Health maintenance begins before we are even born. For most of our lives, it does not consist of complicated interventions, surgeries, or expensive medications. Rather, from the early years through one’s mid-forties [1], health maintenance is almost entirely disease prevention. From the health care delivery end, it involves mainly monitoring and screening, vaccines, and counseling. We know that preventive care can help reduce disease burden in the population and, by doings so, could potentially reduce the overall costs of healthcare.  Since we can anticipate everyone needing this very predictable care, and since we know it will benefit the community, it should be made easier to access. To truly enjoy the benefits of preventive healthcare in the population and maximize its effect, all preventive health services should be covered by a single public payer, not requiring formal enrollment.

Introduction of the Affordable Care Act (ACA) increased insurance coverage and made preventive services a requirement for health insurance companies[2]. Enrollment in insurance programs increased, as did use of the health system. While this is an admirable shift, acquiring health insurance still remains a significant barrier for some subsets of the population. In 2020, some 30 million (11.1%) U.S. residents remained uninsured [3]. Surveys show that the lower the family income, the more likely a family is to be uninsured. [3] those who remain uninsured report most commonly that affordability is still a concern for them [4]. Still, the increase in utilization of preventive services by those who did get coverage [2], suggest that if patients know they are covered they may be more likely to seek preventive care. Making these services universally available would remove the hurdle of needing to acquire employment or independently enroll in a health care plan to access them – and perhaps get these services to the communities who may benefit from them most.

Unlike emergencies or acute illnesses, preventive services are predefined and theoretically given on a predictable schedule. Robust risk assessments are not required to understand their costs, which should be relatively low compared to the expenses associated with hospitalization. This would make it simple to budget for them reliably on an annual basis. Their predictability and guideline-directed frequencies also make the use of co-pays to limit overuse redundant. The ACA did remove cost sharing from preventive services in most circumstances, however there are some exceptions (e.g. receiving them from an out-of-network provider) [2]. With this structure, every provider would essentially be an “in-network” provider for certain services.  Additionally, having one payer for these services could increase bargaining power to further reduce their costs.

The notion of a true single-payer system continues to face substantial resistance and would be very difficult to achieve, both politically and logistically, in the near future. However, there may be more support for universally offering things like vaccines and screenings. Certainly, access to free covid tests over the last two years has been a boon, though the critical nature of the pandemic we are experiencing may have made openness to this a lower-hanging fruit. Yet, it may have set the stage for a culture more supportive of regular preventive care, especially if it is made convenient. Even before covid, there were systems to receive free flu vaccines without insurance, through work, the health department, schools, or state vouchers [5]. Yet, this patchwork systems puts the onus on the patient to figure out where and if they are eligible for a free shot. Why not simplify this in such a way that certain services are simply free, if designated as preventive and take the extra steps out of the equation?

A complete single-payer health system may be a way off, but laying the groundwork for it by at least covering all preventive care could be a step in the right direction. Starting in this way could sidestep the national anxiety on the availability and distribution of complex care in late-stage disease in an entirely socialized system. It could instead focus on lower cost, standard services that everyone needs even at the very beginning of their lives. It may be easier to garner support for this program which provides at least one service to everyone every year, rather than rely on a “pay-it-forward” or altruistic mentality. Though I would hope that equity becomes a core value for all of us one day, the appeal to self-interest could help this intervention succeed. And, in the process of creating this system for free and universal delivery of preventive care services, we would be building and troubleshooting the foundation for a greater single-payer framework.

1. Boersma P, Black LI, Ward BW. Prevalence of Multiple Chronic Conditions Among US Adults, 2018. Prev Chronic Dis 2020;17:200130. DOI: http://dx.doi.org/10.5888/pcd17.200130 https://www.cdc.gov/pcd/issues/2020/20_0130.htm#table
2. Sommers BD, Gawande AA, Baicker K. Health Insurance Coverage and Health – What the Recent Evidence Tells Us. N Engl J Med. 2017 Aug 10;377(6):586-593. doi: 10.1056/NEJMsb1706645. Epub 2017 Jun 21. PMID: 28636831. http://medicine.tums.ac.ir/filegallery/2299016929/nezamoleslami%2031%20ordibehesht.pdf
3. Finegold K, Commy A, Chu RC, Bosworth A, Sommers BD. Trends in the U.S. Uninsured Population 2010-2020. Issue Brief (ASPE) 11, Feb 2021. https://aspe.hhs.gov/sites/default/files/private/pdf/265041/trends-in-the-us-uninsured.pdf
4. Collins SR, Gunja MZ, Doty MM, Beutel S. Who Are the Remaining Uninsured and Why Haven’t They Signed Up for Coverage? Issue Brief (Commonw Fund). 2016 Aug;24:1-20. PMID: 27538268. https://www.commonwealthfund.org/publications/issue-briefs/2019/aug/who-are-remaining-uninsured-and-why-do-they-lack-coverage?redirect_source=/publications/2019/aug/who-are-remaining-uninsured-and-why-do-they-lack-coverage
5. Boston Public Health Commission. GET VACCINATED! Web. Accessed Feb 7, 2022. https://bphc.org/whatwedo/infectious-diseases/flu-information-center/Pages/Get-Vaccinated.aspx

We find ourselves at an inflection point in the history of American K-12 education. The wholesale adoption of an egalitarian public education system powered the United States through the course of the twentieth century. It was once a national source of pride, though in the last few decades this system has bifurcated. Lower-tiered school systems have struggled due to mismanagement and underfunding. The benefits of a solid K-12 education have never been clearer for succeeding in our rapidly evolving world, yet students from socioeconomically disadvantaged backgrounds in the United States have outcomes that are lagging further behind those of other similarly positioned nations.¹⁰ Concern abounds that this unequal education system with slanted outcomes will negatively impact American national security and prosperity going into the future.

Wide cracks in the foundations of our system were prime to burst open with a shock, and they indeed have with the COVID-19 pandemic. American public education has now been in a chronic state of crisis for the better part of the last two years. Our students have lost valuable time and opportunities to learn both hard knowledge and interpersonal skills. Socially challenging behaviors have become more commonplace with a return to broad in-person learning, combined with greater rates of general anxiety and depression.⁴ This compounds the list of worsening health outcomes seen in our students in areas like obesity, substance use, and sexually transmitted infections. Vulnerable children are sicker than in the past and will have a tougher time trying to learn in the classroom as a result.⁷ A big part of mending the damage done to our public education system by COVID-19 has to come in the form of aggressively investing in student health and wellbeing.

Validated tools to tackle such a diffuse problem as student health do exist. School-based health centers (SBHC) have a long history of offering diverse services to at-risk populations. SBHCs were started as a concept in the 1960s as part of the American Academy of Pediatrics Community Access to Child Health (CATCH) program¹ and grew rapidly in popularity as funding streams were solidified. There are approximately 2,000 centers nationwide,⁹ which is good but in total a small amount when compared to the number of public schools. They were incepted to provide a step-up from the traditional school nurse model and make more robust clinical services much more accessible. Clinics can be staffed by an assortment of provider types and offer services ranging from mental health care to dental services to family planning. The beautiful thing is that there is no exact template for a SBHC; it can specialize in the services that are of greatest importance or priority to its specific community. The clinics can and do serve as critical medical homes for those living in under-resourced areas.

The positive healthcare outcomes associated with SBHCs are apparent, especially among those who are underinsured or not insured.¹ Demonstrated improvements in pediatric asthma, obesity, and substance use rates are seen in schools with a SBHC.⁵ The rates of teen pregnancy have also declined while prenatal care for those who do become pregnant has shown improvement.⁵ Mental health, which has likely been the most directly damaged aspect of youth health due to the pandemic, can be aggressively managed right during the school day at a SBHC. Schools are already the most common setting for handling student mental healthcare, whether properly equipped to do so or not.² Schools with a mental health clinician in a SBHC have shown significantly improved outcomes in rates of reported student depressive episodes, suicidal ideation, and suicide attempts when compared to schools without such support.³ The SBHC can also play a role in the screening and early intervention among those with an adverse childhood experience (ACE) or who present with risk factors for committing a violent crime.

Improved health of the student population can have a knock-on effect on the educational and financial well-being of a community. Embedding health services within the school can decrease the need for parents to take time off from their work to bring a child to a medical appointment, helping to prevent loss of income.¹ Decreasing unnecessary and expensive visits to the emergency department can further save money for families, hospitals, and public insurance providers alike.⁸ Such savings can provide an outsized impact amongst vulnerable families with little financial flexibility for exorbitant medical bills.

The SBHC model can limit the amount of time a student has to miss from class. Additional time in the classroom has been shown to impact the educational achievements of students. Increases in GPA and decreases in suspensions and high school non-completion have been appreciated in schools with a SBHC.⁶ The school-based health center model is a demonstrated aid in assisting with scholastic advancement, which can provide more chances for success for disadvantaged Americans and give our nation’s industry the more educated workforce that it so craves.

