and safety as in-person provision of medication abortion care and is highly acceptable to patients (14) . Additionally, telehealth models for medication abortion have been shown to be person-centered models; accommodating childcare and jobs, eliminating the need to travel for care, reducing abortion related costs such as accommodation, lost wages, and childcare, and maintaining privacy (15) (16) (17) . Telehealth delivery of abortion care was in use prior to the COVID-19 pandemic, but its use surged during the pandemic to sustain access to services while observing restrictions on travel and in-person care (18, 19) . While telehealth has the potential to address barriers to abortion care and expand access, its full potential cannot be realized until policies and practices that foster structural inequities in healthcare generally, and specifically in abortion care and telehealth, are addressed. In this perspective we highlight a few of these policies and practices and how they limit the utilization and benefits of telehealth for medication abortion among Black and Latinx populations. Data on the utilization of telehealth for reproductive services is limited. Pre-pandemic, analyses of private claims data found that telehealth accounted for <0.05% of reproductive health claims (contraceptive management, medication abortion, prenatal care, and STI testing and treatment) (20) . Among the reasons for this low utilization is a preference for in-person care, low adoption of services by providers, and a belief that telehealth services 1 Terms used when describing telehealth: site-to-site (provider and patient at different facilities), direct-to-patient (provider at a facility and patient at another location, such as home), synchronous care (care that takes place in real time), asynchronous care (care that takes place through communication that occur at different times) (13). would be less personal or of a lower quality of care (20, 21) . Further, studies outside of abortion have highlighted disparities in telehealth use, with lower utilization seen among adults who were older, Black, self-paying, who had Medicaid, or Medicare status, and were from urban areas (22, 23) . These disparities are particularly concerning because they occur among those who already face systemic barriers to health care. Addressing these disparities requires an explicit look at policies and practices that impact the utilization, adoption, and acceptability of telehealth for medication abortion and have discriminatory effects. Abortion was a common medical procedure prior to the civil war, with a large number of practitioners being Black and Indigenous women (24) . With the end of slavery came a cry for more White births, and an assertion for White men to control the medical field (25) . The American Medical Association refused to admit women and Black people to its ranks and instead undertook a smear campaign to undo the status of midwives in American society (25) . Abortion was criminalized, leaving only the privileged with access to safe abortion care (24) . Although the constitutional right to abortion was established in 1973, there have been repeated attempts to limit practice and scope for both surgical and medication abortion. With regard to medication abortion, there are state restrictions on in-person (and thus, telehealth) dispensing of medication abortion medicines as well as on who can dispense abortion medications (26) . These restrictions work to reduce the ability of Black and Latinx patients to enjoy the benefits of telehealth for medication abortion such as accommodation as well as to engage with telehealth for medication abortion with their provider of choice. These laws also perpetuate the multiple intersecting inequities these communities face that reinforce distrust of the medical system. For more than twenty years, the Food and Drug Administration (FDA) has imposed significant restrictions on the dispensation and distribution of mifepristone, classifying it under a Risk Evaluation and Mitigation Strategy (REMS), allowing for the imposition of restrictions usually only placed on a limited number of drugs. The three REMS requirements were: (1) mifepristone must be dispensed only in a clinic, hospital, or under the direct supervision of a certified medical provider; (2) the prescribing provider must be certified in the mifepristone REMS Program by submitting a Prescriber Agreement Form to the drug distributor; and (3) the patient must sign and the provider must obtain the FDA-approved Patient Agreement Form (27). As a result of the efforts of reproductive health, rights, and justice advocates, on December 16, 2021 the FDA announced it will remove the in-person-dispensing requirement of mifepristone, permanently allowing its dispensing through mail or delivery. (28) While the FDA made it possible for any type of pharmacy to dispense mifepristone, it added a new requirement that these pharmacies be certified. Before the COVID-19 pandemic, telehealth for medication abortion care was available in a site-to-site, or clinic-to-clinic, manner. In this model, the patient had to travel to a clinic to be physically handed the pills due to the REMS (26) . Depending on geographic location, this may have required some patients to travel hours or hundreds of miles to receive pills dispensed after a telehealth visit (clinical evaluation, counseling, consenting). Only patients enrolled in an FDA approved clinical trial could receive direct-to-patient care and be sent medications by mail. Modeling done during the pandemic showed that nearly 2 million clinical abortion contacts could have been avoided if the REMS had been removed (29) . Given that 62% of abortions are provided to Black, Latinx, and other people of color (30) , the risk of exposure to COVID-19 was disproportionately higher for this population seeking this essential reproductive service than their White counterparts. Thirty-three (33) states only allow physicians to dispense mifepristone. These