From The 19th:
The landscape of American health care has undergone an extraordinary transformation in the past several years, with the end of federal abortion protections allowing states to end access to the procedure, and the concurrent rise in bans on gender-affirming care. States that pass one such restriction are more likely to pass the other: Since last June, 13 states have begun enforcing near-total bans on abortion; the procedure is outlawed at six weeks in Georgia, and more bans are on the horizon. And so far, 20 states have passed laws targeting gender-affirming care, largely focusing on minors. Seventeen of those laws passed in this year.
Increasingly, the availability of often vital medical care depends on where you live. The barrage of bans has created a conundrum for medical professionals: Is it worth staying somewhere — no matter how much it feels like home — without the legal freedom to provide health care as they were trained or to receive care themselves? And if health care workers do leave, what do they owe to the people they leave behind?
In few places is the tension more pronounced than Texas, the second-largest state in the nation. Since last summer, the state has enforced a near-total abortion ban. More recently, the state passed a law banning gender-affirming care for minors, which will take effect this fall. Already, Texas leadership has been taking action against hospitals that offer gender-affirming care for minors. Most recently, the attorney general initiated an investigation into Austin-based Dell Children’s Medical Center. Doctors who previously staffed the center have left their jobs as a result.
Physicians who provide adolescent medicine — a field that involves treating minors for conditions as varied as irregular periods and eating disorders — are making plans to leave Texas. Doctors like Shamshirsaz, a hospital-based physician whose job focuses on complex pregnancies, are realizing they cannot continue to practice in Texas.
As a result, many medical professionals worry, comprehensive health care in Texas — home to world-renowned health care institutions but also a place already lacking in nurses, family physicians and mental health specialists — could become incredibly difficult, if not impossible, to come by. Similar patterns, they said, will emerge in other states where lawmakers have worked to restrict access to reproductive health care despite the objections of most medical providers.
“You’re seeing a lot of doctors who don’t want to practice in states like Texas and Idaho. They feel like they can’t,” said Sam Dickson, a physician who moved from Texas to Montana largely so he could continue providing abortions after Roe was overturned. “If you just have a brain drain … to states where doctors are able to practice in a way that’s consistent with their training, that’s going to result in disparities in health outcomes down the line.”
Already, medical schools are collecting data showing just that. Across the board, 2023 figures show a decrease in medical students applying to residencies — the multi-year training program for newly graduated doctors — in states with abortion bans. In Texas, the drop is particularly sizable.
Starting in 2022, months after the state’s six-week abortion ban took effect, the number of medical students applying to Texas-based OBGYN residencies fell by 10.4 percent, according to the Association of American Medical Colleges — while across the country, the number of applicants increased. The share of medical students applying to Texas-based residencies of any kind fell by half a percent that year.
The trend has continued: In 2023, Texas saw a 5.4-percent decrease in applicants to its medical residency programs, with a 6.4-percent decrease for OBGYN, specifically. Both of those are significantly larger decreases than the national average.
There is early evidence indicating the impact the state’s policies have had, said Meredithe McNamara, an assistant professor of pediatrics at Yale University who has tracked access to adolescent medicine in different states. She’s spoken to colleagues in Texas who are preparing to leave the state because of its restrictions on gender-affirming care. That sort of exodus is hardly unusual. The exact same thing has happened, she pointed out, in other states that passed restrictions on care for minors, or where the state government has specifically targeted trans health care.
She pointed as well to data from the American Board of Pediatrics showing that already, in states where the legislature has seriously considered a ban on gender-affirming care, the ratio of adolescent medicine providers to patients is far lower. Currently, Texas has only .5 providers per every 100,000 potential pediatric patients in the entire state. For contrast, Massachusetts has 3.2 such providers per 100,000 patients. Despite having less than a third the number of people as Texas, Massachusetts is home to more adolescent medicine clinicians.
As bans take effect and hostility increases, McNamara noted, the inequality between states will only grow, affecting access not only to reproductive health care, but to the other medical services.
“The thing that’s really heartbreaking is that families are so comforted when they get this care — not just gender-affirming care, but adolescent medicine and the full spectrum of what we provide. We are not afraid of complexity or suffering, and we don’t really buy into this stigma of a lot of things adolescents deal with,” she said. “It is just really sad and totally unnecessary that access to that care would be harmed.”
The impact will likely be more severe in parts of Texas where health care was already more difficult to come by: rural areas, places with higher rates of uninsurance, and places where fewer doctors already practice.
See here, here, and here for previous entries in this series. I’d focused on the abortion ban before, but the ban on gender affirming care is also a factor. Even with the promise and now reality of litigation and the decent chances for a favorable ruling, that effect will just get bigger over time.
I actually think the rural parts of the state won’t be affected all that badly because they’re already in crisis mode and have been there for years, due in large part to the refusal to expand Medicaid. There’s only so much worse it can get, only so much lower the doctors-to-population ratio can go. It’s precisely in the urban and suburban parts of the state, where the growth is, that people will begin noticing how much harder it is to find a doctor and get on their schedule. The key thing is that someone is going to have to point this out and then point the finger of blame at the Republicans who have made it happen. Put this in the folder of what a pro-abortion rights campaign could look like.