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An already-complicated patchwork of abortion coverage laws has become even more complex with the U.S. Supreme Court’s ruling to overturn Roe v. Wade.

“It really is all over the place,” says Fabiola Carrión, J.D., director of reproductive and sexual health for the National Health Law Program’s Los Angeles office. There were plenty of restrictions before, but “it’s becoming really complicated,” she saays

Some states had abortion bans that kicked in immediately after the court’s 5-4 ruling in June 2022. Others have seen their abortion bans temporarily blocked by the courts. And another group of states has moved in the opposite direction, strengthening their abortion rights statutes. “The legal landscape is changing rapidly,” says Meera Shah, M.D., M.P.H.,M.S., the national medical spokeswoman for Planned Parenthood Federation of America.

Even before the Supreme Court ruling, laws governing insurance coverage of abortion varied widely from state to state. As of July 1, 2022, seven states required private health plans to cover abortions, 11 states restricted insurance coverage from private insurance plans and 25 restricted coverage from plans offered on state health exchanges, according to Guttmacher Institute, a research and policy organization committed to supporting sexual and reproductive rights.

Coverage also varies tremendously for women who are insured through a health insurance. The 1977 Hyde Amendment forbids using federal funds for abortions unless a woman’s life is endangered or she is a victim of rape or incest, and many state Medicaid programs hew to that rule, which has been extended to include the military’s Tricare program, Medicare and the Indian Health Service. But 16 states get around the Hyde Amendment by using state funds to pay for abortions for women covered by their Medicaid programs.

Fully insured health plans are subject to state insurance regulation, but self-funded plans fall under the Employee Retirement Income Security Act and aren’t governed by state insurance law. Instead, they fall under the jurisdiction of the U.S. Department of Labor.

With all the differences among states, “for insurers, it could mean one version of a plan in one state and another in another,” observes Sarah Raaii, J.D., an associate in the law firm McDermott Will & Emery in Chicago who focuses on employee benefits.

A number of health insurers, including CVS Health (the parent of Aetna), Cigna and Blue Shield of California have already come out in support of abortion rights and in support of their employees and clients. CVS Health said in an email: “We’ve made out-of-state care accessible for covered CVS Health employees residing in states that have instituted laws that limit access in their state. With the new (Supreme Court) decision, we are evaluating how we can best support the coverage needs of colleagues, clients and customers.” That includes, said the email, providing them “with the flexibility to choose medical and pharmacy benefits to best suit their needs. This includes, subject to plan terms and customer direction for self-funded plans, making out-of-state abortion health care services more accessible and affordable.”

Other payers, such as Blue Cross Blue Shield of Michigan and Blue Cross Blue Shield of Massachusetts, are developing or have developed a travel benefit for those who need to go out of state for an abortion. The Michigan Blues plan said in an email that group customers had requested expanded travel benefits for a number of services, including behavioral health and substance abuse disorder treatment, and that the payer was including an option for abortion coverage in the new benefit. The benefit will be available in the next month or two and will reimburse travel between the patient’s home and location at which they receive care.

But there are concerns that states in places where abortions are banned might try to restrict residents from traveling out of state for an abortion. “It’s potentially murky legal territory,” Raaii says. In a concurring opinion in Dobbs v. Jackson Women’s Health Organization, Justice Brett Kavanaugh said he didn’t think a state could prevent a woman from traveling to another state for abortion care. Raaii says when she has discussed Kavanaugh’s opinion with employers, “this has helped increase their confidence in an abortion travel benefit.” A number of major companies, including Tesla, Starbucks, JPMorgan Chase and Amazon, have said they will cover travel expenses for employees.

Much, though, remains unclear about the travel benefits and insurance coverage of abortion services in general. Carrión says even when companies and health plans say they will offer a travel benefit, it’s not clear the type of transportation that will be covered — the cost of gas if someone drives to another state, a bus ticket or an airline ticket. Will food and lodging be included? If so, for how many days? Carrión notes that some states have a waiting period of 24 to 72 hours before a woman can receive an abortion. Other variables include whether there will be coverage or consideration of loss of income and extra child care expenses.

