If there is one thing that can get always get people’s attention, it’s money. The U.S. is one of the highest spenders in the world when it comes to healthcare, with approximately $3.5 trillion spent in 2017 (Peter G. Peterson Foundation [PGPF], 2019). The cost of healthcare in the U.S. is continually growing (PFPF, 2019). In 1960, healthcare accounted for 5% of the Gross Domestic Product (GDP) of the U.S., and in 2017, it was up to 18% (PGPF, 2019). Reasons for this include a population that is growing older (16% of the population of the U.S. was over the age of 65 in 2017) and healthcare that just continues to increase in cost (PGPF, 2019). However, if a country has good health outcomes, spending a lot of money on healthcare may be justified. Unfortunately, this is not the case in the U.S., which significantly falls behind other developed countries in healthcare outcomes (PGPF, 2019).

As healthcare providers, we must advocate for healthcare policy that emphasizes prevention and health maintenance, rather than the treatment of illness. One of the most important ways to do so is by advocating for family-planning and comprehensive women’s health services. Studies have shown that effective family-planning programs, and their subsequent increase in access to birth control, save billions of dollars for healthcare industries (Welti & Manlove, 2017). Unintended pregnancies can cause negative health sequelae for patients and their children, especially among women who have pre-existing health conditions which make pregnancy dangerous (Welti & Manlove, 2017). A research simulation in which every woman who was not desiring pregnancy in the U.S. had access to highly effective birth control estimated that there would be a 64% reduction in unintended pregnancies and a 67% reduction in abortions (Welti & Manlove, 2017). This ended up being a cost savings of $12 billion annually to the U.S. healthcare system (Welti & Malove, 2017). Just imagine if we could incorporate universal, effective birth control into our healthcare. We could drastically improve health outcomes for women who experience unintended pregnancy and decrease healthcare costs.

The sustainability of these solutions has already been shown by the substantial number of years family-planning services have been provided by government funded programs. The U.S. government has been providing family-planning services to low-income women for over 50 years (Ranji, Salganicoff, Sobel, & Gomez, 2019). With only one-third of low-income women using government programs to get their contraception, the availability of these programs is either not being communicated clearly enough, or is not widespread enough to reach the majority of women (Ranji, Salganicoff, Sobel, & Gomez, 2019). If all low-income women knew about the resources available to them, and there were enough clinics being funded by Medicaid and Title X programming, the country would be one step closer to have universal access to contraception. The recent restrictions placed on Title X funding, covered in previous blog posts, have only brought us further away from this ideal world in which we could save billions of dollars a year on abortions and unintended pregnancies. Once the return on investment is realized from the implementation of policies allowing universal access to birth control, sustainability of these policies won’t be an issue. The billions of dollars a year that could be saved from expanding birth control access could be put to use for other healthcare needs.

Legislation in Arizona to make access to birth control more widespread has been promising in the last year. Senate Bill 1493 would allow pharmacists to dispense birth control to women 18 years of age and older without a prescription from a healthcare provider (S 1493, 2020). This is one example of how policies can be changed and adjusted to make them sustainable within the ever-changing healthcare landscape. Policy modifications take place when negative consequences of policies are realized, or when a potential for beneficial change is seen (Longest, 2010). Policy makers suggest revisions and modifications to policies very frequently, as evidenced by the changes made to Title X regulations in 2019. However, when the changes made to policies have negative impacts on patients and the entire healthcare landscape, there will surely come a time when they are noted to be causing more harm than good. Healthcare providers who are passionate about providing equitable access to family-planning care should continue to advocate for low-income women all across the country. The changes made in 2019 to family-planning services are the opposite of sustainable; there will come a time when policy makers realize that the reduced number of clinics available for providing contraception has created higher healthcare expenditures. Until then, please continue to use your voice to stand up for equitable access to care.

