Rae Woods:
By now, you've probably seen that a leak draft of the Dobbs V Jackson Women's Health Organization majority opinion suggests that the Supreme Court is poised to overturn Roe V. Wade this summer. The decision is not final. And while justices are able to change their mind, this seems unlikely. If finalized the decision would end 50 years of healthcare practice leaving the US with a patchwork system, where about half of states would immediately move to ban or severely restrict abortion. Since the leaked opinion was first reported, I've seen a lot of attention on how restricted abortion will change health outcomes for mothers and for children. And that's for good reason. The US has the highest maternal mortality rate of any industrialized country.

Rae Woods:
I have seen some attempts to model the economic impact, or the impact on inequities, but what I haven't seen yet is an honest conversation on the operational impact that losing access to a healthcare procedure will have. From Advisory Board, we're bringing you a Radio Advisory. My name is Rachel Woods. You can call me Rae.

Rae Woods:
Regardless of any moral, religious, or ethical opinion, abortion is a healthcare procedure and changes to the accessibility and legality of that procedure will have implications across the industry. To talk about the impact that overturning Roe V. Wade will have on the delivery system, I've brought Rebecca Willman, Membership Director of Abortion Care Network. Welcome to Radio Advisory Rebecca. Where are you joining this podcast from?

Rebecca Willman:
I am in Asheville, North Carolina.

Rae Woods:
Oh, Asheville is one of my favorite places in the whole world. I love hiking there, and my husband is a big fly fisher, so he loves going there as well.

Rebecca Willman:
It's a great town.

Rae Woods:
Tell me about your organization, Abortion Care Network.

Rebecca Willman:
Sure. Abortion Care Network is the only national nonprofit membership organization dedicated specifically to the unique needs of independent abortion care providers. So we call independent abortion care providers indies. You'll probably hear me say that a few times as we're talking today. And the reason that we do that is because the majority of abortions are provided at independent care clinics in our country, and so meaningful access in the US really does rely on indies in order for abortion to be accessible.

Rae Woods:
And do these practices provide other maternal health women's health services, or they predominantly providing abortions?

Rebecca Willman:
Most of our members are predominantly providing abortions, but there is a huge spectrum from our memberships. We have some centers that do birth work, that do provide maternal and OB care. Many of our members provide gender affirming care for the LGBTQ community. We have members who are also primary care providers, so it really runs the spectrum. What we tend to find is that in states where access to abortion is more limited, those clinics are providing higher rates of abortion care because there's less access. And so that's really the need for the community. And those clinics tend to provide more abortions and less other services.

Rae Woods:
And that's exactly where I wanted to go next. And look, we know that abortion is one of the most emotionally charged and dare I say, divisive, issues in American society, but you and your organization can provide some very valuable perspective exactly because you work with independent abortion providers that operate in most states, including those states that already have very limited access to abortion. That means that you know, all too well, how the operations of providing abortions can be incredibly complex. What are some of the challenges for providers offering, or maybe even not offering, abortions in today's delivery system?

Rebecca Willman:
You know, all of ACN's clinics do provide abortions right now and will do so as long as they possibly can. I think a lot of their challenges are really similar to the others that folks face in the rest of the healthcare world. Issues about sustainability, financials, staffing, hiring and retention, certainly this year and last year, issues like low Medicaid and insurance reimbursement rates for states that receive Medicaid or insurance.

Rae Woods:
Can you walk me through the process of how this would work in a state that already has limited abortion access, say Texas? What are some of the challenges that abortion providers will face there already?

Rebecca Willman:
It's becoming incredibly complex and difficult for them to serve their patients. So, you can imagine being a provider and patients coming in your door and you have to turn half of them away. I mean, that's really what we're seeing right now. Texas also has a physician law that requires, so there's a mandatory delay that requires a physician do an ultrasound for a patient before a patient is seen. So there are also instances where folks are coming in for their ultrasound. They come back 24 hours later, and then they've already passed the limit just in a short time span. It's incredibly difficult to be able to know how many patients you're going to be able to see, how many patients you're going to be able to care for. And the staff and physicians working in these clinics are just, they're constantly telling these people who desperately need abortions that they're not going to be able to be seen.

