Protecting Health Care for Transgender Older Adults Amidst a Backlash of U.S. Federal Policies

While transgender older adults and advocacy organizations have won important victories in health care for transgender older adults, significant barriers remain. New federal leadership in the United States has brought a bevy of backlash in federal policies that present challenges in accessing health care for transgender older adults. This article focuses on three key areas: insurance coverage for medically necessary care, discrimination, and religious-based exemptions to providing services. Social workers can play a pivotal role in supporting transgender older adults by staying informed of key policy issues and taking proactive steps to protecting the health care of this community.

REISNER SARI, W. HARPER GARY, E. GAMAREL KRISTI, STEPHENSON ROB. State-Level Transgender-Specific Policies, Race/Ethnicity, and Use of Medical Gender Affirmation Services among Transgender and Other Gender-Diverse People in the United States

Policy Points Protective transgender-specific policies (including those related to experiences of discrimination, health insurance coverage, and changing legal documents) are associated with increased access to medical gender affirmation services (hormone treatment, therapy/counseling) for transgender and other gender-diverse people. Restrictive transgender-specific policies are associated with less access to these services. The relationship between race/ethnicity and use of medical gender affirmation services varies across states and is context specific, indicating that race/ethnicity also plays a role in access to these types of care across states. Advocacy is needed to prevent or overturn restrictive policies and promote protective policies for transgender and other gender-diverse people, especially for people of color.

CONTEXT

In the 2010s, the number of federal, state, and local transgender-specific policies increased. Some of these policies advanced protections for transgender and other gender-diverse (TGGD) people, and others were restrictive. Little is known about the relationships between these policies and use of medical gender affirmation services (eg, hormone treatment, therapy/counseling), or about how these associations may vary among different racial and ethnic groups.

METHODS

Multilevel modeling was used to examine the associations between state-level transgender-specific policies and the use of medical gender affirmation services among TGGD people in the United States. Data are from the 2015 U.S. Trans Survey of nearly 28,000 TGGD people. The medical gender affirmation services examined in this study were hormone treatment and therapy/counseling. The state policies we analyzed addressed discrimination, health insurance coverage, and changing legal documents; these policies were measured individually and as a composite index. Race/ethnicity was included in the multilevel regression models as a random slope to determine whether the relationship between race/ethnicity and the use of medical gender affirmation services varied by state.

FINDINGS

Individual policies and the policy index were associated with both outcomes (use of therapy/counseling and hormone treatment services), indicating that protective policies were associated with increased care. Broad religious exemption laws and Medicaid policies that excluded transgender-specific care were both associated with less use of therapy/counseling, whereas transgender-care-inclusive Medicaid policies were associated with more use of therapy/counseling. Nondiscrimination protections that include gender identity were associated with increased use of hormone treatment services. The relationship between race/ethnicity and medical gender affirmation services varied across states.

CONCLUSIONS

State-level transgender-specific policies influence medical gender affirmation service use and seem to affect use by non-Hispanic white TGGD people and TGGD people of color differently. Advocacy is needed to repeal restrictive policies and promote protective policies in order to reduce health inequities among TGGD people, especially people of color.

Medical advocacy in the face of Australian immigration practices: A study of medical professionals defending the health rights of detained refugees and asylum seekers

While medical advocacy is mandated as a core professional commitment in a growing number of ethical codes and medical training programs, medical advocacy and social justice engagement are regularly subordinated to traditional clinical responsibilities. This study aims to provide insight into factors that motivate clinician engagement and perseverance with medical advocacy, so as to inform attempts by policymakers, leaders and educators to promote advocacy practices in medicine. Furthermore, this study aims to provide an analysis of the role of medical advocates in systems where patients' rights are perceived to be infringed and consider how we might best support and protect these medical advocates as a profession, by exploring the experiences and perspectives of Australian clinicians defending the health of detained asylum seekers. In this qualitative study thirty-two medical and health professionals advocating on asylum seeker health in immigration detention were interviewed. Transcripts were coded both inductively and deductively from interview question domains and thematically analysed. Findings suggested that respondents' motivations for advocacy stemmed from deeply intertwined professional and personal ethics. Overall, advocacy responses originated from the union of three integral stimuli: personal ethics, proximity and readiness. We conclude that each of these three integral factors must be addressed in any attempt to foster advocacy within the medical profession. In light of current global trends of increasingly protectionist immigration practices, promoting effective physician advocacy may become essential in ensuring patients' universal right to health.

Improving access to quality medicines in East Africa: An independent perspective on the East African Community Medicines Regulatory Harmonization initiative

Alexander Giaquinto and co-authors discuss the East African Community's Medicines Regulatory Harmonization initiative.