laws prevent non-physicians such as nursemidwives, nurse practitioners, and physician assistants, from providing medication abortion (26) . This restriction is not only harmful because of the growing role of advanced practice clinicians (APCs) in providing clinical services to underserved populations, (31) but also because preliminary evidence shows that nurse-centered care can alleviate medical mistrust (32), due to a history of medical racism (33) . Restricting who can dispense the medications disproportionately disrupts continuity of care for non-White abortion seekers. Despite evidence of its safety and effectiveness, 19 states currently either ban telehealth for medication abortion care or require inperson visits, which effectively bans the use of telehealth (26) . Eleven of these states are considered part of the south; states where Black and Latinx communities are highly represented (34) , that limited access to abortion facilities and providers (35) , and that amplified abortion restrictions during the pandemic (36) . Without telehealth for medication abortion, Black and Latinx patients in these states may have to travel long distances to access abortion care. Research shows that Black, immigrants, and other people of color are less able to travel long distances to obtain abortion care because of reduced material and social resources (37) . During the COVID-19 public health emergency, the federal government took various initiatives to encourage the utilization of telehealth to allow for social distancing and reduce unnecessary clinical contacts (38) . Additionally, the Centers for Medicare & Medicaid Services (CMS) published telehealth guidance to facilitate widespread adoption of telehealth services in state Medicaid programs (39) . However, the Trump Administration denied the American College of Obstetricians and Gynecologists and reproductive justice organizations' requests to lift the in-person dispensing of mifepristone, that would have allowed for the broader use of telehealth delivery of abortions (40). Given findings that Black and Hispanic women were more worried about being able to afford or obtain contraceptive services than their White counterparts during the COVID-19 pandemic (41), this denial placed this population at further disadvantage. Since 1976, an annual appropriations bill rider known as the Hyde Amendment has restricted federal funding for abortion services in Medicaid and other federal programs. The Hyde Amendment was designed to stop people living in poverty from having abortions, creating a de facto ban that would strip people of their constitutionally protected reproductive rights. Representative Henry Hyde, the sponsor who first introduced and long championed the Amendment, laid bare his intent: "I would certainly like to prevent, if I could legally, anybody having an abortion, a rich woman, a middle class woman, or a poor woman. Unfortunately, the only vehicle available is the... Medicaid bill (42) ." In its most recent version, the Hyde Amendment only requires abortion coverage in the narrow circumstances of rape, incest, or life endangerment (43). Thirty-three states cover abortions only as permitted by the Hyde Amendment and one (South Dakota) only covers abortions under life endangerment, violating federal Medicaid law (44) . The impact of the Hyde Amendment has reverberated in state coverage laws where 26 states restrict abortion coverage in plans offered through health insurance exchanges and 11 states prohibit abortion coverage in private plans (44) . Coverage restrictions limit access to abortion in all delivery formats; effectively placing telehealth for medication abortion out of reach for Medicaid beneficiaries, where Black and Latinx communities are vastly overrepresented because of income inequality and other economic challenges faced by this group. A past filled with disinvestments and isolation of communities of color keep telehealth from reaching its full potential. Initially, this can be tied to the practice of redlining, a now outlawed practice of manipulating home lending and ownership that is strongly associated with segregation in neighborhoods, separating Black from Whites. This separation was associated with increasing investments in White neighborhoods, such as health centers, grocery stores, and green spaces, and few to no such investments in Black neighborhoods (45) . While officially outlawed in 1968, with the Fair Housing Act (46) , the impact of redlining is still found today in the increased health disparities and more recently, stronger impacts of COVID-19 in Black and Latinx neighborhoods (47) . The impact can also be traced to a new form of redlining in digital form, found when neighborhoods populated predominately by people of color lack access to the internet and other technology resources compared to wealthier, White neighborhoods (48) . While there are many advancements in broadband access on the horizon, mainstream discussion is focused on rural populations, which tend to be predominantly White (49) . And even if broadband is available, it is not affordable for those living in historically oppressed and ignored areas, leaving them to rely on mobile-only communication options without smart phone capabilities (49) . The result is reduced abilities for Black and Latinx communities to connect to telehealth. A comparison of telehealth engagement and modality use (video vs. telephone) pre-and post-pandemic in a mid-size city's academic medical system, found that among telehealth users, Non-English speakers, Black patients, Medicaid, and Medicare-insured were less likely to use video than telephone (50). Language access is critical to navigating healthcare systems and the complex abortion care landscape. Language access can include oral interpreting, written translations, and provision of services directly in a non-English language (51) . Various federal laws like the Title VI of the Civil Rights Act of 1964 and Section 1557 of the Affordable Care Act