The COVID-19 pandemic has provided an opportunity for a broad rethinking of America’s public K-12 education system. A proper approach to adjustment would be multi-disciplinary and require attention to a diverse area of need, but I hope the argument for keeping the foundational health of our students in mind is clear. The most effective way we can do this is by investing in the widescale implementation of school-based health centers within our communities, particularly those that are at the greatest risk of stagnation. A more cohesive and unified approach to modeling these school-based health centers is required going forward to tackle the massive strain that COVID-19 has placed on the system. If our nation still honestly values investing in opportunities for our vulnerable youth then ubiquitous school-based health centers can provide an elegant model for correcting and leveling the playing field.   

Works Cited:

1. Arenson M, Hudson PJ, Lee N, Lai B. The Evidence on School-Based Health Centers: A Review. Global Pediatric Health. January 2019. doi:10.1177/2333794X19828745.
2. Atkins, MS, Cappella, E, Shernoff, ES, Mehta, TG, Gustafson, EL. Schooling and children’s mental health: realigning resources to reduce disparities and advance public health. Annu Rev Clin Psychol. 2017;13:123-147. doi:10.1146/annurev-clinpsy-032816-045234.
3. Bains, RM, Cusson, R, White-Frese, J, Walsh, S. Utilization of mental health services in school-based health centers. J Sch Health. 2017;87:584-592. doi:10.1111/josh.12528.
4. “Covid Harmed Kids’ Mental Health-and Schools Are Feeling It.” COVID Harmed Kids’ Mental Health-And Schools Are Feeling It | The Pew Charitable Trusts, https://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2021/11/08/covid-harmed-kids-mental-health-and-schools-are-feeling-it. 
5. Keeton, V, Soleimanpour, S, Brindis, CD. School-based health centers in an era of health care reform: building on history. Curr Probl Pediatr Adolesc Health Care. 2012;42:132-156. doi:10.1016/j.cppeds.2012.03.002.
6. Knopf, JA, Finnie, RKC, Peng, Y. School-based health centers to advance health equity: a community guide systematic review. Am J Prev Med. 2016;51:114-126. doi:10.1016/j.amepre.2016.01.009.
7. Michael, SL, Merlo, CL, Basch, CE, Wentzel, KR, Wechsler, H. Critical connections: health and academics. J Sch Health. 2015;85:740-758. doi:10.1111/josh.12309.
8. Ran, T, Chattopadhyay, SK, Hahn, RA; Community Preventive Services Task Force . Economic evaluation of school-based health centers: a community guide systematic review. Am J Prev Med. 2016;51:129-138. doi:10.1016/J.AMEPRE.2016.01.017.
9. “School-Based Health Centers.” Official Web Site of the U.S. Health Resources & Services Administration, 30 July 2017, https://www.hrsa.gov/our-stories/school-health-centers/index.html#:~:text=Nearly%202%2C000%20school%2Dbased%20health,the%20HRSA%20Health%20Center%20Program.
10. United States – OECD. https://www.oecd.org/pisa/publications/PISA2018_CN_USA.pdf. 

I’ve spent the past four years of my life navigating higher education as I learn how to become a doctor, and while I can say that I do indeed feel prepared to enter residency, this experience has been by no means an easy road. For a field that prides itself on objectivity and “evidence-based” principles, medicine’s education system often does not hold itself to those same standards. Change is necessary in order to better our healthcare system.

Take, for example, racism as a public health threat. Studies have shown that patients of color have a life expectancy four years less than their white counterparts, have higher rates of maternal morbidity and mortality, and are more likely to die from COVID-19, to name a few issues.^1,2 So why, when we know this data, does becoming a physician still favor those who are white? One answer to this question is structural racism: communities of color are more likely to experience poverty, receive less compensation for their work, and have higher high school dropout rates than their white counterparts, making the pursuit of higher education more difficult.³ While many medical schools are making changes to their admission processes, investing into pipeline programs, and providing scholarships for education, change has been slow. The students who are admitted to medical schools need to reflect the populations we serve.  

Another point to highlight is the cost of medical education. Medical education has increased 750% since the 1960s, and in 2021, 72% of graduating medical students are at least $200,000 in debt.⁴ In my first two years of school, I went from attending in-person class to watching recorded lectures on my own time. Many of my classmates used other resources to prepare for both national boards and school exams, teaching themselves in a way that worked best for them than their $75,000 a year tuition. At the beginning of COVID-19, medical education went completely remote. Doesn’t it make sense for schools to use pre-recorded materials or to agree to share content? Additionally, some schools, including New York University, the Medical College of Wisconsin, and Duke have options to shorten medical school to three years instead of four. Why don’t more schools offer this? To make medical education more accessible, the cost to attend school needs to decrease.

Lastly, let’s talk about the clinical training in medical school. For this, I want to discuss the psychology of learning. Take the Yerkes-Dodson Law bell curve, for example: it describes a relationship between stress and performance, where memory and attention improve with stress up to a certain point, and too much stress decreases performance.⁵ The neuroscience behind this makes sense: the amygdala, which processes fear, is a crucial part of learning. Animal and human models show that the right amount of cortisol, a stress hormone, released into the blood stream, leads to improvements in memory, but too much, ie fear, significantly decreases retention.⁶

So why is it that, at one of the highest levels of education the teaching culture remains based in embarrassment and fear? I have yet to meet an attending who, upon meeting me, asks me my learning style and actually tries to cater their teaching to my stated needs. I have, however, had my hands hit away during surgery, been made to feel like an outsider, and been the subject of ridicule for not knowing the answer to a question. Other students have shared similar stories with me, and the AAMC reported that 43% of medical students experienced public humiliation.⁷ While not all medical students undergo humiliation by their teachers, the power dynamic and evaluation structure between student and attending, meaning a bad evaluation can ruin a student chances at matching to residency, continues to perpetuate a system in which students’ voices are stifled.

A good representation of this is the concept of “pimping.” While the general public associates this word with the racialized and gendered violence it defines, it was first introduced to medical education in 1989 when it was used it to describe something similar to the Socratic method in medical education. Detsky, in describing this, writes that “pimping occurs when an attending physician, the ‘Pimper,’ poses a series of difficult questions to a resident or medical student, the ‘Pimpee,’ traditionally during morning rounds.”⁸ This strategy may work for some, but overall, it’s usually executed in a way that reinforces medical education’s culture of fear and humiliation. I found this to be the case in my own learning. We need to get rid of this word and create a student-centered medical education system so that future physicians feel empowered both in patient care but also as the next generation of educators.

My experiences in medical school have shaped both the doctor and human I am today. Creating good, caring, culturally competent doctors is important for population-wide healthcare outcomes. It’s important to consider the ways the medical education system is failing its students in an effort to improve patient care.

References

1. Devakumar, D., Selvarajah, S., Shannon, G., Muraya, K., Lasoye, S., Corona, S., Paradies, Y., Abubakar, I., & Achiume, E. T. (2020). Racism, the public health crisis we can no longer ignore. Lancet (London, England), 395(10242), e112–e113. https://doi.org/10.1016/S0140-6736(20)31371-4
2. Paradies Y. A systematic review of empirical research on self-reported racism and health. Int J Epidemiol. 2006; 35(4):888–901. DOI: https://doi.org/10.1093/ije/dyl056
3. Reeves, R., Rodrigue, E., & Kneebone, E. (2016). Five evils: Multidimensional poverty and race in America. Economic Studies at Brookings Report, 1, 1-22.
4. Medical Student Education: Debt, Costs, and Loan Repayment Fact Card for the Class of 2021. Washington, DC: Association of American Medical Colleges, 2021. https://store.aamc.org/medical-student-education-debt-costs-and-loan-repayment-fact-card-for-the-class-of-2021.html
5. Yerkes, R.M., & Dodson, J.D. (1908). The Relation of Strength of Stimulus to Rapidity of Habit Formation. Journal of Comparative Neurology & Psychology, 18, 459–482. https://doi.org/10.1002/cne.920180503
6. Jacob Raber, Shahar Arzy, Julie Boulanger Bertolus, Brendan Depue, Haley E. Haas, Stefan G. Hofmann, Maria Kangas, Elizabeth Kensinger, Christopher A. Lowry, Hilary A. Marusak, Jessica Minnier, Anne-Marie Mouly, Andreas Mühlberger, Seth Davin Norrholm, Kirsi Peltonen, Graziano Pinna, Christine Rabinak, Youssef Shiban, Hermona Soreq, Michael A. van der Kooij, Leroy Lowe, Leah T. Weingast, Paula Yamashita, Sydney Weber Boutros, Current understanding of fear learning and memory in humans and animal models and the value of a linguistic approach for analyzing fear learning and memory in humans, Neuroscience & Biobehavioral Reviews, Volume 105, 2019, Pages 136-137. ISSN 0149-7634. https://doi.org/10.1016/j.neubiorev.2019.03.015.
7. Association of American Medical Colleges. Medical school graduation Questionnarie: 2018 all school summary report. 2018.
8. Detsky AS. The Art of Pimping. JAMA. 2009;301(13):1379–1381. doi:10.1001/jama.2009.247

Yesterday, South Dakota Governor Kristi Noem signed into law a transgender athlete ban – becoming the 10^th state to do so.¹ The law effectively inhibits trans-female athletes from competing in sports at any accredited (public or private) school in the state by asserting that, “only female students, based on their biological sex, may participate in any team, sport, or athletic event designated as being for females, women, or girls.” The law states one’s “biological sex is either female or male and the sex listed on the student’s official birth certificate may be relied upon if the certificate was issued at or near the time of the student’s birth.” The law also goes on to encourage cis-female athletes to pursue legal action against any organization that allows trans-female athletes to compete in sports designated as being for females.