References

1. Longest, B. B. (2010). Policy modification. In B.B. Longest Jr. (Ed.), Health Policymaking in the United States (pp. 147-180). Chicago, IL: Health Administration Press.
2. Peter G. Peterson Foundation (PGPF). (2019, March 15). Why are Americans paying more for healthcare? Retrieved from https://www.pgpf.org/blog/2019/03/why-are-americans-paying-more-for-healthcare
3. Ranji, U., Salganicoff A., Sobel, L., & Gomez, I. (2019, October 25). Financing family planning services for low-income women: The role of public programs. Retrieved from https://www.kff.org/womens-health-policy/issue-brief/financing-family-planning-services-for-low-income-women-the-role-of-public-programs/
4. S 1493, 55th Legislature, 2020.
5. Welti, K., & Manlove, J. (2017). How increasing the use of effective contraception could reduce unintended pregnancy and public health care costs. Child Trends. Retrieved from https://www.childtrends.org/wp-content/uploads/2017/03/2017-03IncreasingEffectiveContraception.pdf

Last week’s blog focused on the advantages of online or mobile applications used for family planning services, such as Nurx and Pill Club. However, along with the use of telehealth services comes the question of how these innovative companies are protecting patients’ private health information. Of course, every health care provider knows that patient information is protected by the privacy rules of the Health Insurance Portability and Accountability Act (HIPAA), which when first put into effect in 1996, dealt primarily with insurance issues (Longest, 2010). Today, HIPAA provides rules for telehealth companies to follow when creating apps or other technology that will carry health information from one person to another (Lucanus, 2019). Developers of the technology, providers using the technology, and any third parties involved in communication of information must follow the security rules made to protect patients (Lucanus, 2019). Even given the potential for data breaches when using telehealth, Lucanus (2019) argues that telehealth can improve the security of patient information. He states that, unlike health organizations which had to incorporate HIPAA compliance after the organization was already established, telehealth companies have the opportunity to build themselves with HIPAA rules already in mind (Lucanus, 2019).

The Department of Health and Human Services (DHHS) has a website which guides developers of health technology in making mobile apps or online platforms that are secure. The Federal Trade Commission even has an interactive tool for developers that they should refer to when creating healthcare apps (Federal Trade Commission, 2016). There is a page on every mobile or online health application’s website regarding their privacy practices and how they remain compliant with HIPAA. However, patients need to remain alert as to where their information may be shared, as some technology companies share information for advertising purposes or to build their patient base.

Nurx’s privacy statement is available online and explains that health information may be released to family members (with permission or without permission in the case of an emergency), law enforcement officers if needed for an investigation or if Nurx suspects a patient of being abused, and for research purposes when approved by a review board (Nurx, 2019). This is an interesting statement, because as many bedside nurses will attest to, if an adult patient comes to the hospital and is suspected of being the victim of abuse, it is only the responsibility of the nurse to report this abuse if the patient requests the nurse to do so. Nurx’s privacy statement makes it seem as though if an adult is suspected of being abused, Nurx may report this abuse without first consulting with the patient themselves. This is one example of why it is important to read through privacy statements thoroughly prior to giving an online application private information.

“If we reasonably believe you are a victim of abuse, neglect or domestic violence, we may disclose your PHI to a governmental authority, including a social service or protective services agency, authorized by law to receive reports of such abuse, neglect, or domestic violence.”

Nurx Privacy Policy Statement

Pill Club also has a privacy statement available online and touches on many of the same points as Nurx (Pill Club, 2020). However, they have a specific section on using patient information for marketing purposes, which is a common finding among telehealth apps. Essentially, Pill Club can use your medical information to determine if they should contact you about certain services or medications which might appeal to you. Pill Club may also release information regarding suspected abuse, but only if the patient provides permission to do so or it is required by law (Pill Club, 2020).

Even though telehealth companies like Pill Club, Nurx, and many others are making it easier for women with limited access to care to get family planning services, it is important to advise patients that they should carefully read the company’s privacy statements. Many women will undoubtedly choose to sign up for the service despite the potential risks of having their information exposed to marketing services or even government officials without their explicit consent. The benefits of having these services most likely outweigh the risks in many cases, as women are able to access birth control and other family planning services from the comfort of their home. However, data security in this ever-evolving landscape of technological innovation is a serious issue, and one that might preclude some wary patients from choosing to participate.

Below is a link to download a presentation on the topic of healthcare apps that I made for a previous course. I invite you to check out the other apps that I researched for this presentation and decide if any of them might be suitable for your patient population.