In 2020, the most recent year for which figures are available, more than 930,000 abortions were performed in the United States, according to Guttmacher Institute. That was up slightly from 2019, when more than 916,000 abortions were performed. But it was far below the more than 1.5 million abortions that occurred in 1991. The abortion rate in 2020 was 14.4 per 1,000 women between the ages of 15 and 44. The rate has declined by half since 1981, when there were 29.3 abortions per 1,000 women. Access to contraception is believed to have helped reduce the abortion rate, and most private health insurance plans are required to cover contraception under the Affordable Care Act. Centers for Disease Control and Prevention data from 2019 for 47 states and the District of Columbia show that 57% of those who had abortions were in their 20s and that teens had just 9% of abortions.

President Joe Biden signed an executive order on July 8, 2022, that that directed the U.S. Department of Health and Human Services to protect and expand abortion access, including to medication abortions; ensure access to all women for emergency medical care; and protect access to contraception. The order does not address issues such as costs and insurance.

An abortion in the first trimester costs about $600, Carrión says. Even those with health insurance may need to cover that cost because many policies have high deductibles. “It’s a big amount for people with low and middle incomes,” she says.

“Hundreds of thousands of people can no longer access the abortion care that they need, and even more are living in confusion about what options are available to them,” says Shah of Planned Parenthood.

Carrie Baker, Ph.D., J.D., M.A., a professor of women and gender studies at Smith College in Northampton, Massachusetts, says her concern is: “Will women be doing dangerous things to get an illegal abortion?”

With the bans in effect, Carrión says that “the people who are going to be most affected are people on the margins who don’t have access to healthcare and services already.

“It will result in two Americas,” she adds. “One with abortion and one without.”

Susan Ladika is an independent journalist in Tampa, Florida, who writes about healthcare and business.

Articles

How Employers, Insurers are Coping With Abortion After Dobbs 

A record amount of private equity flooded into the healthcare sector in 2021. This year, investors seem to be proceeding with a little more caution. Even so, the investment is a major development in how healthcare gets financed and the makeup of the sector’s ownership interest. Some are thumbs-up on the healthcare push by private equity firms, arguing that the surge in investment will improve management and operations. Others see the entry of the profit-seeking enterprises as driving up healthcare costs and, especially in the United States, further fracturing an already fragmented healthcare system.

After declining in 2020 as the COVID-19 pandemic swept the world, the total disclosed value of private equity investment in healthcare more than doubled globally last year. It reached $151 billion in 2021 compared with $66 billion in 2020 and $79 billion in pre-pandemic 2019, according to Bain & Company, a Boston management consulting company. At the same time, the number of healthcare deals involving private equity surged from 380 in 2020 to 515 in 2021, Bain reported.

Last year, private equity investment in telehealth, digital health and health information technology “gained a lot of interest, accelerated by COVID-19,” says Jerry Sokol, global head of McDermott Will & Emery's healthcare practice group. The focus is now on how technology “could help improve the healthcare sector.”

Some of the investment is motivated by “the opportunity to aggregate fragmented providers,” such as physician practices, Sokol says. Investment from private equity firms, he says, can help lead to more sophisticated management of physician practices, cost savings that come from group purchasing and more power when it comes to negotiating managed care contracts.

“If they (investors) see an opportunity for improvement, that’s certainly going to pique their interest,” Sokol says. The capital from private equity can also help providers adhere to government rules, take steps to reduce fraud and abuse and improve billing.

“Private equity typically will raise the bar on compliance.”

But not everyone believes private equity is a boon for the healthcare sector. Private equity investors “exist to make money. They invest in companies that they believe will have a significant return,” argues Elizabeth Mitchell, president and CEO of the Purchaser Business Group on Health. Private equity firms aim, she says, to “increase healthcare costs to maximize return.”

Her organization is a nonprofit coalition of almost 40 private employers and public entities that are major purchasers of healthcare services. Members include companies such as Microsoft and Walmart.

Some private equity-backed staffing companies, for example, tend to utilize surprise billing, which drives up healthcare costs, says Mitchell. Surprise billing is shorthand for patients receiving bills from providers who are out of network even though they were seen in an in-network facility.