Rae Woods:
And you are describing a state of play that's already just messy. And the path forward is about to get even more complicated for delivery systems. I'm curious, how can our listeners start to think about and anticipate some of the big operational challenges that they'll have to face, if and when, Roe is overturned?

Rebecca Willman:
In truth, the operations of providing abortions would be quite simple if it wasn't for the unnecessary scrutiny and TRAP law. So, TRAP stands for Targeted Regulation of Abortion Providers. In clinic or surgical abortion procedures and medication abortion procedures are some of the simplest medical procedures that one can have.

Rae Woods:
Sure.

Rebecca Willman:
They typically only require one or two interactions with medical professionals. There are some providers that have strong referring relationships with local primary care, OBGYNs, or they work at hospitals where transfer agreements are in place. But these things are not typically super necessary because the rate of complication is so incredibly low. It's hard to know, after a half century of precedent where abortion has been relatively accessible for most people in the US, what that's going to look like operationally for other providers. What I can say, is that what we've seen in places like Texas and other places where copycat bills similar to SBA are in effect, is that care coordination with regard to patients seeking to travel for care is going to be extremely difficult. Long wait times at open clinics and clinics where they can receive patients are going to be extremely difficult.

Rebecca Willman:
Patients are going to be pushed to have abortions at later gestations because of the wait times, the need for travels. We do know that people are more likely to show up to ERs, or their OBGYN, or their primary with questions about managing a miscarriage where typically those patients would've gone to abortion clinics, and that those providers are not going to be able to provide good answers about how to help. We know that this is disproportionately going to affect people of color, poor people, undocumented folks, queer communities, as we already know that this has been happening for a long time. There's going to be a relative like, state of chaos, quite frankly.

Rae Woods:
Yeah.

Rebecca Willman:
And there's going to be a lot of referral questions and care coordination questions that, even for those of us in abortion work, are still just at the beginning of trying to figure out.

Rae Woods:
I want to pick up on something that you mentioned, which is that the entire healthcare system for the last 50 or so years has been operating under the reality that they personally did not have to provide abortions because in most cases, another provider could actually offer that service. I'm seeing a lot of talk about the kind of obvious implications to abortion providers, should Roe be overturned, but what's less obvious and what's less talked about, and what I want your take on, is how organizations that actually want to stay anti-abortion will be impacted. What's your take there?

Rebecca Willman:
I don't know that changes with legality because in most instances that I understood, most of those folks aren't making referrals.

Rae Woods:
Oh, they're not making referrals already.

Rebecca Willman:
Some of them will, and don't get me wrong, there's really ethical providers working in a lot of these institutions who are willing to do that, but I don't know that the answer ever came from institutions that are inherently anti-abortion when, again, the reasons that people want to abort are systemic. And if there are institutions, whether individuals, or institutions, or healthcare, or other organizations, if folks don't have affordable childcare, access to safe schools, if they can't leave abusive relationships, those are the issues that need to be worked out in order for people to not seek out abortion. And I don't know what those organizations are prepared to do to support those changes. What I can also tell you is that I know that people who are denied abortion are far more likely to experience pregnancy complications and death in labor.

Rebecca Willman:
So, if you oppose abortion and you want to decrease that need, then that may be a serious priority shift for you. Especially if you're concerned about maternal mortality rates, if you're concerned about C-section rates, all of those things, it's a broken system, right? And again, we also know that these issues related to maternal mortality disproportionately impact black folks, people of color, and undocumented folks. And so if you want to see your C-section numbers not go up, if you want to see your complication rates stay low, better care for those communities is going to be really important, which is why I continue to go back to this systemic issue.

Rae Woods:
Yes, yes. Whether you are providing abortion care or not, addressing the systemic root cause problems that ultimately affect some of your other priorities, like health equity, like maternal mortality, make sure that you are still focused on those, especially given that those challenges might get a lot harder.

Rebecca Willman:
Exactly.

Rae Woods:
I want to keep talking about action steps, because the leaking of this decision does provide an opportunity for healthcare organizations to take action now and prepare for the effects of restricted abortion access. Now, I know that leaders are going to need to understand the legal environment in their state and in surrounding states, especially if you're a multi-state organization. That's going to be particularly complicated, but it still leaves a lot of questions for clinical teams. Clinical teams that are going to have to make a real, and let's be honest, sometimes life and death decisions about patient care. What are some of the scenarios that clinical leaders need to start preparing for and making plans for right now?