References:

1. Federal Trade Commission. (2016, April). Mobile health apps interactive tool. Retrieved from https://www.ftc.gov/tips-advice/business-center/guidance/mobile-health-apps-interactive-tool
2. Longest, B. B. (2010). Briefly annotated chronological list of selected U.S. federal laws pertaining to health. In B.B. Longest Jr. (Ed.), Health Policymaking in the United States (pp. 245-292). Chicago, IL: Health Administration Press.
3. Lucanus, A. (2019, November 7). Telemedicine and HIPAA. Retrieved from https://telemedicine.arizona.edu/blog/2019/telemedicine-and-hipaa
4. Nurx. (2019, November 12). Notice of privacy practices. Retrieved from https://www.nurx.com/privacy-practices/
5. Pill Club. (2020). Privacy policy. Retrieved from https://thepillclub.com/privacy

Many women already find it difficult to make time for their health, and the shortage of clinics providing Title X funded care has made it even harder for low-income women to access family planning care. An overwhelming majority (99%) of women have used contraception of some form at some point in their life, and it is one of the most common reasons women see a healthcare provider (American College of Obstetricians and Gynecologists [ACOG], 2015). It’s no wonder that alternative ways to access birth control and other family planning services have become popular in the online sector. One company, called Nurx, offers contraception, testing for sexually transmitted infections (STIs), and pre-exposure prophylaxis for HIV all through an online service (Jain, Lu, & Mehrotra, 2019). Another example of a direct-to-consumer telemedicine company is called Pill Club, which offers free or low-cost birth control mailed directly to the patient’s door (Jain, Lu, & Mehrotra, 2019). Pill Club has the added perk of sending other helpful items along with the patient’s birth control, like lubricant samples or a piece of chocolate (Jain, Lu, & Mehrotra, 2019). These innovative companies are providing exactly what patients need during a time when navigating tricky insurance policies and carving out time for appointments is too much hassle.

When it comes to telemedicine, Arizona has been ahead of the curve. The Arizona Telemedicine Council has been meeting quarterly since 1996 (Arizona Telemedicine Program, 2020). Current members of the Council include Senator Heather Carter and Representative Kate Butler, as well as other legislative members, and representatives from agencies like the Arizona Department of Health Services and the University of Arizona (Arizona Telemedicine Program, 2020). Senate Bill 1089 (2019) amended telehealth laws to allow broader scope of telemedicine and ensure coverage of telemedicine services. Overall, the state has been forward-thinking with regards to patients accessing care remotely.

Online applications like Nurx and Pill Club make it easy for women of any income to access the select family planning services they offer (contraception, testing for STIs) (Jain, Lu, & Mehrotra, 2019). But what about broader access to care and health information? Women have healthcare needs beyond contraception and STI testing, after all. A study in Boston evaluated the use of a women’s health mobile application by low-income women (Reyes, Washio, Stringer, & Teitelman, 2018). Recognizing that low-income women statistically have lower access to preventive health services and higher rates of morbidity and mortality, the authors studied a health information app called Everhealthier Women. The app provided an easy method of accessing preventive health information such as screenings and disease-prevention behaviors. Users of the app can create personalized health plans and track which screenings they are due for according to their age and risk factors. The study found that the app was well-received, with women reporting it was easy to use and had helpful information (Reyes, Washio, Stringer, & Teitelman, 2018). Considering that misinformation about contraception is a major hindrance to its use, an app that educates women and promotes self-management of health is very promising (ACOG, 2015).

Representative Daniel Hernandez, Jr. represents Santa Cruz County in Arizona. He is a strong advocate for women in Arizona, especially those who have been impacted by the loss of Title X funding to Planned Parenthood clinics (D. Hernandez, personal communication, February 28, 2020). After Planned Parenthood removed themselves from the Title X program, Representative Hernandez’s constituents have had very few options for accessing family planning care (D. Hernandez, personal communication, February 28, 2020). He reports that women in his county were already limited to only a couple of choices for getting care, and now they are even further restricted (D. Hernandez, personal communication, February 28, 2020). Many women in rural communities find it hard to get transportation to the clinics that could provide them care, so online and mobile applications can be incredibly helpful to these patients.

As healthcare providers, it is important to realize that health inequities impact patient’s access to care, whether it is a lack of transportation or a lack of available clinics offering affordable care. Telemedicine may feel like it is a new field being explored, but it has been on the radar of Arizona legislators since the 1990’s (Arizona Telemedicine Program, 2020). While there are some aspects of women’s health and family planning care that cannot be dealt with remotely, birth control, health education and promotion, and STI testing are some of the resources being provided by these innovative companies. It is the responsibility of all healthcare providers to be aware of the mobile applications available, and to inform patients having difficulty accessing care about these options.