Another of Mitchell’s concerns is what she sees as the focus of private equity investment on relatively narrow areas of care (emergency department physicians, for example, or radiologists). Her group wants to see more integrated care, she says, and with private equity undercutting integration, healthcare in the U.S. is “harder to navigate and harder to manage,” Mitchell says.

A recent survey of leaders of private equity firms by McDermott Will & Emery and WSJ Intelligence, part of 

, found that 40% of respondents had the most interest in investing in healthcare IT and telehealth in the next three years, followed by 37% interested in partnerships with large health systems. More than 30% were interested in investing in pharmaceuticals and biotechnology, and in physician practice management. “Large health systems have been struggling recently because of the pandemic,” Sokol says, adding that even before the pandemic, “a lot of profitable procedures migrated out of hospital settings.”

The survey respondents said they were most interested in healthcare industry inefficiencies, the expansion of value-based care models and reducing costs. Nearly three-quarters agreed that “the healthcare sector was ripe for structural change prior to the onset of the pandemic, which has accelerated opportunities for investing in new modes of healthcare delivery.”

Mitchell agrees that “there is certainly need for innovation” in healthcare. Some private equity investment leaders have expressed support for value-based care, and Mitchell says “incumbents have failed miserably” when it comes to implementing value-based care models. “It’s not that the incumbents don’t require some disruption.” But she is skeptical that private equity investors will improve the situation. 

Findings from a study conducted by researchers at Weill Cornell Medical College might stoke Mitchell’s skepticism. They compared nursing homes owned by private equity firms to those owned by other for-profit entities. Patients who stayed in nursing homes owned by private equity investors had more emergency room visits and hospitalizations, and that drove up Medicare costs for patients from those facilities, according to the results, reported last year in the journal 

. Residents of private equity-owned nursing homes were 11% more likely to need care at an emergency room and almost 9% more likely to experience a hospitalization. Those services translated into Medicare costs that were 4% higher — $1,080 more per resident — for residents of the private equity-owned nursing homes than those of residents at the other for-profit homes.

The pressure to generate profits for private equity investors could result in a reduction in staff, services, supplies or equipment at those nursing homes, researchers said.

“Our findings indicate that private equity firm-owned facilities offer lower-quality long-term care,” Mark Unruh, M.S., Ph.D., associate professor of population health science at Weill Cornell Medicine, said in a press release. “The majority of revenue that pays for care in nursing facilities comes from public sources. After private equity acquisition, quality of care declines and Medicare spending goes up for residents, and that should be a concern for policymakers.”

The largest private equity deal announced in 2021 was the $34 billion investment in Medline, a medical supply company headquartered in Northfield, Illinois. The money came from private equity firms Blackstone, The Carlyle Group and Hellman & Friedman. The second largest of the year was Bain Capital and Hellman & Friedman investing $17 billion in Athenahealth, a health tech company headquartered in Watertown, Massachusetts.

But during the first part of this year, private equity lost some of its appetite for healthcare investment. A report by KPMG found that from the fourth quarter of 2021 until the first quarter of 2022, activity by private equity investors in healthcare fell by as much as 50%. “Deal activity in 2021 was at a feverish pace that was unsustainable,” says Ross Nelson, principal and national healthcare strategy leader for KPMG.

The KPMG report found that private equity companies slowed their investments in hospitals and health systems due to rising labor and supply costs, although interest in healthcare IT and physician practices remained strong. The Russian invasion of Ukraine also was a factor and raised further supply chain concerns. Nelson says the continued switch of patients from traditional Medicare to Medicare Advantage plans “will continue to drive deal activity longer term.” At the same time, for many corporations, “balance sheets remain strong … and (private equity) still has a lot of money to deploy.”

Private equity firms have pulled back some this year, but money has been pouring into the healthcare sector. Will the cash infusion make healthcare more efficient or drive up costs as investors seek returns? 

The Private Equity Bet on Healthcare

As many health insurers wrestle with how to handle cover of abortion in the wake of the U.S. Supreme Court’s decision last week to overturn Roe v. Wade, a few payers have already voiced their commitment to continue to cover the procedure.