require language access services; states also have codified their own protections (52) . However, there is a significant shortage of bilingual providers, translated documents, and medical interpreters in the healthcare system, as shown during the COVID-19 pandemic (53, 54) . Language concordant care is further limited by reimbursement, with few insurers directly reimbursing for interpreter services and others reimbursing at a lower rate (55) . In this context, adults with limited English language proficiency face language related barriers to care. Initial studies during the COVID-19 pandemic demonstrate varied levels of acceptance of telehealth, with Black respondents favoring telehealth visits over Spanish-speaking Latinx respondents, in large part because of unaddressed language access issues (56). Given the potential of telehealth to address inequities in health care access as well as its ability to offer care in ways that are patient centered, it is imperative policy and practice barriers be removed to ensure all the benefits of telehealth can be realized. In keeping with the reproductive justice framework, we believe systems changes will promote better reproductive autonomy and create communities in which people can thrive. The announcement that the FDA will permanently remove the in-person dispensing requirement for mifepristone solidifies telehealth as one service delivery method of medication abortion care. Results from a study out of the United Kingdom that examined what happens when in-person dispensing requirements are lifted, found that clinical outcomes for those using telehealth were equivalent to in-person care, abortion wait times were significantly reduced, and patients were able to access medication abortion care earlier in pregnancy (57) . Similarly, new data from Gynuity's TelAbortion study from the US confirmed that providing medication abortion through telehealth and mailed medication is safe and effective (58) . Among the nearly 1,400 abortions provided via telehealth, 95% were completed without a subsequent surgical procedure and 99% experienced no serious adverse events. While the FDA's suspension of the in-person distribution requirement for mifepristone is a step in the right direction, more can be done. Patient and provider certifications, that provide no additional safety mechanisms, should be removed, as should the recently added pharmacy certification requirement. Expanding the reach and acceptability of telehealth, will also require the removal of bans on telehealth delivery and restrictions on who can dispense the medications. Once telehealth for medication abortion is widely available, efforts must be made to facilitate integration of the service across multiple health facilities including community health centers, hospitals, in addition to abortion clinics. This will involve (1) instituting Federal grant programs that support the inclusion of telehealth and mobile integrated health to boost access to abortion care, and (2) a greater investment in resources for adults with limited English proficiency including reimbursement for medical interpreters by all insurers and adequate reimbursement rates. To ensure all people have the same ability to choose from all abortion delivery options available, efforts must be made to enhance the abilities of reproductive health facilities to offer abortion and telehealth for medication abortion care. This requires first that abortion coverage be expanded across the United States and second that public and private insurance agencies as well as managed care plans recognize and reimburse for abortion care across different modalities (such as telehealth) and a range of providers. As such, Congress must end the Hyde Amendment and pass the Equal Access to Abortion Coverage in Health Insurance Act, which would restore insurance coverage of abortions in health programs and plans such as Medicaid (59) and make available all delivery models of abortion. Federal and state laws must be updated, and resources must be allocated for increased broadband connectivity and utilization of devices. A recent Congressional allocation of $65 billion in broadband investments is a welcome first step to improve telehealth access (60) . Additionally, policymakers should allow consumers to use and permit Medicaid coverage of audioonly phones to access health services, like medication abortion. Approximately 97% of US residents own a cellphone of some kind (61) , making this device a ready point of connection between provider and patient. Further, services administered in-person or via live-video conferencing should be paid at the same rate as audio-only services. Such coverage would particularly benefit Black and Latinx communities since they have the least access to broadband, computers, tablets, and smart phones (62) . While telehealth is not the only solution to expand access to medication abortion, it should be considered part of a longterm, complementary, safe, and sustained strategy to improve access and convenience for every individual. During the COVID-19 pandemic, there has been rapid expansion in telehealth usage for various health services, including abortion care. It remains unclear whether telehealth addressed or exacerbated existing health inequities. However, now is the time to reflect on the system within which telehealth is being implemented and utilized, to work with communities of color, center a reproductive justice framework in the delivery of telehealth, and ensure systems are built that consider those facing the most hardships. Future research efforts should prioritize approaches that engage Black and Latinx communities in their formulation and implementation and seek to understand reasons for lower utilization of telehealth for medication abortion and the strategies that might address these challenges. The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s. The development of this perspective received no external funding. However, the article processing