References:

1. American College of Obstetricians and Gynecologists (ACOG). (2015). Committee opinion no. 615: Access to contraception. Obstetrics & Gynecology, 125, 250-255.
2. Arizona Telemedicine Program. (2020). Arizona Telemedicine Council. Retrieved from https://telemedicine.arizona.edu/about-us/atc
3. Hernandez, D. (2020, February 28). [Phone interview.]
4. Jain, T., Lu, R.J., & Mehrotra, A. (2019). Prescriptions on demand: The growth of direct-to-consumer telemedicine companies. Journal of the American Medical Association, 322(10), 925-926. doi: 10.1001/jama.2019.9889
5. Reyes, J., Washio, Y., Stringer, M., & Teitelman, A.M. (2018). Usability and acceptability of Everhealthier Women, a mobile application to enhance informed health choices. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 47, 853-861. doi: 10.1016/j.jogn.2018.04.139
6. S 1089, 54th Legislature, 2019.

Many would argue that providing assistance to those in need is a fundamental value of the United States. For centuries, the government has been creating programs and policies on a federal level that seek to provide healthcare for those who cannot afford it on their own (Longest, 2010). The type of health insurance that a person has correlates with their race and socioeconomic status, with a significantly higher percentage of minorities receiving government-funded insurance (Williams & Phillips, 2019). Those who can afford private insurance and/or receive insurance through their employers often have better access to care than those who receive government-funded insurance (Williams & Phillips, 2019). Many lower-sector occupations do not offer health insurance to their employees, so this population must rely on government programs (Williams & Phillips, 2019).

The first instance of the government creating a program to serve women and infants in need was in 1921, when the Maternity and Infancy Act was put in place (Longest, 2010). This law provided $1 million annually to states for maternity and infant care in an effort to stem the growing maternal mortality rate in the US (“The Sheppard-Towner Maternity and Infancy Act”, n.d.). Next came an amendment to the Social Security Act of 1935, the Maternal and Child Health and Mental Retardation Planning Amendments, which sought to improve the health of mothers who specifically had conditions of pregnancy which could lead to mental retardation of their child (Longest, 2010).

The Family Planning Services and Population Research Act of 1970 was the legislation that created the Office of Population Affairs and brought Title X to the Public Health Service Act of 1944 (Longest, 2010). This was an important step in the landscape of women’s health care in the public sector, as it was the first piece of legislation to specifically provide for family planning programs and services (Longest, 2010). This law, along with the creation of Medicaid in 1965, provided comprehensive coverage for women, pregnant and non-pregnant, who could not afford to pay for their care (Longest, 2010).

Further changes to the landscape of women’s health in the public sector came when the Breast and Cervical Cancer Prevention and Treatment Act of 2000 amended Medicaid to provide assistance to states for the treatment of these two cancers for low-income women (Longest, 2010). Studies have shown that patients who are insured by Medicaid have a higher risk of death from cancer than those who are covered by private insurance (Williams & Phillips, 2019). Since government funding covers screening for these two types of cancers, it makes sense that they should also cover treatment when a positive diagnosis is given to the patient.

One of the biggest and most recent changes to healthcare policy came in 2010 with the signing of the Patient Protection and Affordable Care Act (ACA) by President Obama (Sobel, Salganicoff, & Gomez, 2018). Although the ACA itself is a public sector policy, it reached within the private sector by requiring coverage for all contraceptive options approved by the Food and Drug Administration (Sobel, Salganicoff, & Gomez, 2018). Most states already covered contraception, but it was not a universal mandate and the patient often had to pay a portion of the cost (Sobel, Salganicoff, & Gomez, 2018). On a state level, Arizona Revised Statutes 20-2329 requires all insurance companies that provide coverage for other prescription medications to provide coverage for contraceptives (National Conference of State Legislatures [NCSL], 2012). Employers may request exemption on religious grounds (NCSL, 2012).

There has been plenty of legislation over the years to provide low-income women with pregnancy care and other health services. The provision of public policies that cover women’s health can become confusing, given that there are several different policies which cover different aspects of women’s health. Women currently can qualify for healthcare under Medicaid, Title X, or other state and federal programs. Overall, the US has ensured that low-income women have access to pregnancy care and preventive health services through public sector grants and programs.