Rebecca Willman:
What we anticipate is that far more folks are going to be showing up to ERs, urgent care centers, with questions about a possible miscarriage or self-managed abortion that is having complications. Folks haven't seen that a ton. Although I will say, that access has always been a challenge for a lot of communities in our country regardless of the legality. And so these things are not necessarily new. That said, training for your staff around what to do in those scenarios is going to be really helpful. Relying on organizations that are doing work, The Center for Reproductive Rights, ACLU, having a clear understanding of the legalities in your state about what you are able and not able to provide care for, is going to be extremely important. I anticipate a level of chaos, if and when, Roe is overturned, because there is going to be so much difference from state to state about what is able to be provided in one place versus another place.

Rebecca Willman:
And that is probably going to be changing pretty frequently for a long time. And so being in touch with legal counsel about what you can do is going to be really important. There are resources, there's an M+A, it's M+A, hotline, which is a place that you can support folks in turning to if they are self-managing an abortion or miscarrying. There's a repro legal helpline, which offers legal advice for folks who are self-managing. Training staff to not criminalize people who are coming in and self-managing care.

Rebecca Willman:
We saw just very recently a woman who was in the ER for care, because she was extremely scared about a miscarriage that she was having. She was suspected of self-managing an abortion. While in care at the hospital, was turned in to the authorities in the hospital. Was put in jail the same day that she was having a miscarriage. And this is stuff that happens. This happens all the time. This is stuff that has already happened. There are plenty of people in jail right now because of being suspected of self-managing an abortion. And so training for your staff about what to do and what not to do and how to genuinely offer care for the people who are experiencing loss is incredibly important.

Rae Woods:
You're getting at some of the, not just operational or clinical impacts, but you're getting at some of the business impacts that leaders are going to have to prepare for. Starting with understanding very deeply the legal environment and the, to use your word, chaos that is likely to come. But I imagine there are probably some other business impacts that leaders aren't thinking about yet. What are some steps that you recommend leaders take to anticipate and address some other impacts to their business?

Rebecca Willman:
Folks are going to need to up their game in terms of caring for their staff.

Rae Woods:
Yes.

Rebecca Willman:
Honestly, ensuring paid parental leave, ensuring PTO, wellness benefits. If you want your staff to sustain the wave of need that is coming, they are going to need to be cared for. Right now, abortion is legal in all states. Make sure that people know that.

Rae Woods:
Yes.

Rebecca Willman:
And when the landscape changes, update them and update them regularly. In your own communities, know what hospitals and care providers are not religiously affiliated so that they can be given a better chance for more care options. Know which providers are going to be supportive of all options so that they can support people in getting the care that they need. Again, talk to your staff about not taking punitive legal measures against folks that they might suspect be having a self-managed abortion experience. Prepare your teams.

Rae Woods:
I love your communication example because that's, dare I say, an easy thing that leaders can do right now because the very nature of elite decision has just created immense confusion. It's confusing for patients. It's confusing for employees, who are going to be getting or asking questions about what they should do, right? And so making sure that all of your front desk staff, all of your clinicians, are prepared with answers and prepared with a single source of truth is going to be really, really important. And that's something that all leaders can do right now. But Rebecca, you've been bringing up a really important point that I want to make sure we can acknowledge, which is the effect that this ruling will have on the healthcare workforce. I know that conversations on abortion elicit intense feelings and feelings that are shaped by strongly held moral, religious, philosophical beliefs. How should organizations go about understanding the feelings and the fears of their own staff in order to anticipate their needs?

Rebecca Willman:
Abortion is really common, and there are people in your workforce and on your staff who have had abortions and they might be feeling a range of emotions right now. It's good to let them know your values and that you're there with them. Again, reassure your staff. Help make sure that they know that abortion is still legal. It's still available. Provide information on where folks can get care. It's super easy to have a one pager at a front desk, especially for folks who are answering phones, with a couple of directories. Abortionfinder.org. ineedana.com.

Rebecca Willman:
There are a lot of really fantastic referral sources on the web that folks can be directed to that will offer patients information about where to get care, where to get funding, where to get additional support so that they can arrange their care. And providing that little bit of support to your staff can ensure that they are clear about their expectations. Where they can refer, when they should refer. And they can also feel empowered that it's okay to do so. If you're not having those conversations with your staff, then they might be tight lipped. And that could really change and be extremely detrimental to someone's life.