Two payers with major national footprints – Aetna and Cigna – have both pledged to support the right to choose.

CVS Health, the parent company of Aetna, said in a statement: “We will continue to provide colleagues, clients, and consumers with the flexibility to choose medical and pharmacy benefits to best suit their needs. This includes, subject to plan terms and customer direction for self-funded plans, making out-of-state abortion healthcare services more accessible and affordable.”

In a statement, Cigna said: “We will continue to do everything we can to support our customers, clients and employees in accessing affordable, high-quality healthcare. Employers are deeply invested in the health and well-being of their people, and they understand their unique needs. We’ve long held the philosophy that there is no ‘one-size-fits-all’ approach to health coverage, and we will continue to partner with each of our clients individually to provide meaningful options, which include travel benefits.”

Both CVS Health, based in Woonsocket, Rhode Island, and Cigna, in Bloomfield, Connecticut, are headquartered in states that affirmed their commitments to abortion rights. Rhode Island in 2019 enacted a law upholding a woman’s right to have an abortion.

Connecticut this spring passed a law declaring the state a “safe harbor” to protect women from out of state who want an abortion. The law takes effect July 1.

Other payers are still determining how to navigate the Supreme Court decision.

“While there are many questions left to be answered, we are focused on supporting the health of our employees, members, and others, and we will continue to assess the implications of the ruling where we operate,” Humana said in a statement. The payer is based in Louisville, Kentucky.

Kentucky has a “trigger law,” banning abortions, but a circuit court judge temporarily blocked it Thursday. Judges in at least three other states have also temporarily blocked trigger laws, according to USA Today.

“We have a lot more questions than answers at this point,” says Alexandra Lucas, a partner who works in the Chicago office of the law firm ReedSmith and works with a number of health plans.

Among the open questions are whether payers will run into issues if they cover a member who lives in a state where in an abortion is banned, and then travels to another state to get the procedure.

It’s unclear “whether states can regulate outside of their borders,” Lucas says.

Payers need to understand both the laws in the location where they operate, as well as where their members are located, she adds.

The companies issued statements referencing out-of-state abortions and travel benefits. Both are in headquartered in states with strong abortion rights laws.

CVS Health, Cigna Signal Support for Coverage of Abortion

Access to abortion will be curtailed in many states after today's U.S. Supreme Court decision overturning 

 At the same time, other states and organizations are making it easier to obtain contraception and medication abortion drugs.

With increased availability of contraception, “there are certainly (fewer) unwanted pregnancies and abortions,” said Krishna Upadhya, M.D., M.P.H., FAAP, vice president of quality care and health equity at Planned Parenthood Federation of America. 

Before the court decision today, the number of abortions in the U.S. had been steadily decreasing for about 30 year. But a 

 from the Guttmacher Institute showed an 8% increase from 2017 to 2020 (862,320 in 2017 to 

 Thirteen states have "trigger laws" that will ban abortion after the Supreme Court ruling today.  

While access to abortion is being curtailed, some states, organization and businesses are taking steps that are increasing access to contraception. Allowing people to obtain hormonal birth control without a prescription is one way some states have improved access to contraception. In February 2022, North Carolina became the most recent state to enact such a law, which allows people to purchase contraceptive pills and patches at drugstores after consulting with a pharmacist but without a prescription from a doctor. According to the Guttmacher Institute, it’s one of 17 states and the District of Columbia that allow pharmacists to provide birth control, a group that includes right-leaning states such as Arkansas (its regulations are still being developed) and Idaho. 

However, a majority of states still require a prescription — that can be a barrier to access for some people, notes Upadhya. They may lack transportation to get to a healthcare provider or have a busy schedule with work and child care issues. Even if birth control is dispensed at a drugstore without the need for a prescription, it may be difficult to travel to a brick-and-mortar store pharmacy, Upadhya says.

Cost is also an issue, notes Carrie N. Baker, Ph.D., J.D., professor of American studies and professor of the study of women and gender at Smith College. Birth control may not be covered by insurance if it is acquired without a prescription. And some women with insurance still face copays or provider charges, she points out. The Affordable Care Act requires coverage for 18 methods of contraception without cost sharing, but health insurers can use formularies, prior authorization requirements and other restrictions that wind up limiting contraceptive choices, according to the Guttmacher Institute.