References:

1. Longest, B. B. (2010). Briefly annotated chronological list of selected U.S. federal laws pertaining to health. In B.B. Longest Jr. (Ed.), Health Policymaking in the United States (pp. 245-292). Chicago, IL: Health Administration Press.
2. National Conference of State Legislatures (NCSL). (2012). Insurance Coverage for Contraception Laws. Retrieved from https://www.ncsl.org/research/health/insurance-coverage-for-contraception-state-laws.aspx
3. “The Sheppard-Tower Maternity and Infancy Act.” (n.d.). Retrieved from https://history.house.gov/Historical-Highlights/1901-1950/The-Sheppard%E2%80%93Towner-Maternity-and-Infancy-Act/
4. Sobel, L., Salganicoff, A., & Gomez, I. (2018, March 28). State and federal contraceptive coverage requirements: Implications for women and employers. Retrieved from https://www.kff.org/womens-health-policy/issue-brief/state-and-federal-contraceptive-coverage-requirements-implications-for-women-and-employers/
5. Williams, S.D., & Phillips, J.M. (2019). Eliminating health inequities through national and global policy. In R.M. Patton, M.L. Zalon, & R. Ludwick (Eds.), Nurses Making Policy From Bedside to Boardroom (pp. 391-422). New York, NY: Springer.

The Title X program was enacted on a federal level in 1970 as the only federal grant program dedicated to providing family planning care (United States Department of Health and Human Services [USDHHS], 2019). In the 1960’s, it became clear that unintended pregnancies could cause financial hardship and poor health outcomes among women living in poverty (Gold, 2001). It was necessary to find a means of providing family planning care to women who could not afford health insurance.

The Title X program is administered by the Office of Population Affairs, which is currently directed by Diane Foley, MD, FAAP (USDHHS, 2019). As Deputy Assistant Secretary, Dr. Foley directs the OPA in advising the Secretary and the Assistant Secretary for Health on many issues, including family planning, adolescent health, and sterilization (USDHHS, 2019). Dr. Foley spent many years working in pediatrics and has led medical missions to countries such as Haiti, Zambia, and Sierra Leone (USDHHS, 2019). In addition, she previously served as the President/CEO of an anti-abortion organization called Life Network, which provides financial and emotional support to women facing unintended pregnancies (USDHHS, 2019). The personal history of a political appointee such as Dr. Foley is important in policy-making, because when a high-level appointee takes an interest in a certain issue, the issue can suddenly be catapulted to prominence among members of the legislature (Kingdon, 2011).

Of course, it is difficult to look up the Title X controversy of 2019 and not find information about Planned Parenthood. Planned Parenthood clinics were hit especially hard by the new regulations imposed on Title X funds because the new regulation requires both physical and financial separation from abortion services (Title X funds were never able to be used for abortion services, but now abortion services cannot take place in the same building as Title X services) (Frederiksen, Salganicoff, Gomez, & Sobel, 2019). The regulations imposed in 2019 on Title X funding cut off all Planned Parenthood centers from being able to use these funds, as it would have been an impossible undertaking to create a physical separation between all other services Planned Parenthood provides and their abortion services (Frederiksen, Salganicoff, Gomez, & Sobel, 2019). However, these attempts to undermine Planned Parenthood were not the first of their kind. As Florida State University law professor Mary Ziegler explains, Planned Parenthood has been under fire by the government since the time of the Reagan administration (Kelly, 2018). For a very brief time in 1992, the first attempt at a gag rule on Title X was in effect before being rescinded by President Clinton in 1993 (National Family Planning & Reproductive Health Administration [NFPRHA], 2017). Currently, 23% of sites previously using Title X funding have removed themselves from the program (Frederiksen, Salganicoff, Gomez, & Sobel, 2019).

On a state level, the Arizona Family Health Partnership (AFHP) has been the recipient of the Title X Grant in Arizona since 1983, and partners with 7 different agencies to support access to free family planning care (AFHP, 2019). The AFHP is a non-profit organization, first established in 1974, which serves over 36,000 patients a year in Arizona (AFHP, 2019). The current president of the AFHP is Audra Koester Thomas, who has graduate degrees in public administration and political science from the University of Houston (Thomas, 2019). She is currently the manager of Transportation Planning for Maricopa County and a court appointed special advocate for children in the foster system (Thomas, 2019). As a civil servant, she has the ability to foster relationships with members of the government and the potential to influence the growth of policy proposals, but she has much less influence than an appointed official (Kingdon, 2011).