charges were funded by the Barrus Medical Foundation, the Collaborative for Gender and Reproductive Equity, and an anonymous funder. United Nations Population Division | Department of Economic and Social Affairs A reproductive justice history Population group abortion rates and lifetime incidence of abortion: United States Are higher unintended pregnancy rates among minorities a result of disparate access to contraception? Abortion in the Lives of Women Struggling Financially: Why Insurance Coverage Matters Health Coverage by Race and Ethnicity Available online at Kaiser Family Foundation. Medicaid Coverage Rates for the Nonelderly by Race/Ethnicity Available online at Racial Disparities in Income and Poverty Remain Largely Unchanged Amid Strong Income Growth in 2019 Guttmacher Institute Claim That Most Abortion Clinics Are Located in Black or Hispanic Neighborhoods Is False Socioeconomic outcomes of women who receive and women who are denied wanted abortions in the United States The effect of receiving versus being denied an abortion on making and achieving aspirational 5-year life plans Side effects, physical health consequences, and mortality associated with abortion and birth after an unwanted pregnancy Opportunities and Barriers for Telemedicine in the U.S. During the COVID-19 Emergency and Beyond Available online at Telemedicine for medical abortion: a systematic review Athome telemedicine for medical abortion in australia: a qualitative study of patient experiences and recommendations It was close enough, but it wasn't close enough": a qualitative exploration of the impact of direct-to-patient telemedicine abortion on access to abortion care TelAbortion: evaluation of a direct to patient telemedicine abortion service in the United States Trends in the use of telehealth during the emergence of the COVID-19 pandemic-United States The American Telemedicine Association. The Adoption of Telehealth Telemedicine in sexual and reproductive health Disconnects and digital divides: black women and birthing people's maternal telehealth experiences during the COVID-19 pandemic Disparities in use of telehealth at the onset of the COVID-19 public health emergency Characteristics of telehealth users in NYC for COVID-related care during the coronavirus pandemic Available online at: https:// healthlaw.org/resource/abortion-is-health-care The Racist History of Abortion and Midwifery Bans Kaiser Family Foundation. The Availability and Use of Medication Abortion Food and Drug Administration Approved Risk Evaluation and Mitigation Strategies (REMS) Food & Drug Administration. Questions and Answers on Mifeprex Available online at State and federal abortion restrictions increase risk of COVID-19 exposure by mandating unnecessary clinic visits Characteristics of U.S. Abortion Patients in 2014 and Changes Since Primary care nurse practitioners physicians in low-income rural areas Trust mistrust, racial identity and patient satisfaction in Urban African American primary care patients of nurse practitioners Race, medicine, and health care in the United States: a historical survey Six Maps that Reveal America's Expanding Racial Diversity Planned Parenthood Map: Abortion Laws and Access in the South State Action to Limit Abortion Access During the COVID-19 Pandemic Distance traveled to obtain clinical abortion care in the United States and reasons for clinic choice Available online at Policy Considerations for States Expanding Use of Telehealth. COVID-19 Version Early Impacts of the COVID-19 Pandemic: Findings from the 2020 Guttmacher Survey of Reproductive Health Experiences Office of the Federal Register NA and RA. Public Law 115 -245 -Department of Defense and Labor, Health and Human Services, and Education Appropriations Act Available online at Guttmacher Institute Regulating Insurance Coverage of Abortion The legacy of structural racism: associations between historic redlining, current mortgage lending, and health The United States Department of Justice The Fair Housing Act National Community Reinvestment Coalition. Redlining and Neighborhood Health National Community Reinvestment Coalition CNET the Broadband Gap's Dirty Secret: Redlining Still Exists in Digital. Available online at Discriminates Against Black Americans and Other Communities of Color Disparities in telephone and video telehealth engagement during the COVID-19 pandemic Appropriate use of medical interpreters Summary of State Law Requirements Addressing Language Needs in Health Care The Health Care System Is Shortchanging Non-English Speakers National Health Law Program. Discriminatory Provision of COVID-19 Services to Persons with Limited English Proficiency Reconsidering reimbursement for medical interpreters in the era of COVID-19 Equity in the Age of Telehealth: Considerations for California Policymakers Effectiveness, safety and acceptability of no-test medical abortion (Termination of Pregnancy) provided via telemedicine: a national cohort study Expansion of a direct-to-patient telemedicine abortion service in the United States and experience during the COVID-19 pandemic EACH Act of 2021 The Infrastructure Bill Is the Biggest Thing Congress Ever Did for Broadband Demographics of Mobile Device Ownership and Adoption in the United States Missed opportunity? Leveraging mobile technology to reduce racial health disparities. J Health Polit Policy Law We would like to thank those who contributed to the completion of this perspective, in particular Kelly Cleland, Kirsten Moore, Jane Perkins, Caitlin Gerdts, and Sonya Borrero. We are also grateful to the Reproductive Justice movement for their vision and tireless actions to push us towards a world where all can exercise their reproductive autonomy. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.Publisher's Note: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.Copyright © 2022 Thompson, Northcraft and Carrión. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). 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