Maternal mortality, abortion access, and optimizing care in an increasingly restrictive United States: A review of the current climate

The United States is facing a national crisis related to increasing rates of maternal morbidity and mortality. Over the past few years, significant focus has been turned to initiatives that aim to address maternal morbidity and mortality rates. In parallel, the United States has seen a significant increase in restrictive abortion access state laws. The link between abortion restrictions and worsening maternal outcomes has been proposed. This review article outlines the national crisis of maternal morbidity and mortality, the potential role of limiting abortion access in this crisis, and the significant racial, socioeconomic, and geographical disparities that exist.

Availability of Internationally Controlled Essential Medicines in the COVID-19 Pandemic

Section 2 of the 2019 World Health Organization Model List of Essential Medicines includes opioid analgesics formulations commonly used for the control of pain and respiratory distress, as well as sedative and anxiolytic substances such as midazolam and diazepam. These medicines, essential to palliative care, are regulated under the international drug control conventions overseen by United Nations specialized agencies and treaty bodies and under national drug control laws. Those national laws and regulations directly affect bedside availability of Internationally Controlled Essential Medicines (ICEMs). The complex interaction between national regulatory systems and global supply chains (now impacted by COVID-19 pandemic) directly affects bedside availability of ICEMs and patient care. Despite decades of global civil society advocacy in the United Nations system, ICEMs have remained chronically unavailable, inaccessible, and unaffordable in low- and-middle-income countries, and there are recent reports of shortages in high-income countries as well. The most prevalent symptoms in COVID-19 are breathlessness, cough, drowsiness, anxiety, agitation, and delirium. Frequently used medicines include opioids such as morphine or fentanyl and midazolam, all of them listed as ICEMs. This paper describes the issues related to the lack of availability and limited access to ICEMs during the COVID-19 pandemic in both intensive and palliative care patients in countries of all income levels and makes recommendations for improving access.

Coming together to improve access to medicines: The genesis of the East African Community's Medicines Regulatory Harmonization initiative

Hiiti Sillo and colleagues reveal how the East African Community's Medicines Regulatory Harmonization initiative improves access to important medicines in Africa.

The Affordable Care Act's Medicaid Expansion and Impact Along the Cancer-Care Continuum: A Systematic Review

BACKGROUND

Health reform and the merits of Medicaid expansion remain at the top of the legislative agenda, with growing evidence suggesting an impact on cancer care and outcomes. A systematic review was undertaken to assess the association between Medicaid expansion and the goals of the Patient Protection and Affordable Care Act in the context of cancer care. The purpose of this article is to summarize the currently published literature and to determine the effects of Medicaid expansion on outcomes during points along the cancer care continuum.

METHODS

A systematic search for relevant studies was performed in the PubMed/MEDLINE, EMBASE, Scopus, and Cochrane databases. Three independent observers used an abstraction form to code outcomes and perform a quality and risk of bias assessment using predefined criteria.

RESULTS

A total of 48 studies were identified. The most common outcomes assessed were the impact of Medicaid expansion on insurance coverage (23.4% of studies), followed by evaluation of racial and/or socioeconomic disparities (17.4%) and access to screening (14.5%). Medicaid expansion was associated with increases in coverage for cancer patients and survivors as well as reduced racial- and income-related disparities.

CONCLUSIONS

Medicaid expansion has led to improved access to insurance coverage among cancer patients and survivors, particularly among low-income and minority populations. This review highlights important gaps in the existing oncology literature, including a lack of studies evaluating changes in treatment and access to end-of-life care following implementation of expansion.

Eight years of the East African Community Medicines Regulatory Harmonization initiative: Implementation, progress, and lessons learned

Jane H. Mashingia and colleagues reveal the progress made to date for the East African Community Medicines Regulatory Harmonization initiative.

Impact of Medicaid Expansion on Insurance Coverage Rates Among Adult Populations with Low Income and by Obesity Status

OBJECTIVE

This study examines insurance coverage rates among working-age adults with low income and with or without obesity before and after Medicaid expansion under the Affordable Care Act.

METHODS

Individual-level data on noninstitutionalized and nonpregnant adult participants aged 18 to 64 years with household income below $15,000 from the Centers for Disease Control and Prevention 2006-2017 Behavioral Risk Factor Surveillance System were used. A difference-in-differences design with logistic regression was used to examine the likelihood of insurance coverage before and after Medicaid expansion.