Rae Woods:
How can leaders support their workforce and maybe offer some kind of emotional support when their workforce is going to be carrying out decisions that may or may not match their personal ethics?

Rebecca Willman:
You know, that's really difficult. And I've worked with a lot of providers over the years who have approached this in different ways. Again, there are a lot of people who have had abortions. Abortion is incredibly common. Being open to a range of conversations with your staff and listening is one of the best things that you can do. Listen without a need to respond, open the doors for tough conversations. Folks don't always have to be on the same page, but in creating a culture where what is perceived as difficult conversations can happen, especially conversations that involve essential healthcare, you can shift the way in which a work environment feels, and you can allow people to have their own perspectives, but offer ethical, just, dignified, care.

Rae Woods:
Do you have any recommendations for ensuring that staff's personal safety is cared for during this time?

Rebecca Willman:
That is a difficult question that I don't know that we have found the best answers to quite yet honestly. I wish I had a better answer for you. There are a lot of ways that folks can protect themselves online. There's a lot of incredible organizations. Digital Defense Fund is one of them, and there are a lot of ways that folks can maintain online control of their identity and personal life. Unfortunately, a lot of the answers to that question is community based. It's based on your city council, it's based on your local PD, your local law enforcement. Most states, every state really, should have a local FBI contact that folks can be involved with and engaged with to offer reports of suspicious, or harassment, or violent activity. And there's a lot of trainings that can be done through national organizations. If you're a member of the National Abortion Federation and the Feminist Majority has a lot of security based trainings. So it really depends, partly on what the need is and where you are. Legal counsel is always advised.

Rae Woods:
What's next for Abortion Care Network, depending on the outcome of the Supreme Court's decision?

Rebecca Willman:
Yeah. And you know, in a way we're going to be doing the same thing that we've always done, which is work to ensure that indies are able to provide the care that they are experts at providing, that they have the tools to face whatever comes next, whether that's scaling up or winding down, or navigating unknowns. We can't do that without supporters and donors. And so we will keep fundraising for our largest, and probably most important, campaign, which is Keep Our Clinics. A hundred percent of money raised for that goes directly to independent care providers so that they can continue providing care in their own communities. We're going to continue collaborating with movement partners. There's a fantastic campaign right now called Liberate Abortion that is a national collaborative of movement partners. You also can sign up for their emails and get on their list for state by state information about how to support efforts in your community. We will continue to be involved in that. We'll continue to lift up of abortion providers and national media and press. We'll be supporting our members and talking to the press. We'll just keep doing it.

Rae Woods:
Rebecca, I want to give you a moment to kind of speak directly to our audience. What is the most useful thing that you want to see all leaders in healthcare do right now, regardless of their ideology, to prepare for the chaos that is likely to come when a decision is final?

Rebecca Willman:
I really want you to donate to keep our clinics. I want you to donate to abortion funds. I want you to help people get the abortions that they need, especially knowing that the care and the costs and all of the logistics of seeking and receiving abortion care are going to increase exponentially. I want folks to get louder. I want people to talk to one another. Talk with your staff, your communities, your parents, your patients, your friends. Make your values clear. Release the stigma. Be open. Get to know your abortion community. Get to know your abortion providers. If you're interested in what you can do, and you want to know how to support people who are providing and seeking abortions, talk to abortion providers and find out what they need. Talk to abortion funds and find out what the folks who are calling needing support really need. They are the people who know exactly what the communities needed. They've been doing it for a long time. They are experts. Go to them, follow their lead.

Rae Woods:
Well, Rebecca, thanks so much for coming on Radio Advisory.

Rebecca Willman:
Thank you so much. It was great to be here.

Rae Woods:
Radio Advisory was created to offer practical guidance to leaders grappling with some of the biggest issues in healthcare, and abortion access is one of those issues. The time to be proactive is now. Start to think through the scenarios that your organization is going to have to deal with regardless of your personal preference. Advisory Board is going to continue to research this topic, as we navigate an incredibly complex, polarizing, and frankly sensitive part of healthcare delivery. Look, I cannot promise that I am going to please everyone, but I can promise, as always, we're here to help.