This week, I had the opportunity to attend the March of Dimes’ Day at the Capitol. Although the Title X regulations were created at the federal level, it was eye opening to see the process of bills being discussed and passed through various levels of the government on a state level. The process seems cumbersome and complicated, so I can only imagine how complicated it might get when creating laws on a federal level.

Healthcare providers also have the ability to influence policy, and must not be forgotten as key players in this game. According to Inouye, Leners, and Miyamoto (2019), a nurse’s most influential way to exert political capital is by using grassroots efforts. The workforce of registered nurses far exceeds the workforce of other health professions, with nurses outnumbering physicians by 314% (Inouye, Leners, & Miyamoto, 2019). Just imagine if every nurse advocated for the health policy that he or she believes in. The regulations imposed on Title X in 2019 are restricting patient access to essential information and care, as described in my previous blog posts. If you are one of the many healthcare professionals opposed to these regulations, I encourage you to make your voice heard through avenues such as the Arizona Nurses’ Association’s Public Policy Committee or by supporting the Arizona Family Health Partnership.

References

1. Arizona Family Health Partnership [AFHP] (2019). Title X’s impact in Arizona/Dollars and sense of Title X. Retrieved from https://www.arizonafamilyhealth.org/wp-content/uploads/2019/05/TitleX-For-Web.pdf
2. Frederiksen, B., Salganicoff, A., Gomez, I., & Sobel, L. (2019, September 20). Data note: Impact of new Title X regulations on network participation. Retrieved from https://www.kff.org/womens-health-policy/issue-brief/data-note-impact-of-new-title-x-regulations-on-network-participation/
3. Gold, R.B. (2001). Title X: Three decades of accomplishment. The Guttmacher Report on Public Policy, 1-8. Retrieved from https://www.guttmacher.org/sites/default/files/article_files/gr040105.pdf
4. Inouye, L., Leners, C., & Miyamoto, S. (2019). Building capital: Intellectual, social, political, and financial In R.M. Patton, M.L. Zalon, & R. Ludwick (Eds.), Nurses Making Policy from Bedside to Boardroom (2nd ed.), (pp. 195-224). New York, NY: Springer.
5. Kelly, M.L. (Host). (2018, May 18). The History of Title X Throughout U.S. History [Radio broadcast episode]. Retrieved from https://www.npr.org/2018/05/18/612441155/the-history-of-title-x-throughout-u-s-history
6. Kingdon, J.W. (2011). Participants on the inside of government In J.W. Kingdon (Ed.), Agendas, Alternatives, and Public Policies (2nd ed.) (pp.21-44). Glenview, IL: Pearson.
7. National Family Planning & Reproductive Health Association [NFPRHA]. (2017). Domestic gag rule fact sheet. Retrieved from https://www.nationalfamilyplanning.org/file/Domestic-Gag-Fact-Sheet.pdf
8. Thomas, A.K. User Profile. LinkedIn. Viewed 12 Feb, 2020. https://www.linkedin.com/in/akoesterthomas
9. United States Department of Health and Human Services [USDHHS]. (2019). Office of Population Affairs. Retrieved from https://www.hhs.gov/opa/

Health policy-making is a human endeavor, and as such, is inextricably linked with the ethics of those involved (Longest, 2010). A lesson learned early on by nursing students are the ethical principles of autonomy, justice, beneficence, and nonmaleficence (Longest, 2010). Each of these pillars has its own place in the world of health policy, and can also be found in the political decisions which shape family planning policies in Arizona. However, rather than listing and defining these principles, which you are likely very familiar with, I would like to introduce a concept known as person-centered care (McCormack & McCance, 2017).

Person-Centered Care

Many healthcare providers will be familiar with practicing person-centered care, even if they have not labeled it as such in their daily work. The concept of person-centered care is explained by McCormack and McCance (2017) as a practice which treats people as autonomous individuals, while building trusting, therapeutic relationships. This concept emphasizes the importance of shared-decision making between a provider and their patient (McCormack & McCance, 2017). It weaves together the pillars of autonomy, justice, beneficence, and nonmaleficence and has been acknowledged by the World Health Organization (2015) as “an approach to care that consciously adopts the perspectives of individuals, families, and communities… [requiring] that people have the education and support they need to make decisions and participate in their own care.”