Women can face other challenges as well when it comes to obtaining contraception. Approximately 19 million women live in contraception deserts, where they “lack reasonable access to healthcare,” says Varsha Rao, MBA, CEO of Nurx, a virtual care startup in San Francisco that focuses on women’s health. Most contraception deserts also have few pharmacies, including rural areas or urban ones that underserve, Rao says.

Nurx was founded in 2015 to help address that shortage by offering a women-focused healthcare platform. Along with providing contraception to residents of almost 40 states, it offers services such as tests for sexually transmitted infections, pre-exposure prophylaxis for HIV, and some migraine and dermatological treatments. 

Chelsea Clinton, daughter of former President Bill Clinton and vice chair of the Clinton Foundation, is a board member. In February, Nurx merged with Thirty Madison, a specialty healthcare company that has brands that offer care for migraines, hair loss and other conditions.

Nurx provides asynchronous care, meaning the patient provides information about their needs and then a provider reviews it and asks questions if needed before writing a prescription. The birth control is delivered to the patient’s door. Most patients pay with their own money, but the company also accepts insurance.

As the COVID-19 pandemic swept through the country, Nurx saw demand for contraception jump 50%, Rao says, and requests for emergency contraception jumped 300% as the pandemic made it more difficult for patients to see providers. Emergency contraception, which prevents pregnancy, can involve the insertion of a copper intrauterine device, which prevents sperm from fertilizing an egg, or oral medications such ulipristal and progestin that inhibit ovulation. Nurx sells the oral medications.  Nurx serves approximately 400,000 consumers each month, and approximately 40% of its patients are in the South.

Planned Parenthood has moved toward providing services remotely. The organization has an app through which residents of 40 states and the District of Columbia can request birth control or emergency contraception. Once they pay, the contraception is mailed to them. Planned Parenthood accepts Medicaid from residents of Michigan, Minnesota and Wisconsin. The organization also has a telehealth option that accepts some health insurance plans.

The abortion case the court decided today is called 

Dobbs v. Jackson Women’s Health Organization

. At issue was a Mississippi law that bans almost all abortions after 15 weeks of pregnancy. The majority opinion was written by Justice Samuel Alito and joined by four other justices in overturning Roe V. Wade. Chief Justice John Roberts voted to uphold the Mississippi law but didn't sign on to Alito's opinion overturning Roe v. Wade.

According to a Guttmacher tally before today's court decision, nine states have enacted 33 abortion restrictions this year. Among the most restrictive is the law in Texas that bans most abortions as soon as any cardiac activity can be detected, which is at approximately six weeks of pregnancy. 

Rao says requests for emergency contraception from Texas have nearly doubled since the “heartbeat law” went into effect.

Anti-abortion activists are increasingly focusing on medication abortions, which now account for almost 55% of the abortions in the United States; in Europe they account for 90% of abortions, notes Baker. 

In medication abortion, a drug called mifepristone is taken first. It blocks the production of progesterone so the pregnancy can’t continue.  Misoprostol is then taken 24 to 48 hours later, causing cramping and bleeding that empties the woman’s uterus.

Results of a small study reported in the Aug. 24, 2021, issue of 

 showed that medication abortion drugs delivered by telehealth was safe and effective. Ushma Upadhyay, Ph.D., M.P.H., an associate professor of obstetrics, gynecology and reproductive science at the University of California, San Francisco, and her colleagues reported that 105 of the 110 participants having a medication abortion had a complete abortion without intervention.

Nineteen states require providers to distribute the medication in person, Baker says. Women may try to get around those rules by going to other states for telehealth abortions, having medication sent to friends in other states or using a mail-forwarding service, she says.

Allowing access to abortions via telehealth reduces travel time and costs for women who don’t live near a clinic and would have to travel elsewhere for care, says Kaori Sueyoshi, M.P.A., M.P.P., director of innovation at Planned Parenthood. Telehealth also means women don’t have to take time off work or find child care, as they would with an in-person abortion, she says: “It fits the needs of people who are most underserved,” Sueyoshi says. 