This comes after a record-breaking year of anti-LGBTQ+ legislation, where more than 250 bills were proposed in 35 states, which overwhelmingly targeted trans youth.²

I received the notification of the South Dakota bill after I had just seen my third trans-identifying patient presenting to the pediatric emergency department for suicidal ideation – just four hours into my eight-hour shift. These patients all cited a crippling aloneness brought on by a constant bombardment of misgendering and the discrimination they felt on a daily basis. It is heart-breaking to consider there are pediatric patients reporting to emergency departments all over the country, and some lawmakers seem most concerned with assuring these patients be discriminated against in every aspect of their lives.

While one may try to argue these sports bans do not have an impact on all trans youth, a survey conducted by the Trevor project last year showed that over 80% of trans youth said that these sport bans negatively affected their mental health, regardless of their participation in sports.³

These discriminative bans are an assault on the mental health of an already extremely vulnerable population. Trans youth are disproportionally dying every year due to suicide. In 2019, the Centers for Disease Control and Prevention reported that about 35% of transgender students have attempted suicide.⁴ Transgender students are also more likely to engage in self-mutilation behaviors and use substances, such as cocaine, amphetamines, and inhalants than their cis-gendered peers.^5-6 This increase in risk was observed as early as middle school. Surveyed trans youth also reported feeling unsafe at or going to or from school (27%) and about 35% reported being bullied at school.⁴

Despite the discrimination-caused health risks seen in trans youth, proponents of these sport ban bills often cite the need to protect cis-female athletes from competitive disadvantages. However, experts state “no evidence that trans athletes are disproportionately dominating sports that correlate with their gender identity or that they have an advantage in their sport.”⁷ One of these experts, Dr. Eric Vilain, a pediatric geneticist who studies the competitive differences of athletics based of sex, says “there are no good faith reasons to limit transgender women’s participation in sports, especially at the high school level. It is merely a way to target women who look different.”⁸ In fact, most lawmakers who support these sports bans are not aware of a single instance within their state or region where a transgendered athlete’s participation has caused problems for cis-gendered athletes.⁹

This push to pass these legislative bans is nothing more than fear-mongering to push a political agenda that thrives on the divisiveness created by these “culture wars.”

This need to protect cis-gendered athletes from this non-existent problem is coming directly at the expense of the health of our trans youth. There is abundant evidence that having an opportunity to participate in sports leads to positive outcomes, such as improved self-esteem, better grades, and higher educational and occupational aspirations,^10-11 and these bans effectively inhibit trans youth from experiencing these benefits.  

Currently, 15 states have high school sports associations that have “trans-friendly” policies in place, but California is the only state that has passed legislation protecting trans athletes, according to Transathlete, a website that tracks and advocates for the inclusion of transgender athletes.¹² The California law also bans state-funded travel to any state which has discriminatory anti-LGBTQ+ laws in place.¹³ States with trans-friendly policies should adopt legislation similar to California’s law, which would create strong financial consequences for states that continue to discriminate against LGBTQ+ youth, as well as create a robust showing of support for trans youth throughout the country.

Trans youth are disproportionately dying every day, and we continue to let our lawmakers to discriminate against them. It is time to act.

1. Yurcaba, Jo. “South Dakota Governor Signs 2022’s First Trans Athlete Ban into Law.” NBCNews.com, NBCUniversal News Group, 4 Feb. 2022, https://www.nbcnews.com/nbc-out/out-politics-and-policy/south-dakota-governor-signs-2022s-first-trans-athlete-ban-law-rcna14725.
2. “In 2021, Our Fight for LGBTQ Rights Moved to the States.” American Civil Liberties Union, 16 Dec. 2021, https://www.aclu.org/news/lgbtq-rights/in-2021-our-fight-for-lgbtq-rights-moved-to-the-states.
3. “New Poll Illustrates the Impacts of Social & Political Issues on LGBTQ Youth.” The Trevor Project, Trevor News, 10 Jan. 2022, https://www.thetrevorproject.org/blog/new-poll-illustrates-the-impacts-of-social-political-issues-on-lgbtq-youth/.
4. “Transgender Identity and Experiences of Violence Victimization, Substance Use, Suicide Risk, and Sexual Risk Behaviors among High School Students – 19 States and Large Urban School Districts, 2017.” Centers for Disease Control and Prevention, 24 Jan. 2019, https://www.cdc.gov/mmwr/volumes/68/wr/mm6803a3.htm?s_cid=mm6803a3_w.
5. Liu, Richard T., and Brian Mustanski. “Suicidal Ideation and Self-Harm in Lesbian, Gay, Bisexual, and Transgender Youth.” American Journal of Preventive Medicine, Elsevier, 14 Feb. 2012, https://www.sciencedirect.com/science/article/pii/S0749379711009172?casa_token=XLsPx6NULzUAAAAA%3ATC2jCkG0Vby17pgRECrO-C9iqzzu6ZcZpnz-XAc0GfNqEEmOhXFGkxoJ1US75puDS19PGyfHAQ.
6. Pedro, Kris Tunac De, and Tamika D. Gilreath. “Substance Use among Transgender Students in California Public Middle and High Schools.” Wiley Online Library, John Wiley & Sons, Ltd, 6 Apr. 2017, https://onlinelibrary.wiley.com/doi/full/10.1111/josh.12499.
7. Alfonseca, Kiara. “South Dakota Signs 1st Anti-Transgender Sports Law of 2022.” ABC News, ABC News Network, 3 Feb. 2022, https://abcnews.go.com/US/south-dakota-signs-1st-anti-transgender-sports-law/story?id=82672739.
8. Ermyas, Tinbete, and Kira Wakeam. “Wave of Bills to Block Trans Athletes Has No Basis in Science, Researcher Says.” NPR, NPR, 18 Mar. 2021, https://www.npr.org/2021/03/18/978716732/wave-of-new-bills-say-trans-athletes-have-an-unfair-edge-what-does-the-science-s.
9. Crary, David. “Lawmakers Can’t Cite Local Examples of Trans Girls in Sports.” AP NEWS, Associated Press, 3 Mar. 2021, https://apnews.com/article/lawmakers-unable-to-cite-local-trans-girls-sports-914a982545e943ecc1e265e8c41042e7.
10. Fredricks, J. A., & Eccles, J. S. (2006). Is extracurricular participation associated with beneficial outcomes? Concurrent and longitudinal relations. Developmental Psychology, 42(4), 698–713. https://doi.org/10.1037/0012-1649.42.4.698
11. Nelson MC, Gordon-Larsen P. Physical activity and sedentary behavior patterns are associated with selected adolescent health risk behaviors. Pediatrics. 2006 Apr;117(4):1281-90. doi: 10.1542/peds.2005-1692. PMID: 16585325.
12. Mosier, Chris. “TRANSATHLETE High School Transgender Athlete Policies.” Transathlete, https://www.transathlete.com/k-12.
13. Castronuovo, Celine. “States Blast California for ‘Penalizing’ Travel to Them over LGBTQ Legislation.” The Hill, 29 June 2021, https://thehill.com/homenews/state-watch/560737-states-blast-california-for-penalizing-travel-to-them-over-lgbtq.

At the state public hospital where I was first learning to care for patients, the stark inequity in healthcare was inescapable, further magnified behind the bolted metal doors on the floor of incarcerated patients. After one of my patients had undergone an extensive medical workup with plans for discharge to jail once stabilized, I learned she would be unable to get her methadone during her detainment. Methadone, one of the three FDA approved treatments for opioid use disorder (OUD), had helped my patient maintain abstinence from opioids for over a decade. Not only is it unethical to withhold essential treatment, but the rapid taper off methadone that occurs in jails and prisons, often known as ‘forced detoxification,’ inhumanely precipitates severe withdrawal. Given the widespread impact of the opioid epidemic on communities across the United States, how is it possible that structures and systems can still deny patients this lifesaving medication?