RESULTS

Working-age adults (analytic sample N = 316,151) who were white, female, less educated, unemployed, and living in a Medicaid-expansion state were more likely to have insurance coverage. The insurance coverage rate in Medicaid-expanded states in years after expansion increased for both subgroups with and without obesity. However, the increase was slightly lower for the subpopulation with obesity (5.59%, 95% CI: 2.35%-8.83%) compared with the subpopulation without obesity (7.35%, 95% CI: 5.35%-9.34%).

CONCLUSIONS

Increased attention should be paid to reduce insurance coverage barriers for working-age adults with low income and obesity to address potential health disparities caused by lack of access to care. This is important, as access to care provides opportunities to increase prevention and treatment-oriented services to address obesity and associated health care costs.

Federal Right to Try: Where Is It Going?

Policy-makers, bioethicists, and patient advocates have been engaged in a fierce battle about the merits and potential harms of a federal right-to-try law. This debate about access to investigational medical products has raised profound questions about the limits of patient autonomy, appropriate government regulation, medical paternalism, and political rhetoric. For example, do patients have a right to access investigational therapies, as the right-to-try movement asserts? What is government's proper role in regulating and facilitating access to drugs that are still in development? In this review, we analyze the history of the right-to-try movement, review the arguments put forth by supporters and opponents of the legislation, and consider the movement's consequences. Two possible scenarios may emerge. One is that the right-to-try pathway may fail to meaningfully increase patient access to investigational products. Alternatively, certain companies may attempt to rely on the federal right-to-try legislation to sell investigational products, taking advantage of the provision that allows for direct costs, as there is currently no clear mechanism for enforcement or monitoring of cost calculations.

Differences in realized access to healthcare among newly arrived refugees in Germany: results from a natural quasi-experiment

BACKGROUND

Germany has a statutory health insurance (SHI) that covers nearly the entire population and most of the health services provided. Newly arrived refugees whose asylum claim is still being processed are initially excluded from the SHI. Instead, their entitlements are restricted and parallel access models have been implemented. We assessed differences in realized access of healthcare services between these access models.

METHODS

In Germany's largest federal state, North Rhine-Westphalia, two different access models have been implemented in the 396 municipalities: the healthcare voucher (HcV) model and the electronic health card (eHC) model. As refugees are quasi-randomly assigned to municipalities, we were able to realize a natural quasi-experiment including all newly assigned refugees from six municipalities (three for each model) in 2016 and 2017. Using claims data, we compared the standardized incidence rates (SIR) of specialist services use, emergency services use, and hospitalization due to ambulatory care sensitive conditions (ACSC) between both models. We indirectly standardized utilization patterns first for age and then for the sex.

RESULTS

SIRs of emergency use were higher in municipalities with HcV (ranging from 1.41 to 2.63) compared to emergency rates in municipalities with eHC (ranging from 1.40 to 1.71) and differed significantly from the expected rates derived from official health reporting. SIRs of emergency and specialist use in municipalities with eHC converged with the expected rates over time. There were no significant differences in standardized hospitalization rates for ACSC.

CONCLUSION

The results suggest that the eHC model is slightly better able to provide refugees with SHI-like access to specialist services and goes along with lower utilization of emergency services compared to the HcV model. No difference between the models was found for hospitalizations due to ACSC. Results might be slightly biased due to incompletely documented service use and due to (self-) selection on the level of municipalities with municipalities interested in facilitating access showing more interest in joining the project.

Right-to-Medicines Litigation and Universal Health Coverage: Institutional Determinants of the Judicialization of Health in Brazil

Over the past three decades, Brazil has developed a decentralized universal health system and achieved significant advances in key health indicators. At the same time, Brazil's health system has struggled to ensure equitable and quality health services. One response to the broad promises and notable shortcomings has been a sharp rise in right-to-health litigation, most often seeking access to medicines. While much has been written about the characteristics of patient-plaintiffs and the requested medicines in right-to-health litigation in Brazil, little research has examined potential community-level and institutional drivers of judicialization and their role as mechanisms of accountability. To explore these dimensions, we used a mixed-effects analytical model to examine a representative sample of lawsuits for access to medicines filed against the state of Rio Grande do Sul in 2008. We found that the presence of a Public Defender's Office was associated with a sevenfold increase in the likelihood of a municipality having a medicine-requesting lawsuit. This effect was maintained after controlling for a series of municipality characteristics. As low- and middle-income countries seek to achieve universal health coverage within the framework of the Sustainable Development Goals, Brazil's experience may be illustrative of the challenges that health systems will face and the institutional mechanisms that will emerge, advancing accountability and individual patients' interests in response.