Anti-abortion activists and lawmakers say medication abortion drugs obtained via telehealth subvert state laws, and some states prohibit them. Texas, for example, has added fines and possible jail time for anyone who prescribes the pills by way of telehealth or through the mail.

Demand for birth control obtained through telehealth or without a prescription continues to grow, and some states have loosened up their rules. Meanwhile, groups and organizations involved in contraception are bracing themselves for the effects of the U.S. Supreme Court decision today overturned Roe v. Wade and the constitutional right to abortion. 

Making Contraception More Available

As consumers embrace wellness apps to help them do everything from reducing stress to improving their sleep, some health insurers are throwing their weight behind the trend, offering members free access to certain apps designed to improve health and well-being. “People are looking for an easy way to get better,” says Anne Hoverson, vice president of digital transformation at Florida Blue, which looks to “curate the right thing at the right time” for its members.

The first health and wellness apps were introduced more than a decade ago and, even today, “most don’t do much,” says Bryce Williams, vice president of MindBody Medicine for Blue Shield of California. “They’re just kind of a transitory experience for most people.”

But some apps can play a vital role in member care, he adds. “We felt the field had matured far enough that it was a really great opportunity that could help our members.”

The California insurer has a special website called Wellvolution that offers tools to help members do such things as manage their diabetes, lose weight and deal with mental health issues. The abundance of wellness apps can create what behavioral economists call overchoice: People freeze up when facing too many options. Blue Shield of California makes sure that all apps on the Wellvolution website have been clinically validated and deemed effective in real-world settings, according to Williams. The company launched Wellvolution in 2008 and started “experimenting” with apps in 2010, Williams says. Now, members who go to the site can discuss health concerns and the insurer will suggest apps and other tools to help them meet their goals. Health plan members do not pay extra for the programs. They may be connected to apps such as Ginger, which provides online mental health care; WW (previously Weight Watchers) to lose weight; Clickotine to quit smoking; and Virta Health to manage diabetes. In an email to 

e®, Blue Shield of California said that all of the payment models in Wellvolution are pay for performance. In the case of Ginger, the health plan says it pays on milestone basis, and the milestones include engagement, sustained engagement and clinical outcomes based on common mental health scoring tools.

Florida Blue launched a new section of its website last year where members can relay their health concerns and be linked to appropriate care. Plan members have no-cost access to meQuilibrium, an app designed to reduce stress and build resiliency using cognitive behavioral therapy at a time when many Americans are struggling because of the mental toll of the COVID-19 pandemic. A Florida Blue member with diabetes might have access to Livongo for Diabetes, which monitors blood glucose readings through a connected device. Members may receive automated “nudges” to help them stay on track or can chat with a care coach or diabetes educator. The Livongo for Diabetes website say it is a $75-per-month benefit paid for by an employer or health plan.

As demographics shifted and younger people, who are more inclined to use apps, started to sign up for healthcare coverage, Florida Blue began to increase its app offerings, Hoverson says. Meanwhile, app development, including wellness apps, boomed. The wellness apps also cater to the high value people place on convenience. There is no appointment, no travel time, no waiting room. An app “is always there for you, always in the palm of your hand,” Williams says. The pandemic has also been a factor, propelling a major shift to virtual care and familiarity with getting healthcare delivered digitally. The pandemic, says Hoverson, “brought down a lot of barriers.”

That growing demand for virtual care has also fueled a wave of investment in the overall digital health sector, which includes apps. Noom, the weight loss program and app that uses cognitive behavioral techniques, raked in the largest investment in the digital health area in 2021, bringing in $540 million, according to Rock Health, a venture fund that focuses on digital health.

Overall, venture funding for digital health start-ups soared to $29.1 billion last year, a new record, according to Rock Health, and about double the investment funding in 2020. The 2021 money went to 729 deals, with the average deal reaching almost $40 million. Digital health start-ups in the fitness and wellness sector drew $4.3 billion in funding last year, according to Rock.

One issue with health and wellness apps is covering their cost. Some are available to consumers for free, many charge a monthly subscription fee and others are available only to health plan members.