There are well documented associations between OUD and the criminal legal system¹, which may have historical foundations given the United States’ penchant for criminalizing mental illness and addiction.  Furthermore, the nuanced social and economic factors that perpetuate community vulnerability to opioid use are the same factors associated with increased rates of incarceration, such as economic insecurity, housing instability, structural racism, aggressive policing, and years of generational trauma.^2-5 The opioid epidemic and mass incarceration are inter-related and overlapping crises and necessitate simultaneous examination to mitigate their impacts. As national policy discourse shifts to recognize these co-occurring public health crises, policymakers need to act urgently – starting with ensuring universal access to medication for opioid use disorder (MOUD) in the carceral setting.  

Between May 2019 and May 2020, the United States saw the highest number of overdose deaths ever recorded in a twelve month period at 81,000 lives lost.⁶ The standard of care for opioid use disorder is MOUD, consisting of methadone, buprenorphine (commonly known by the brand name ‘Suboxone’), or the long-acting injectable, naltrexone. These medications have demonstrated substantial evidence in helping patients achieve abstinence, decrease overdoses, reduce complications such as infections, and even decrease recidivism in the carceral system.^7-9 Despite the high prevalence of OUD among incarcerated individuals, with nearly two-thirds meeting criteria for substance use disorder (SUD)¹⁰ and one in five for OUD¹¹, access to treatment in jails and prisons is limited. Less than 20 percent of incarcerated individuals receive treatment for SUD¹² due to a myriad of systemic and policy barriers, and this has severe consequences.

In Massachusetts, where I am training, the rate of opioid overdose for formerly incarcerated individuals is 120 times that of the general population and overdose deaths account for half of all deaths for persons released from jail or prison in the state.¹³ These overdoses and overdose related deaths are often attributed to the cessation of MOUD in the carceral setting, as individuals develop a lower opioid tolerance during incarceration making them higher risk for overdose post-release. Currently only two state prison systems (Rhode Island and Vermont) and a limited number of jails across the country offer all three forms of MOUD to incarcerated people.^14,15 Research in these settings has shown that initiating or continuing MOUD while incarcerated actually improves treatment retention post-release and reduces post-release mortality.^16,17  Fortunately, this has led to professional organizations like the American Society on Addiction Medicine to release policy statements advocating for MOUD in the carceral setting.¹⁸ In addition, a few recent court cases citing violations of the Eighth Amendment “cruel and unusual punishment” clause and Title II of the Americans with Disabilities Act have pushed the mark on achieving access to MOUD in jails and prisons for select individuals.^19,20

Despite the shifting societal perspectives of MOUD and evolving legal standards influencing care for patients with OUD, there remain persistent challenges to achieving universal access to treatment in carceral systems. A major factor that has hindered implementation of MOUD in the carceral setting is the hyper regulation of MOUD at the federal level.  Buprenorphine can only be prescribed by licensed clinicians who have completed additional training and obtained a DEA waiver, and even after clinicians are still restricted to patient caps. Methadone, even more tightly regulated, can only be administered by clinicians at federally regulated clinics called Opioid Treatment Programs (OTPs). Jails and prisons often struggle to recruit and employ enough buprenorphine-waivered clinicians to meet patient demand and the process of obtaining an OTP license is even more arduous. There is an urgent need to make legislative and regulatory changes exempting correctional facilities from the regulatory barriers to prescribing and dispensing MOUD. Even in facilities that have obtained licensure to offer MOUD, the concerns regarding sustainability of these largely grant-funded programs are driven by federal laws that prohibit the use of Medicaid funds during incarceration. This “inmate exclusion” policy also greatly disrupts continuity of care as individuals are kicked off their insurance coverage during detainment and face numerous barriers to re-enrollment upon release. Federal regulation to eliminate this discriminatory and harmful policy is needed to ensure continuation of healthcare coverage throughout incarceration and ease the transition back into the community.

The most profound examples of health inequity that I have seen in my medical training thus far have been within the highly regulated systems that ought to best serve patients, but too often fall short.  Access to lifesaving medication is a basic fundamental right, and the standard of care practiced in the community must be extended to our jails and prisons. As the structures and institutions that fuel mass incarceration must be dismantled to achieve justice, so too must the laws and policies developed to combat the opioid epidemic. 

Sources

1. Winkelman TNA., Chang VW, Binswanger IA Health, Polysubstance Use, and Criminal Justice Involvement Among Adults With Varying Levels of Opioid Use. JAMA Netw Open 2018;1(3):e180558 Doi: 10.1001/jamanetworkopen.2018.0558.
2. Albright DL, Johnson K, Laha-Walsh K, McDaniel J, McIntosh S. Social Determinants of Opioid Use among Patients in Rural Primary Care Settings. Soc Work Public Health. 2021 Aug 18;36(6):723-731. doi: 10.1080/19371918.2021.1939831. Epub 2021 Jun 24. PMID: 34167439.
3. Sugarman OK, Bachhuber MA, Wennerstrom A, Bruno T, Springgate BF (2020) Interventions for incarcerated adults with opioid use disorder in the United States: A systematic review with a focus on social determinants of health. PLoS ONE 15(1): e0227968. https://doi.org/10.1371/journal.pone.0227968
4. Eaves, E.R., Camplain, R.L., Lininger, M.R. and Trotter II, R.T. (2021), “Adverse childhood experiences in relation to drug and alcohol use in 30 days prior to incarceration in a county jail”, International Journal of Prisoner Health, Vol. 17 No. 2, pp. 142-155. https://doi.org/10.1108/IJPH-06-2020-0038
5. Henry, B. F. (2020). Adverse experiences, mental health, and substance use disorders as social determinants of incarceration. Journal of Community Psychology, 48(3), 744– 762. https://doi.org/10.1002/jcop.22289
6. Press Release, CDC, Overdose Deaths Accelerating During COVID-19 (Dec. 17, 2020), https://www.cdc.gov/media/releases/2020/p1218-overdose-deaths-covid-19.html
7. Miller SC, Fiellin DA, Rosenthal RN, Saitz R, Kan D, Zweben J, Stine SM, et al. Pharmacological and psychosocial treatment for opioid use disorder. ASAM Principles of Addiction Medicine. Philadelphia: Wolters Kluwer; 2019. p. 805–828
8. World Health Organization. Guidelines for the psychosocially assisted pharmacological treatment of opioid dependence [Internet]; 2009.
9. Ma J, Bao Y, Wang R, et al. Effects of medication-assisted treatment on mortality among opioids users: A systematic review and meta-analysis. Mol Psychiatry. 2019 Dec; 24(12):1868–1883
10. CASA Columbia.  Behind Bars  II:  Substance Abuse and America’s  Prison Population.  February 2010.  Available  at: https://www.centeronaddiction.org/addiction-research/reports/behind-bars-ii-substance-abuse-andamerica%E2%80%99s-prison-population  
11. Bronson J, Stroop J, Zimmer S, Berzofsky M. Drug Use, Dependence, and Abuse Among State Prisoners and Jail Inmates, 2007-2009. Bureau of Justice Statistics: NCJ 250546; 2017
12. Chandler RK, Fletcher BW, Volkow ND. Treating drug abuse and addiction in the criminal justice system: Improving public health and safety. JAMA. 2009 Jan; 301(2):183–190
13. Massachusetts Department of Public Health. An assessment of fatal and nonfatal opioid overdoses in Massachusetts (2011-2015) [Internet]; 2017.
14. Prescription Drug Abuse Policy System. Medication Assisted Treatment in State Correctional Facilities [Internet]; 2019. http://www.pdaps.org/datasets/medication-assisted-treatment-in-correctional-facilities.
15. Mace S, Siegler A, Wu KC, et al. Medication-assisted treatment for opioid use disorder in jails and prisons: A planning & implementation toolkit [Internet] Vital Strategies.
16. Hedrich  D,  Alves P,  Farrell  M  et  al.  The effectiveness  of  opioid maintenance  treatment  in prison settings:  a systematic  review.  Addiction.  2012 Mar;107(3):501-17.  doi:  10.1111/j.1360-0443.2011.03676.x.
17. Green TC, Clarke J, Brinkley-Rubinstein L, et al. Postincarceration fatal overdoses after implementing medications for addiction treatment in a statewide correctional system. JAMA Psychiatry. 2018 Apr; 75(4): 405–407American Society of Addiction Medicine. The ASAM national practice guideline for the treatment of opioid use disorder: 2020 focused update [Internet]; 2020.
18. Pesce v. Coppinger, 355 F. Supp. 3d 35 (D. Mass. 2018)
19. Smith v. Aroostook County, 922 F.3d 41 (1st Cir. 2019)

I studied Spanish throughout secondary school and completed a major in Spanish Language in college, spending multiple months in Spanish-speaking countries to build my fluency. I also helped lead the Tufts Interpreter Program in medical school, which developed medical interpreting skills and medical vocabulary in students who already spoke non-English languages. Despite these experiences I am not a certified interpreter, but this has not prevented providers from often asking me to serve as one for the reasons discussed below.

