ACP adapts reproductive health policy

I just spent the weekend at one of the colleges my son is considering attending in the fall—one of many weekends like this between now and May, when my twin boys will need to make their final decisions about where they plan to spend their next four years. My daughter is only one year behind them, and as a junior is now taking the SAT and making her preliminary list of schools under consideration. This is all certainly a big life change for them and for my family, but it is one that we were expecting and for which we are planning. What I did not expect was the additional layer of consideration regarding where their schools of interest will be located, particularly following the Supreme Court's decision in Dobbs v. Jackson Women's Health Organization. Will they be able to access any or all health care services that they or their partners may require?

Prior to 2018, ACP's public policy on women's health specifically and reproductive health more broadly was quite limited and was primarily woven into other policy papers on issues like access to care and the patient-physician relationship. ACP's Health and Public Policy Committee recognized and addressed this policy gap by developing two papers, both published in Annals of Internal Medicine in 2018. The first, titled “Achieving Gender Equity in Physician Compensation and Career Advancement,” focused on summarizing the unique challenges that female physicians face over the course of their careers and made recommendations to improve gender equity and ensure that the full potential of female physicians could be realized. The second, “Women's Health Policy in the United States,” outlined several recommendations focused on policies intended to improve the health outcomes of women and ensure a health care system that supports the needs of women and their families over the course of their lives.

The latter paper addressed a number of issues, including:

• the importance of training internal medicine physicians in the primary and comprehensive care of women;
• the recommendation that health insurers should no longer be allowed to charge women higher premiums or impose higher cost sharing on women because of their gender;
• the need for universal access to family and medical leave policies that provide a minimum of six weeks of paid leave;
• increased availability of effective screening tools for physicians and education and resources for patients on intimate partner and sexual violence; and
• the need to improve representation of women's health in clinical research and to close knowledge gaps related to specific women's health issues.

However, what likely caught the most attention from this 2018 paper was that it specifically addressed abortion. Of note, this policy did not come exclusively from the Health and Public Policy Committee at that time, but also from an ACP Board of Governors (BOG) resolution on the same topic. The paper stated:

“ACP believes in respect for the principle of patient autonomy on matters affecting patients' individual health and reproductive decision-making rights, including about types of contraceptive methods they use and whether or not to continue a pregnancy as defined by existing constitutional law. Accordingly, ACP opposes government restrictions that would erode or abrogate a woman's right to continue or discontinue a pregnancy. Women should have sufficient access to evidence-based family planning and sexual health information and the full range of medically accepted forms of contraception.”

The paper also stated that “ACP opposes legislation or regulations that limit access to comprehensive reproductive health care by putting medically unnecessary restrictions on health care professionals or facilities.”

Since the development of this policy, ACP has actively advocated against such restrictions, alone and with a number of other medical societies. Honestly, although we should have, none of us really believed that something as well established as Roe v. Wade would be overturned. Then, in May 2022, the potential decision in Dobbs v. Jackson Women's Health Organization was leaked, and it became clear that the landscape was about to change dramatically. ACP determined we needed to update our policy to ensure we could still actively advocate on this issue in alignment with the spirit of the original policy and BOG resolution even when constitutional law was expected to change.

Therefore, in late May 2022, ACP released an update to our women's health policy paper. Given the time-sensitive nature and speed of this update, it was carefully constructed to simply remove the reference to “existing constitutional law” while still maintaining the full original intent of the policy. Of note, this policy update also used more gender-neutral language, replacing the term “women” with “individual” to reflect that it is not only women who may need to seek out comprehensive reproductive health care.

Once the final Dobbs decision was released in June 2022, the landscape for reproductive health care immediately began to change. In several states, “trigger” bans that prohibit abortion entirely began to take effect. At the time of this writing, 24 states are certain or likely to ban access to reproductive health care services in the absence of federal protections. Additionally, many state laws are imposing stringent criminal penalties on physicians and other health care professionals who perform, assist with, or otherwise facilitate reproductive health care services based on their clinical judgment. Already, at least one state imposes penalties on clinicians of up to life in prison, five states up to 15 years, one state up to 14 years, five states up to 10 years, five states up to five years, one state up to three years, two states up to two years, and two states up to one year. Additional civil penalties include fines in the thousands of dollars and professional licensure penalties. Beyond these issues, new legal approaches are being used to limit the ability of residents in some states to access abortion services, such as criminalizing the crossing of state lines to obtain health care services and limiting access to certain prescription medications, such as mifepristone.

Given this rapid shift in the environment, ACP felt it was important to further update and add to our policy regarding reproductive health care services in the United States. ACP's updated policy statement is as follows:

“ACP believes that individuals have the right to make their own decisions, in partnership with their physician or health care professional, on matters affecting their individual reproductive health, including about types of contraceptive methods they use and whether or not to continue a pregnancy. ACP opposes government restrictions that would erode or abrogate equitable access to reproductive health care services, including family planning, sexual health information, the full range of medically accepted forms of contraception, and abortion, that are evidence-based, clinically indicated, and guided by biomedical ethics.”

The new policy brief, “Reproductive Health Policy in the United States,” also reiterates our opposition to restrictive laws and/or regulations that impose criminal and/or civil penalties for providing, receiving, referring, assisting, or otherwise facilitating clinically appropriate health care services that meet the standard of care and reaffirms that individuals should have equitable access to high-quality health care regardless of where they live or work. This includes support for the ability of appropriately licensed entities to ship and deliver legally prescribed drugs to patients and support for patients to be able to travel across state or U.S. jurisdictional lines in order to access health care services.

It is important to note that in this updated policy brief, the College recognizes and respects that people, including physicians and patients, may have deeply held personal beliefs rooted in their perception of the ontological or moral status of a fetus that may inform their views on abortion or contraception. However, the paper discusses that while viability may be one of many appropriate biomedical, ethical, and clinical considerations a health professional makes in determining the best course of care, ACP believes it is an insufficient legal standard given its clinical complexity and the criminalization risks it opens up for physicians who are working to provide the best possible medical care.

When I think back on my own time in college, I recall how important it was to me and to other women I knew to have a women's health clinic somewhere nearby, whether it was simply to get a checkup because our parents may not have been comfortable taking their daughters to a gynecologist, to fill a prescription for reproductive health issues, or to investigate the options if we became pregnant. As a parent now, I would like to think that my children will not have to pursue or help a partner pursue unexpected services like these. I would like to think that my relationships with them are close enough that they will reach out to me if they need help. Yet we can never read another person's mind and cannot predict the future. Given that, my hope is that my children (now mostly young adults) live in an area where they can receive any or all health care services that they need in a safe and timely manner.