The digital health company Big Health has tackled the issue by working with a pharmacy benefit manager (PBM). Big Health promotes its apps, which use cognitive behavioral techniques, as nondrug alternatives for insomnia and anxiety. The company says its apps — Sleepio for insomnia and Daylight for anxiety — have undergone clinical study, including 13 randomized clinical trials.

The company works with CVS Caremark, the PBM arm of the pharmacy giant. “By pioneering the ability to bill through the PBM, employers and health plans can easily add Big Health to their formulary and pay for their use via a drug claim, which is the same way they pay for medications,” Big Health co-founder and CEO Peter Hames said in an email. A person can access a Big Health app only if their employer has signed them up.

Big Health and a few other companies are trying to break away from the pack with claims that their apps have passed clinical trial muster. But in a recent opinion piece in 

, David Simon, Ph.D., a research fellow at the Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics at Harvard Law School, and his colleagues from Harvard discussed the dearth of regulation of many wellness products, including direct-to-consumer apps that people use to help assess their health. The FDA tends to focus on the risk a product might pose to consumers, they noted. The agency draws a line between devices that diagnose diseases and conditions or purport to cure, treat or prevent disease and those intended for general use and wellness. “Even though some general wellness products may be ‘devices,’ the FDA will not regulate these products if they only promote a healthy lifestyle or help reduce the risk of certain chronic diseases based on accepted interventions,” the authors wrote.

Simon said in an interview that one of his concerns is whether consumers who use wellness apps are “aware they are not meant to diagnose diseases.” There are also questions about reliability of the information generated by wellness apps and what physicians can or should do with that information.

As for regulation, “the FDA can’t be out there policing tens of thousands of apps that exist” with the agency’s limited resources, said Simon.

By offering apps, health plans hope to increase connection and engagement with members.

For Florida Blue members, apps can serve to manage chronic conditions more effectively, Hoverson says. “The better they do, the healthier they are,” which can reduce emergency room visits and hospital admissions while lowering costs for the insurer.

Williams of Blue Shield of California agrees. He says offering the apps “improves the lives of those we serve. By improving health, all the rest (on the business side) is going to take care of itself.”

Florida Blue and Blue Shield of California are among the insurers curating and offering free access to wellness apps for their members.

Keeping Members by Making Them ’Appy: Health Plans and Wellness Apps

Fabric Health is, you might say, working to do its part to wash away health disparities by offering residents in Philadelphia, access to healthcare services at laundromats. The idea behind Fabric Health is to “meet busy families where they are,” says co-founder Courtney Bragg, MBA.

Along with washing and drying their clothes, customers at five Philadelphia laundromats have been able to sign up for health insurance, get a mammogram, undergo a skin cancer screening or get a blood test for liver cancer or hepatitis B. Braggs says laundromats are “de facto community centers,” as many customers show up weekly to wash their clothes.

Fabric Health is one of a number of efforts that move healthcare communication and some service delivery to unusual settings. Other groups have found ways of using barbershops and churches.

Bragg and co-founder Allister Chang were introduced by friends over a year ago. They had both spent a lot of time at laundromats, and together, they dreamed up the idea for Fabric Health, a for-profit social impact startup. They then spent time talking to healthcare leaders to “understand their pain points,” Bragg says.

Bragg has experience in education and healthcare, and Chang is a member of the Washington, D.C., State Board of Education and has worked with various nonprofits, including four years as executive director of Libraries Without Borders. Over the years, the pair had gotten to know Brian Holland, co-owner of The Laundry Café, and they launched Fabric Health out of The Laundry Café’s five locations in North and West Philadelphia. The founders received grants and investments to start their venture.

Before launching, they visited laundromats and talked to people as they helped them wash and fold their clothes. “You can’t just parachute in and parachute out and expect people are going to trust you and talk to you,” Bragg says.

If healthcare inequity is the problem, then Philadelphia is a good place to test solutions. The city is the poorest large city in the United States. One in 4 of Philadelphia’s households lives below the federal poverty line.