My clinical experiences throughout medical school revealed that medical providers have a wide definition of acceptable interpretation practices. It also revealed that there are essentially no systems in place to hold providers accountable for their use, or mis-use, of interpreter services, other than poor patient outcomes. A few of the best examples of patient-centered communication include providers who are native speakers of a language interviewing fellow native-speaking patients, or a provider taking the time to schedule a certified interpreter to be present for morning rounds. On the other hand, I have also witnessed English-speaking providers walking into a Spanish-speaking patient’s room, two days out from receiving abdominal surgery, and palpating their belly while asking, “¿dolor?”, assessing whether their facial expressions conveyed an appropriate amount of discomfort given the size of their incision. 

The difference in these approaches is more than cultural insensitivity; it is dangerous to patient safety. 

The population of United States residents that is classified as Limited-English Proficiency (LEP) has grown rapidly over the previous decades. From 1990 to 2013, the number of LEP individuals in the US grew 80%, from 14 million to 25.1 million. Further, 61.6 million people spoke a language other than English at home in 2013.¹ Per more recent US census data, the speed of diversification across the country continues to accelerate, and will likely lead to even more variety of language utilization.² While Flores et al. recognize that much research has already highlighted the communication challenges present within healthcare, less insight is available into how hospitals can provide adequate support to LEP populations.³

Currently, Title VI of the Civil Rights Act mandates that any healthcare facility receiving federal funds must provide LEP patients with language services. The spectrum on which states align reimbursement policy with interpreter services though, is broad. 13 states and the District of Columbia provide direct, third party reimbursement for interpreter services, through Medicaid and the State Children’s Health Insurance Program (SCHIP), though the remaining 37 states do not offer such a straightforward mechanism which leaves hospital systems to construct and finance their own versions of adequate services.³

In one state-wide evaluation of hospital language services conducted in New Jersey (a state that does not reimburse for interpreter services through Medicaid/SCHIP), only 13% of surveyed hospitals stated they had a formal interpreter services department, though 97% of hospitals did contract with a telephone interpreting service. Of note, 31% of hospitals reported having English-only signs placed around the building. When asked if whether reimbursement from Medicaid/ SCHIP would improve access to interpreter services, 79% of hospitals responded affirmatively, with one adding that, “lack of reimbursement for outside interpreters means relying on bilingual hospital employees”.³ 

In the above quote, we see one of the major pitfalls that hospital systems experience in designing accessible and equitable interpreter services: reliance on bilingual employees who are not being compensated for interpretation services, and who may have not received formal training in the field. One of the flaws with this model was exposed by Speaking Together: National Language Services Network, a national initiative designed to improve the quality and availability of language services in US hospitals.⁴ A major finding of the initiative was that relying on bilingual staff members resulted in a majority of encounters with LEP patients being conducted using family and friends as impromptu interpreters.⁴ 

Various studies have shown the danger of using family and friends, over trained medical interpreters, including Lee et al, Hampers et al, and Flores et al demonstrating that the use of trained interpreters, either in phone or telephonic led to the best patient outcomes, the best patient satisfaction, and the fewest errors of potential clinical consequence.^{5, 6, 7} Lastly, while it is important to remember that the experience of Latinx parents cannot be directly generalized to other language groups, there is value in recognizing that “Latino parents consider the lack of interpreters and Spanish-speaking staff to be the single greatest access barrier to health care for their children, and one in 17 parents reported not bringing their child in for needed medical care because of language issues”.⁸ 

Surprisingly, simply increasing the number of trained interpreters available did not alleviate the issue of LEP patients receiving services in some cases.⁹ Unfortunately this was demonstrated in a hospital with adequate in-person interpreters, where LEP patients were found to have lower rates of documented informed consent for invasive procedures.¹⁰  In addition to resources, there is tremendous value in educating providers about the harms of using ad hoc interpreters.⁹ 

How can hospital systems both increase their interpreter resources and utilize them efficiently? At a national level, this process would be expedited by tying federal reimbursement programs to documented use of interpreter services, as a majority of hospital systems are already screening for patients’ preferred languages.⁴ At the state level, it is essential for the 37 states that do not link Medicaid/SCHIP with language service reimbursement to do so, though doing so is likely limited by political will in many of the 37 states. The increased and/or improved reimbursement mechanisms mentioned above would allow hospital systems to implement many of the concrete improvements to follow. 

The Speaking Together initiative identified  many traits from model programs that could be beneficial to other hospitals with LEP populations, namely systematic improvements such as directly linking patient registration systems (i.e. primary language information) with interpreter scheduling systems. Another systems-level solution includes tracking and displaying interpreter use data within the electronic medical record (EMR).⁴ For example, a consulting team would be able to view that the primary team or Emergency Department staff has been utilizing a phone interpreter during each documented encounter  Making this information visible on a patient ID banner would increase awareness about patient needs as well create accountability for subsequent providers to use proper language services.

Perhaps most importantly are hospital system resources devoted to providers to provide required training for interpreter utilization as well as certification for providers who are multilingual. Of course, the coordination of many of the above strategies is necessary to overcome the difficulties faced by LEP populations, and especially those faced by native speakers of less common languages. 

As providers and hospital systems consider how to improve the quality and accessibility of language services, we must be cognizant that we are establishing a foundation for systems that will grow continuously as the United States population becomes more diverse racially, ethnically, and linguistically. 

Works Cited: 

(1) United States Census Bureau. Detailed languages spoken at home and ability to speak english for the population 5 years and over: 2009-2013. Census.gov. Accessed 1/30/21

(2) Frey WH. The nation is diversifying even faster than predicted, according to new census data. Brookings. Accessed 1/30/21

(3) Flores, Glenn, et al. “Access to Hospital Interpreter Services for Limited English Proficient Patients in New Jersey: A Statewide Evaluation.” Journal of Health Care for the Poor and Underserved, vol. 19 no. 2, 2008, p. 391-415. Project MUSE, doi:10.1353/hpu.0.0007.

(4) Regenstein M. Measuring and improving the quality of hospital language services: insights from the Speaking Together collaborative. J Gen Intern Med. 2007;22 Suppl 2(Suppl 2):356-359. doi:10.1007/s11606-007-0358-2

(5) Lee LJ, Batal HA, Maselli JH, et al. Effect of Spanish interpretation method on patient satisfaction in an urban walk-in clinic. J Gen Intern Med. 2002 Aug;17(8):641–5

(6) Hampers LC, McNulty JE. Professional interpreters and bilingual physicians in a pediatric emergency department: effect on resource utilization. Arch Pediatr Adolesc Med. 2002 Nov;156(11):1108–13

(7)  Flores G, Laws MB, Mayo SJ, et al. Errors in medical interpretation and their potential clinical consequences in pediatric encounters. Pediatrics. 2003 Jan;111(1):6–14.

(8) Flores G, Abreu M, Olivar MA, et al. Access barriers to health care for Latino children. Arch Pediatr Adolesc Med. 1998 Nov;152(11):1119–25.

(9) Bischoff A, Hudelson P. Access to Healthcare Interpreter Services: Where Are We and Where Do We Need to Go? International Journal of Environmental Research and Public Health. 2010; 7(7):2838-2844.

(10) Schenker, Y., Wang, F., Selig, S.J. et al. The Impact of Language Barriers on Documentation of Informed Consent at a Hospital with On-Site Interpreter Services. J GEN INTERN MED 22, 294–299 (2007).

My third year of medical school began with five weeks of Family Medicine at a single-physician private practice in a small town on Cape Cod. My first responsibility was to discuss new treatment options with a patient whose chronic obstructive pulmonary disease (COPD) was not responding to her current therapy. After documenting the encounter in the patient’s electronic medical record, my preceptor called me into her office, where we had the following (paraphrased) discussion:

“This is not a complete note,” she stated. “You forgot her treatment plan for her diabetes, hypertension, hyperlipidemia, and osteoarthritis.”

“I thought that since she only needed care for her COPD today, that is what I should document.”

“Everything else she has should still be billed for. I would go out of business tomorrow if I only got paid for the chief complaint.”

Physician reimbursement in the United States is a convoluted process, and one not routinely taught in medical education. While discrepancies¹ in coverage for routine medical services have been publicly debated ad nauseum, one question has lingered for me since that first day in Family Medicine: who actually decides how much COPD costs to treat? Or diabetes? Or an MRI? The answers reveal issues inherent to our attempt to force the square peg of healthcare into the round hole of the free market economy, and why true healthcare reform might not be possible without an overhaul of the current system of price determination. 