Person-centered care has grown in importance and recognition, and many countries throughout the world are making efforts to incorporate it into their healthcare systems (McCormack & McCance, 2017). It is a concept which McCormack and McCance (2017) argue should be integral to health policy-making, because our healthcare landscape today needs policies that put patients, families, and communities at the crux of decisions.

Justice in Family Planning Services

There are different perspectives on the concept of justice, which is why creating a person-centered health system does not come easily (Longest, 2010). An individual who holds an egalitarian view of the principle of justice would argue that healthcare resources should be equally available to all people (Longest, 2010). This involves understanding that people seek healthcare with different backgrounds and different needs, and that some patients may require more assistance than others (Longest, 2010). Supporters of government-funded family planning services, such as Medicaid and Title X funding, would subscribe to an egalitarian point of view in that they believe those who have less money should receive support from the government in order to receive the same care as those who have more money. The majority of patients who receive care under programs such as Title X are living at or below the poverty line (Sobel, Salganicoff, & Frederiksen, 2019). The patients that rely on these programs are among the most vulnerable in our communities, and it is our responsibility as healthcare providers to promote programs that will support them.

Reproductive Autonomy

The World Health Organization (WHO) (2020) emphasizes that it is a woman’s fundamental right to have access to reproductive health information and care, free from coercion. The principle of autonomy defends the right of patients to make their own choices after being given a complete and accurate description of their healthcare options (Longest, 2010). This principle also means that patients should have the right to choose who their healthcare provider is and where to receive care. Discussing family-planning options with patients involves a discussion of pregnancy timing, possible birth control options, continuation or termination of pregnancies, and other sexual health issues. These are all topics that women should feel safe and comfortable bringing up with their healthcare provider. However, the Gag Rule on Title X funded clinics has forced clinics that wish to provide comprehensive, bias-free care from withdrawing from the program (Sobel, Salganicoff, & Frederiksen, 2019). Rather than accepting the limitations put on clinics that are accepting funding from the Title X program, some clinics have chosen to decline funding and continue providing the comprehensive education and care they have always provided (Sobel, Salganicoff, & Frederiksen, 2019). Women who cannot pay for services without the assistance of the Title X program will be forced to find new healthcare providers, even though they may have built a trusting relationship with their current provider.

The Gag Rule which has been enforced on clinics receiving government funding for family planning services threatens the concept of person-centered care. It takes away the ability of providers to engage in shared-decision making with their patients, and erodes the trust that providers work so hard to build with their patients. When discussing such intimate and personal matters as sexual health and pregnancy, patients expect their providers to listen and respond with empathy and honesty, not to withhold information on resources because they are afraid of losing their jobs or funding for their clinic. What’s more, it interferes with the principle of justice as providing equal access to care for all. Women who rely on government programs to receive important health screenings, birth control, and obstetric care are put at a disadvantage when they cannot receive information on abortion when it is requested. It is not the place of the government to tell providers what they can or cannot discuss with their patients.

References:

1. Longest, B. B. (2010). Developing competence in the policymaking process. In B.B. Longest Jr. (Ed.), Health Policymaking in the United States (pp. 181-216). Chicago, IL: Health Administration Press.
2. McCormack, B., & McCance, T. (2017). Person-Centred Practice in Nursing and Healthcare: Theory and Practice. Oxford, UK: John Wiley & Sons.
3. Sobel, L., Salganicoff, A., & Frederiksen, B. (2019,March 8). New Title X regulations: Implications for women and family planning providers. Retrieved from https://www.kff.org/womens-health-policy/issue-brief/new-title-x-regulations-implications-for-women-and-family-planning-providers/
4. World Health Organization [WHO]. (2015). WHO Global Strategy on People-centred and Integrated Health Services: A Report. Retrieved from https://apps.who.int/iris/bitstream/10665/155002/1/WHO_HIS_SDS_2015.6_eng.pdf?ua=1&ua=1
5. World Health Organization [WHO]. (2020). Abortion. Retrieved from https://www.who.int/health-topics/abortion#tab=tab_1