The Fabric Health founders learned through their discussions with healthcare experts that more than 100,000 Philadelphians did not have health insurance. One of their first moves was handing out flyers to laundromat customers, asking whether they knew anyone who was uninsured. Bragg and Chang also directly talked to people — and got an earful amid the din of the washers and dryers. So, they connected with Pennie, the state’s health insurance marketplace, to provide information and help laundromat customers sign up for health insurance coverage. 

Consumers are “inundated with information” about insurance, Bragg says, but they don’t know how to sort through it. Bragg and Chang recognized an opportunity to introduce Pennie to the uninsured and answer people’s questions. They even got Pennie’s Executive Director Zachary Sherman to attend an in-person question-and-answer session at the laundromat.

Sherman says he welcomed the chance to connect with those who may not be aware of their insurance coverage options. “Disproportionately, they tend to be in communities of color. They tend to be lower income,” he says. Many of the uninsured qualify for Medicaid or for coverage through Pennie at low or no cost, Sherman explains. Taking advantage of the time people have on their hands at a laundromat is a “really cool (and) interesting idea,” Sherman says.

Bragg and Chang also connected with Jefferson Health, a large health system that competes with Penn Medicine in the Philadelphia market. Jefferson Health has an RV that is equipped to do mobile cancer screenings, including 3D mammograms. With the RV, Jefferson Health has offered free mammograms and other cancer screenings at Fabric Health locations.

Amy Leader, Dr.Ph., M.P.H., an associate professor of public health at Thomas Jefferson University who leads the mobile cancer screening efforts, calls the RV “one of our crown jewels,” allowing the health system to do screenings at at libraries, churches and community centers. — and laudromats.

Fabric Health has started to expand. With a $500,000 grant from the Richard King Mellon Foundation, it is going to open up business in Pittsburgh.

In 2019, The University of Texas at Austin School of Nursing, with support from the city of Austin, began providing mental health and wellness care at two Black churches in a program called African American Mental Health and Wellness Program (AMEN). Part of the goal is to combat the stigma surrounding mental health issues in the Black community. Initially, the program provided training for pastors who “sometimes felt ill-equipped to handle” church members with mental health issues, and they received information on when and where to refer people for further care, explains Jacklyn Hecht, managing director of the project.

When COVID-19 hit, the program became remote. As many people were left feeling isolated at home, the nursing school worked with the pastors to develop an outreach program. Healthcare workers also called congregants to see how they were faring. “With (COVID-19), no one has been immune from having some kind of mental health stress,” Hecht says.

“Members just wanted to talk,” says Angela Bigham, a community health worker the University of Texas, who is involved with AMEN at her church, Rehoboth Baptist, in Austin. If people were troubled, the pastor would be notified so he could reach out to them.

The university also set up mobile COVID-19 vaccination clinics at the churches, and church members were encouraged by their pastors to get vaccinated. “If they see someone they know and trust, they follow,” Bigham says.

Over time, AMEN has added discussion sessions and classes on topics such as grief, loss, racism, mindfulness and nutrition. Bigham’s church has a community garden where they offer tours to teach visitors about the food they grow and its nutritional value. AMEN aims to “build infrastructure within the church and sustain the program,” Hecht says.

Stephen B. Thomas, director of the Center for Health Equity at the University of Maryland School of Public Health in College Park, founded Health Advocates In-Reach and Research (HAIR). The program focuses on training Black barbers and hairstylists so they can offer customers health education and connect them with medical services. Why barbers? “They have the trust the medical community has lost,” says Thomas.

The HAIR program is now up and running in three Maryland counties. One program, supported by a grant from the state of Maryland, involves barbers and hairstylists who provide COVID-19 education and host vaccination events. Thomas received a call from the White House this past year, requesting the HAIR program be part of an initiative to recruit Black barbershops and salons to be part of a national vaccination campaign. The barbers and stylists involved with HAIR also promote and support screenings for colorectal cancer and other conditions. Televisions in the shops feature health programming.

“The message is important, (and) so is the messenger. Trust matters,” Thomas says.

Susan Ladika is an independent journalist in Tampa, Florida, who covers healthcare and business.

Fabric Health is bringing healthcare services to laundromats in Philadelphia and Pittsburgh. Other organizations are using barbershops and churches to deliver healthcare services and messages.