Using Medicare as an example, physician reimbursement is a three-part process². First, the service provided (in our case, an office visit) must be coded using the Current Procedural Terminology (CPT) database; next, the patient’s diagnosis(es) (diabetes, COPD, asthma, etc) must be coded using the International Classification of Diseases (ICD) manual; finally, the Center for Medicare and Medicaid Services (CMS) determines the appropriate fee using a system known as Relative Value Units (RVUs). Each CPT/ICD combination (for example, “outpatient visit for COPD management”) carries a unique corresponding RVU amount. The formula for determining RVUs contains three parts: physician work/expertise (~52%), practice expense (~44%), and professional liability insurance (~4). Each part is multiplied by a geographic cost index (GPCI) that accounts for geographic variations in wages, cost of living, etc. Finally, the total amount is multiplied by a conversion factor (CF) that is updated annually by CMS. The result is a manual of region-specific fees for all types of medical management imaginable. The formula can be visualized as so:

Total RVU = (Work RVU x GPCI) + (Practice Expense RVU x GPCI) + (Professional Liability RVU x GPCI)

Total Payment = Total RVU x CF

Where things get murky is that the CPT coding system is a proprietary product of the American Medical Association (AMA), the largest association of physicians in the US³. Since the adoption of the CPT coding system by CMS, the AMA has charged healthcare providers for using it when negotiating with insurance companies, generating over $70 million in yearly revenue for the AMA (25% of yearly revenue). While the AMA recommends RVU updates to CMS annually, CMS accepts the revisions more than 90% of the time, leaving the AMA as the de facto final arbiter of all things medical pricing. In some instances, certain doctor services still include assumptions about routine care that are now decades out-of-date⁴. In other words, taxpayer dollars are sometimes paying for medical care that is grossly mis-valued.

To recap: the prices charged for the provision of healthcare are determined by an organization based occasionally on archaic methodology that artificially inflates the true cost of the service. This organization charges other physicians and hospitals for the right to use this pricing system (the only system available). This system is the basis for CMS reimbursement rates, which in turn serve as the benchmark against which private insurance companies negotiate their own rates. 

This system sheds a new light on my discussion with my preceptor. Operating under a traditional fee-for-service model, physicians have been backed into a corner by CPT monopoly. In what other “free market” must providers of goods and services be forced to price their services according to the only menu of prices available, then watch from the sidelines as middlemen negotiate around this menu to pay them a different amount altogether? Further, the budget neutrality clause of the 1989 Omnibus Budget Reconciliation Act (that established the RVU system of pricing) states that whenever the price of one clinical service is boosted, the price of another must decrease proportionally. This pits physician against physician, most often rewarding specialists at the expense of primary care physicians like my preceptor.

Cost-containment strategies in recent years have continued to operate under the assumption that healthcare is bought and sold in a traditional marketplace. While some efforts (introducing physician performance metrics, penalizing providers for unnecessary resource utilization, Accountable Care Organizations) have succeeded in slowing the growth of healthcare expenditure, market justice will never coexist with price monopolization. CMS should consider establishing its own independent panel of policy makers, economists, third-party insurance payers, public health experts, and physicians to offer a second opinion (checks and balances?) on the AMA’s pricing recommendations. This panel should more regularly investigate codes that are overvalued and overbilled, as well as those for more essential primary care and prevention services that are severely undervalued. Such codes should be contextualized alongside current best practice guidelines to assign value based on the appropriateness of resource utilization. At the very least, Congress should force the AMA to relinquish proprietary control on the CPT system to allow for the development and testing of alternative pricing models.

Assigning accurate value to medical services is also crucial to the ongoing effort of price transparency for patients. If a true marketplace relies on a fully informed consumer, patients should be aware of what their healthcare costs. As it currently stands, patients are not shopping for healthcare, but rather for access to healthcare in the form of insurance. They are paying negotiated rates for access to services that are overvalued (specialist services) or undervalued (primary care preventive services). Not only would an overhaul of the current valuation system reduce nationwide healthcare expenditure, but it would also help re-establish trust in the medical profession that has been steadily eroded by patient concerns that their physicians care more about their paychecks than they do about their patients.

Reconciling the need for compassionate and meaningful patient care with the need for appropriate physician compensation is somewhat of a Hippocratic paradox. Physicians have a duty to do the best by their patients, but this duty is also their economic livelihood. For students like me on the verge of graduating with hundreds of thousands of dollars of medical school debt, reimbursement is our path to financial freedom. Yet we must not forget that behind our paychecks are sick patients who are depending on us to become well, and it is only fair to accept payment according to the truest value of the care we have been trained to give them.

1. Kliff S, Katz J. Why Hospitals and Health Insurers Didn’t Want You to See Their Prices – The New York Times. Published August 22, 2021. Accessed January 26, 2022. https://www.nytimes.com/interactive/2021/08/22/upshot/hospital-prices.html

2. Baadh A, Peterkin Y, Wegener M, Flug J, Katz D, Hoffmann JC. The Relative Value Unit: History, Current Use, and Controversies. Current Problems in Diagnostic Radiology. 2016;45(2):128-132. doi:10.1067/j.cpradiol.2015.09.006

3. Roy A. Why the American Medical Association Had 72 Million Reasons to Shrink Doctors’ Pay. Forbes. Accessed February 1, 2022. https://www.forbes.com/sites/theapothecary/2011/11/28/why-the-american-medical-association-had-72-million-reasons-to-help-shrink-doctors-pay/

4. McGinty, A. Physician Panel Prescribes the Fees Paid by Medicare. Wall Street Journal. https://www.wsj.com/articles/SB10001424052748704657304575540440173772102. Published October 26, 2010. Accessed February 1, 2022.

The American health system is in shambles, and that is certainly no secret. We have astronomical costs for subpar care with patients often on the receiving end of a one-size-fits-all approach. The system also suffers from the many of the same ills, injustices, and prejudices that pervade the United States. Medical care as we know it upholds structural racism, classism, and sexism (to name a few), and is entrenched in a hierarchy that for so long has barred the diversity of thought, creativity, perspective, and expression that reflects the population it serves. While most definitely not a cure-all for this myriad of problems, community health workers (CHWs) can combat some of these ailments if systems are in place to support them sufficiently.

Community health workers are public health workers who help provide culturally appropriate care and lower barriers to patient wellbeing. Whether it is providing education about chronic conditions, mother-baby visitation programs, or care coordination, patient outcomes improve with CHW involvement.^1,2,3 CHW work is often founded in these providers’ understanding of the community they serve, making their ability to conduct home visits, convey medical information, and connect with patients integral to their work. They serve a health need different from those served by hospitals and clinics—they meet people where they are and need help most, out in the community.⁴

Hired for their flexibility, adaptability, and expertise in their community, it is unsurprising that compared to other medical professionals, there is little formalized training for CHWs and no uniform way to financially support the profession. Licensure and reimbursement models vary from state to state, with some states requiring state-standardized curriculums and offering direct reimbursement through Medicaid,⁵ while others have no set financial structure or training requirements.⁶ It is also worth noting that up to 40% of CHWs are volunteers,⁷ and the majority of paid workers are funded through grants,⁸ meaning that the valuable insights and service CWHs provide to augment the health of their communities is without a long-term financial foundation. What is needed is a clear path to individual direct reimbursement such as the ICD codes used throughout other medical professions.

While direct insurance reimbursement for a field with such variable certification seems like a faraway dream, many gains have been made to support financial autonomy in the field of community health workers. Standardized credentialing is crucial in the pursuit of CHW’s ability to bill for services. In recent years, twelve states have developed a state-standardized certification, seven more have privately operated certification programs, and 17 others considering or developing a standardized program.⁶ These programs help uphold and regulate the integrity of the field, leading to opportunities for insurance-based reimbursement.

With CHWs lacking the formal medical training to make diagnoses, perform procedures, or prescribe treatments, one might wonder what could be billed for in a direct reimbursement model. That line of thinking is very narrow regarding how health is achieved and maintained. The social, communal, interpersonal, and embodied perceptions of health and medical conditions are the ones that ultimately influence the course of an illness and are the aspect of care CHWs are attuned to. They have life-altering impacts on patient care, with effects so profound as to even ameliorate the detriment that structural injustices such as poverty, isolation, and marginalization have on patient wellbeing.^9,10 The time, education, support, and reassurance that CHWs provide for their patients are what could be billed for, much in the same way routine visits are done at a primary care office.

In a brief web search, there are many blogs, forums, and opinions about how primary care can best use visit time and diagnoses addressed to increase their profitability. Every effort should be made to expand these techniques to include the work of CHWs. The ability to bill for time is essential to primary care sustainability, and with careful documentation of the education and resources provided, it is the foundation of primary care reimbursement.¹¹ Other ICD codes specifically target the conditions addressed in the visit and have a range encompassing diabetes management to “z codes” for social determinants of health.¹² Considering insurance companies have already agreed to reimburse for these “z codes” (encompassing “problems related to housing and economic risk factors,” “problems relating to education and literacy,” and “problems related to employment and unemployment”)¹³ there is no reason that this billing strategy should not be capitalized upon by CHWs.            

Community health workers are not going to be the silver bullet solving the problems of the American health care system, but they are certainly under-supported in their crucial work. To combat the injustices enacted on our patients and communities, we need people with the skills they have to do the work they do. Our role must be to support them in every way possible, including advocating for a financial structure that values them at their worth.

1. Shah, M. K., Heisler, M., & Davis, M. M. (2014). Community health workers and the Patient Protection and Affordable Care Act: an opportunity for a research, advocacy, and policy agenda. Journal of health care for the poor and underserved, 25(1), 17–24. https://doi.org/10.1353/hpu.2014.0019
2. Lassi, Z. S., & Bhutta, Z. A. (2011). Unfolding the universe of newborn health interventions: the role of innovative community-based strategies. BJOG : an international journal of obstetrics and gynaecology, 118 Suppl 2, 18–21. https://doi.org/10.1111/j.1471-0528.2011.03106.x
3. Fedder, D. O., Chang, R. J., Curry, S., & Nichols, G. (2003). The effectiveness of a community health worker outreach program on healthcare utilization of West Baltimore City Medicaid patients with diabetes with or without hypertension. Ethnicity and Disease, 13(1), 22-27.
4. Brownstein, J. N., Hirsch, G. R., Rosenthal, E. L., & Rush, C. H. (2011). Community health workers “101” for primary care providers and other stakeholders in health care systems. The Journal of ambulatory care management, 34(3), 210-220.
5. Willaert A. (2005). Minnesota Community Health Worker Workforce Analysis: Summary of Findings for Minneapolis and St. Paul. Mankato, Minn: Healthcare Education Industry Partnership. http://www.apha.org/policies-and-advocacy/public-healthpolicy-statements/policy-database/2014/07/09/14/19/support-for-community-health-workers-to-increase-health-access-and-to-reduce-healthinequities.
6. Map of state approaches to CHW certification – ASTHO. (n.d.). https://www.astho.org/Programs/Clinical-to-Community-Connections/Documents/Map-of-State-Approaches-to-CHW-Certification/
7. The Arizona Prevention Research Center of the University of Arizona. The 2014 National Community Health Worker Advocacy Survey (NCHWAS). http://azprc.arizona.edu/content/2014-national-community-health-worker-advocacy-survey-reports.
8. Grant funding for Community Health Worker Programs – RHIhub toolkit. Grant Funding for Community Health Worker Programs – RHIhub Toolkit. (n.d.). https://www.ruralhealthinfo.org/toolkits/community-health-workers/6/grant-funding#:~:text=Grant%20funding%20for%20community%20health%20worker%20(CHW)%20programs%20and%20research,%2C%20state%2C%20and%20foundation%20grants.
9. Association of State and Territorial Health Officials. Building a Sustainable Community Health Worker Workforce in Massachusetts. December 2013. http://www.astho.org/Workforce-Committee-CHW-Presentation-12-11-13/.
10. Singh P, Chokshi DA. Community Health Workers—A Local Solution to a Global Problem. N Engl J Med 2013 Sep 5; 369(10):894-896.
11. Tips for using total time to code E/M office visits in 2021. AAFP Home. (2020, November 23). https://www.aafp.org/journals/fpm/blogs/gettingpaid/entry/total_time_tips.html
12. 10 code lookup. ICD. (n.d.). https://icdcodelookup.com/icd-10/common-codes/primary-care
13. Using Z codes: The Social Determinants of Health … – CMS. Centers for Medicare and Medicaid Services (n.d.). https://www.cms.gov/files/document/zcodes-infographic.pdf

I learned about the shooting on the first morning of my emergency medicine rotation. Luckily, no one had been injured when a car pulled up to the ER and fired more than 20 bullets into the front entrance just two days before, but the incident had shaken staff. Nurses discussed workplace safety in the break room and department leaders updated staff about the metal detectors and bulletproof glass being ordered. Meanwhile, I became aware of the city police department office in the ER lobby and its inability to prevent Saturday’s attack.

The hospital is a busy, urban, county hospital that handles a huge volume of trauma. The communities it serves are majority Black and Latinx and their patients include people who recently immigrated, are incarcerated, do not have homes, are struggling with substance use disorders, and are without insurance. In other words, patients who have abundant, often personal, reasons for being suspicious of the police. However, I saw and interacted with law enforcement on nearly every shift of my rotation. I passed the city police outpost on my way into the department, I interviewed patients from the county jail while their guards sat on the other side of the curtain, and I witnessed police detectives questioning gun shot wound patients at the bedside. All of these experiences prompted me to think more critically about law enforcement’s role in emergency department safety.

Violence is a problem in healthcare settings. A 2014 report from the International Healthcare Security and Safety Foundation found that 89% of hospitals had at least one episode of workplace violence in the past year.¹ These events often occur in the emergency department. A prospective study found that ER staff experience an average of 5.5 violent events per person per year, including 1.5 assaults per year. Notably, these violent events are not evenly distributed, with nurses experiencing more than double the rates of violence than their physician colleagues, leading to acute stress symptoms and lost productivity.²

The majority of hospitals employ their own security personnel to handle patient and staff safety issues, in large part to assume control over the training provided to these staff when hospital liability is involved.^1,3However, some hospitals have a police presence in addition to or instead of hospital security. 35% of public hospitals have a police presence and 76% have security with the ability to arrest compared to 18% and 51% respectively at private hospitals. Hospital security, in whichever form, are armed with hand guns in 52% of hospitals.¹

However, law enforcement presence does not make everyone feel safer. As lawyer Ji Seon Song puts it, policing of emergency rooms “raises the same concerns of racialized street policing because of the convergence of police and marginalized groups in safety-net emergency rooms.”⁴ This association between law enforcement and emergency rooms in marginalized communities leads to mistrust of healthcare systems and poorer health. One emergency room physician reported having a patient who delayed treatment for new seizures for months because of concern about being picked up by law enforcement in the ER for an outstanding warrant.⁵ Many studies have uncovered similar stories from patients, including refusing police transport to the ER, withholding information from medical providers because of law enforcement presence, and avoiding the hospital because of perceived collusion with Immigration and Customs Enforcement.^6–8

Law enforcement can also influence patients’ healthcare in more direct ways. Many researchers have raised concern over patient confidentiality and protected health information, especially following a highly publicized incident in 2017 in which a video shows a police officer arresting a nurse for refusing to collect a blood sample on an unconscious patient, despite being read the hospital policy regarding law enforcement access to health information.⁹ This story is a dramatic illustration of a common concern over police access to health information in the ED. One physician reported that, “There are [officers] who if they’re in the department will grab the stickers from patients who are there…[they] will run warrants from hospital registration data.”⁵Many physicians reported police presence during medical interviews and physical exams, including trauma resuscitations, and access to patients’ personal property.^3,5,6,7  

Law enforcement officers also perpetrate violence and trauma on patients. The work of Black Lives Matter activists has made it impossible to ignore the frequency and racism of police violence in the pre-hospital setting, but police violence occurs within hospitals as well. In 2016, the New York Times published a piece about Alan Pean, a 26-year-old who had sought emergency psychiatric treatment in Houston. When he became increasingly delusional and difficult to control, two off-duty police officers working as hospital security responded by shooting and handcuffing him to the bed. Miraculously, he survived the gun shot wound to his chest. The article mentions other recent police shootings or inappropriate Taser use in hospitals in Ohio, Virginia, Utah, Pennsylvania, and Indiana.¹⁰

Mental health crises and illicit substance intoxication are common themes in each of these horrific stories and are often the reason patients are seeking medical care in the first place. The Times points out that “uniforms and weapons may, in fact, exacerbate delusions, since many psychotic patients are paranoid and…believe they are being pursued.”¹⁰ Additionally, 23% of ER shootings involve someone reaching for an officer’s gun, as in the case of the fatal shooting of Ruben Jose Herrera, suggesting that guns initiate or escalate conflicts.^10,11 Police presence inherently criminalizes patients, and often for health-related behaviors. As one emergency medicine physician put it, “if a patient swings at me, it’s a health care incident. But if the same fist is swung against even an off-duty officer, the encounter is subject to criminal investigation.”¹²

The American College of Emergency Physicians has reinforced that law enforcement activities should not interfere with patient care and that emergency physicians have an obligation to protect their patients’ rights and welfare.¹³ Many have called for additional policy reform and education surrounding patients’ legal rights and law enforcements’ scope of practice. Some have called for limiting law enforcement access to patients until they are medically stable and mentally prepared to participate in an interview or prohibiting security from carrying firearms in emergency departments.^12,14 It is time to take this one step further and fundamentally grapple with how much access law enforcement has to our ERs. Armed, city police did not prevent, or even have the chance to intervene, in a major shooting that threatened the safety of patients and staff on my emergency medicine rotation. Indeed, the literature shows that violent events continue in hospitals and emergency rooms at high rates despite security and police presence. More worrisome still, the public hospitals that are most likely to have police on-site are also the hospitals that are most likely to serve patients with traumatic relationships with law enforcement, at best exacerbating health inequities for these populations and at worst leading to fatal confrontations. If we are serious about eliminating health inequities, addressing medical racism, and caring for the most marginalized in our communities, we need policies that do more to limit law enforcement presence in emergency settings and investigate methods for de-escalation and crisis management outside of a carceral framework.

References

1.         International Healthcare Security and Safety Foundation. Weapons Use Among Hospital Security Personnel [Internet]. Duke University Medical Center; 2014 [cited 2022 Feb 3]. Available from: https://cdn.ymaws.com/www.iahss.org/resource/collection/48907176-3B11-4B24-A7C0-FF756143C7DE/2014_Weapons_use_among_hosptial_security_personnel.pdf

2.         Kowalenko T, Gates D, Gillespie GL, Succop P, Mentzel TK. Prospective study of violence against ED workers. Am J Emerg Med 2013;31(1):197–205. 

3.         Tahouni MR, Liscord E, Mowafi H. Managing Law Enforcement Presence in the Emergency Department: Highlighting the Need for New Policy Recommendations. J Emerg Med 2015;49(4):523–9. 

4.         Song JS. POLICING THE EMERGENCY ROOM. Harv LAW Rev 134:75. 

5.         Harada MY, Lara-Millán A, Chalwell LE. Policed Patients: How the Presence of Law Enforcement in the Emergency Department Impacts Medical Care. Ann Emerg Med 2021;78(6):738–48. 

6.         Jacoby SF, Richmond TS, Holena DN, Kaufman EJ. A safe haven for the injured? Urban trauma care at the intersection of healthcare, law enforcement, and race. Soc Sci Med 1982 2018;199:115–22. 

7.         Liebschutz J, Schwartz S, Hoyte J, et al. A Chasm Between Injury and Care: Experiences of Black Male Victims of Violence. J Trauma 2010;69(6):1372–8. 

8.         Hacker K, Chu J, Leung C, et al. The impact of Immigration and Customs Enforcement on immigrant health: Perceptions of immigrants in Everett, Massachusetts, USA. Soc Sci Med 2011;73(4):586–94. 

9.         Wamsley L. Utah Nurse Arrested For Doing Her Job Reaches $500,000 Settlement [Internet]. NPR. 2017 [cited 2022 Feb 1];Available from: https://www.npr.org/sections/thetwo-way/2017/11/01/561337106/utah-nurse-arrested-for-doing-her-job-reaches-500-000-settlement

10.       Rosenthal E. When the Hospital Fires the Bullet [Internet]. N. Y. Times. 2016 [cited 2022 Feb 2];Available from: https://www.nytimes.com/2016/02/14/us/hospital-guns-mental-health.html

11.       Jackie Lacey, District Attorney. Officer Involved Shooting of Ruben Ordaz-Herrera Los Angeles Police Department. 2017. 

12.       Tsai J. Get Armed Police Out of Emergency Rooms [Internet]. Sci. Am. [cited 2022 Feb 1];Available from: https://www.scientificamerican.com/article/get-armed-police-out-of-emergency-rooms/

13.       American College of Emergency Physicians. Law Enforcement Information Gathering in the Emergency Department: Policy Statement. Ann Emerg Med 2017;70(6):942–3. 

14.       When Health Care And Law Enforcement Intersect In Trauma Care, What Rules Apply? | Health Affairs Forefront [Internet]. [cited 2022 Jan 26];Available from: http://www.healthaffairs.org/do/10.1377/forefront.20180926.69826/full/

I have been in the exam room as a patient cried with heaving sobs, knowing that her fetus would not survive outside of her womb. I have held a patient’s hand as she recounted her fear of her abusive ex-husband and worries about continuing her pregnancy. I have stamped a card with tiny footprints for parents that could have lived in a year of agony with their child on a ventilator. I have counselled a young woman who dreamed of becoming a doctor. All of these patients had an abortion, and none of them came to their decision lightly. As the Supreme Court prepares to deliver a ruling in the Dobbs vs. Jackson Women’s Health Organization case, I think about these patients.

The case centers on a law in Mississippi that bans abortion at 15-weeks, much earlier than viability (usually defined as 24 weeks).¹ Though less restrictive than the much-publicized Texas abortion ban, this law is enforced by the state rather than citizens, and upholding this law would pave the way to overturning Roe v. Wade. The case has already been argued in front of the Supreme Court, and a decision is expected in June 2022. Likely, the ban will be upheld, and Roe v Wade will be overturned.² Patients like mine, across the United States, will have difficult decisions become even harder, as they are forced to weigh the cost and time of cross-state travel against the heartache and trauma of continuing pregnancy.

Adverse outcomes are not just hypothetical. In the Turnaway Study, conducted by researchers at UCSF, women who were denied an abortion were more likely to experience poor mental health, financial poverty, and intimate partner violence.³ Their existing children were also less likely to meet normal developmental milestones.⁴ When a pregnant person’s choices in the present are restricted, their outcomes in the future are as well.

These restrictions are not spread equally across the United States in geography or demographics. While many Americans are aware of Texas’ six-week abortion ban, they may not know of quieter attempts to ban abortion in other states. According to the Guttmacher Institute, 26 states are likely or certain to ban abortion if Roe v. Wade is overturned.⁵ This need for travel between states will put undue costs on pregnant people, the majority of whom are low-income, belong to a minority group, and already have child.⁶

When I hear these statistics and facts, I think of my patients. I imagine telling them to travel 300 miles to have their abortion, when all the supplies to perform the procedure safely are within twenty steps of the examination room. I think of them sitting with their grief and fear while having to contemplate costs and delays. Most troublingly, I think about them not having a choice at all.

Opponents have suggested that, as most people seeking abortion are low-income and belong to a minority group, abortion is a genocidal conspiracy. This view is short-sighted. It is akin to suggesting that type 2 diabetes is a plot by insulin manufacturers. Black and Hispanic women, as well as poor white women, are more likely to have abortions for many reasons. They are less likely to have education about contraception or have access to contraception. When they do have access, they are more likely to have access to lower quality contraception.⁷ Like in any other area of medicine, we strive to treat our patients with respect and acknowledge the barriers they face. Decision-making about healthcare does not occur in a vacuum. Patients present to us with different stories, different challenges, and different reasons for their abortions.

While the Supreme Court prepares to revoke the right to abortion, Congress has started to take action with the Women’s Health Protection Act. The Women’s Health Protection Act (WHPA) seeks to codify the patient’s right to abortion and the right of physicians to provide them. The WHPA recognizes that pregnant people across the United States have a right to hear accurate information, to have procedures in a timely manner, and to have control of their own bodies.⁸ This act would be invaluable for both patients and physicians. As we have yet to provide equal healthcare access more broadly across the country, we can at least preserve the right to receive it. This act has passed the House of Representatives. However, only forty-eight senators agree.

I do not know the experiences of the senators who do not support the act. I do not know if they have held the hand of a grieving would-be mother. I do not know if they have helped a patient achieve independence from an abusive spouse. I do not know if they have told a young woman that her future could proceed as planned. I do, however, know my own experience and that of my patients. And if I could vote for the Women’s Health Protection Act, I would. I would  prevent an already difficult decision from becoming more so.

References

1. Sobel L, Ramaswamy A, Salganicoff A. Abortion at SCOTUS: Dobbs v. Jackson Women’s Health. Kaiser Family Foundation. https://www.kff.org/womens-health-policy/issue-brief/abortion-at-scotus-dobbs-v-jackson-womens-health/. Published November 2, 2021. Accessed February 3, 2022.
2. Howe A. Majority of court cppears poised to roll back abortion rights. SCOTUSblog. https://www.scotusblog.com/2021/12/majority-of-court-appears-poised-to-uphold-mississippis-ban-on-most-abortions-after-15-weeks/. Published December 1, 2021. Accessed February 3, 2022.
3. The harms of denying a woman a wanted abortion: findings from the Turnaway Study. Advancing New Standards in Reproductive Health. University of California San Francisco. https://www.ansirh.org/sites/default/files/publications/files/the_harms_of_denying_a_woman_a_wanted_abortion_4-16-2020.pdf. Accessed February 3, 2022.
4. Introduction to the Turnaway Study. Advancing New Standards in Reproductive Health. University of California San Francisco. https://www.ansirh.org/sites/default/files/publications/files/turnawaystudyannotatedbibliography.pdf. Published March 2020. Accessed February 3, 2022.
5. Nash E, Cross L. 26 states are certain or likely to ban abortion without Roe: here’s which ones and why. Guttmacher Institute. https://www.guttmacher.org/article/2021/10/26-states-are-certain-or-likely-ban-abortion-without-roe-heres-which-ones-and-why. Published October 28, 2021. Accessed February 3, 2022.
6. Jerman J, Jones RK, Onda T. Characteristics of U.S. abortion patients in 2014 and changes since 2008. Guttmacher Institute. https://www.guttmacher.org/report/characteristics-us-abortion-patients-2014. Published May 2016. Accessed February 3, 2022.
7. Dehlendorf C, Harris LH, Weitz TA. Disparities in abortion rates: a public health approach. Am J Public Health 2013;103;1772-9. PMID:29073129 doi: 10.2105/AJPH.2013.301339
8. The women’s health protection act. Actforwomen.org. Equal Access to Abortion, Everywhere. https://actforwomen.org/the-womens-health-protection-act/. Accessed February 3, 2022.