My Vote. Our Health. | Maternal Health & Reproductive Health

[00:00:06] Hi, I'm Dr. Mitzi Krockover, host and producer of Beyond The Paper Gown, and this episode is part of My Vote, Our Health, our special webinar series leading up to the midterm elections, sponsored by Women's Health Advocates, Community Catalyst, the Menopost Foundation, and Beyond The Paper Gown. Throughout this series, we've been examining something that can be easy to overlook during an election. But health policy, especially policy pertaining to women, isn't abstract.

[00:00:34] Decisions made by elected officials help determine what gets researched, what gets covered, which treatments reach patients, where care is available, and sometimes whether women receive that care at all. Our goal is not to tell you how to vote. It's to help make the connection between the issues affecting women's health and the policy decisions and policymakers that shape them, so that each of us can ask better questions and make more informed choices.

[00:01:02] In this episode, we look at reproductive and maternal health across a continuum, fertility and infertility, fibroids, and other gynecologic conditions that can go undiagnosed for years, maternal mental health, access to contraception, telemedicine, and the often invisible role reimbursement plays in all of them. You'll hear from clinicians, innovators, industry leaders, and advocates. And although they approach these problems from very different perspectives,

[00:01:31] listen for a common thread. In many cases, the science or the solution already exists. What stands between that solution and the woman who needs it is often the system around it. Coverage, funding, regulation, reimbursement, education, and access. And those are policy choices. And in an election year, they are choices worth understanding. Here's the conversation.

[00:01:58] Good morning. Good morning. Good afternoon, everyone. And welcome. I'm Linda Goler Blount, president and CEO of Community Catalyst and a founding member of Women's Health Advocates.

[00:02:23] And I'm honored to be your moderator today for the fourth series of My Vote, Our Health, a five-part webinar series brought to you by Women's Health Advocates alongside our partners Beyond The Paper Gown Podcast, Community Catalyst, and the National Menopause Foundation.

[00:02:40] Women's Health Advocates is a nonpartisan organization uniting advocates, researchers, clinicians, policymakers, and investors around a single urgent truth that women's health has been understudied, underfunded, and underprioritized for too long. And that government policy is one of the most powerful levers we have to change that.

[00:03:04] We translate lived experience and scientific evidence into education, advocacy, and action on Capitol Hill. We have organized the first ever Women's Health Capitol Hill Day, and we brought advocates from 15 states to meet directly with members of Congress. And we're building the constituency of voters and providers, of payers and researchers who will hold our government accountable.

[00:03:32] Policy decisions, who gets reimbursed and at what rate, what research gets funded, how care is delivered in rural communities, and who has access to telehealth. These decisions ripple through every aspect of the healthcare ecosystem. They determine whether a Black woman in rural Mississippi can see a mental health provider, whether a cancer survivor gets the follow-up care she needs, whether an obstetrician can afford to keep her doors open.

[00:03:59] My vote, our health, because this is an election year. And because the people on this panel and on this call have the power to shape what comes next. We are here to make that power visible and to put it to work. Today, we have two panel discussions. The first, infertility and the gynecologic issues we miss. Examines the care and system challenges and barriers we face in receiving fertility and diagnostic care.

[00:04:28] We'll explore why so many fertility and gynecologic conditions go undiagnosed, misdiagnosed, or dismissed. And what that delay costs women and families in the health system. Our panelists will bring a clinical, entrepreneurial, and patient advocacy perspective, spawning reproductive medicine, fertility care innovation, and uterine fibroid research and policy.

[00:04:53] They'll help us understand why these conditions are so often missed and what it will take to close that gap. In the second panel, maternal health access and contraception will dive deep into the challenges of contraceptive access despite years of progress. I want to briefly introduce each of our panelists for the first session. Dr. Elizabeth Beth Garner is CEO of Senna Therapeutics.

[00:05:20] They're developing first-in-class therapeutics for PMOS, and she is the immediate past president of the American Medical Women's Association. Jessica Bell VanderWaal is the co-founder and CEO of Frame Fertility, a company focused on proactive fertility care and earlier intervention. Jessica will join us in a few minutes. And Soteria Venable.

[00:05:46] Soteria is founder of the Fibroid Foundation and a leading advocate who has taken the fight over one of the most common and most overlooked gynecologic conditions directly to Congress and the state legislatures. So let's begin. Beth, I'll start with you.

[00:06:07] So for the past 10 to 15 years or so, the global maternity care bundle payment, a single comprehensive payment to an obstetrician, gynecologist, or midwife covering prenatal visits, labor and delivery has been sort of what we're used to. And, you know, a brief postpartum window has governed how we reimbursed maternal health care in the United States. That's changing in 2027 as maternal care payment unbundles.

[00:06:38] Tell us how this will affect patients and physicians. Yeah, thanks for that, Linda. And first, I just want to acknowledge, and, you know, the second panel is going to talk about this as well, I'm sure. But the abysmal maternity care for women in the U.S. And the fact that, you know, women of color and low income women are affected even more. You know, there's such a need for better, in particular, postpartum care in the U.S.

[00:07:08] So as it relates to sort of the bundling, for the last about 10 to 15 years, there's been sort of a single payment, right, a single comprehensive payment that goes from all the way from the early stages of maternity all the way to postpartum. That's been working maybe in some ways, right?

[00:07:29] But what's interesting is that beginning in 2027, maternity care will actually undergo really its most significant payment transformation in decades. ACOG, which is the American College of Obstetricians and Gynecologists, and now actually the American Medical Association as well, they've obviously, you know, recognized the bundling, just sort of putting this one comprehensive payment has not served providers,

[00:07:58] and I would argue has not really been good for patients either. So unbundling basically means that rather than having that single payment, this allows for patients and for physicians, right, rather than just doing that fixed payment, they can offer sort of more flexibility, right, for patients in particular who have a high risk, underserved patients and so on.

[00:08:25] I believe this will be helpful, right, because this allows the patients, but also particularly the physicians, to sort of figure out where they need, where that patient may need or not need specific things, right? So and you can do that by bundling. So my hope is that this will be helpful. There are some pros and cons, and if we have time, we can sort of talk about those. But that's basically what's happening.

[00:08:52] So, you know, you were practicing for a while, and you treated many patients with gynecologic conditions and maternal health issues. So kind of to tie them together, like one question is, how would this be beneficial? But also, you know, how has diagnosis and treatment changed in the last 20 years? And will unbundling help, harm, or, and, you know, honestly, what gives you hope?

[00:09:20] I don't think we really know that for sure, right? I mean, there are, like I said, pros and cons, right? So for patients, I believe that unbundling will lead hopefully to more individualized care. I think it will be a little bit easier for patients to get reimbursed for certain services that they need. I hope this will be better for high-risk patients in particular who need extra visits, right?

[00:09:48] For practitioners, I think, again, greater flexibility to tailor care to each patient, more accurate reimbursement, as I said. I think some of the cons can be for the patients in particular can lead to higher out-of-pocket costs. I think there's going to be sort of more likely to have kind of surprise billing here and there.

[00:10:11] And care might be maybe even more fragmented in some ways if the services are not kind of well-coordinated. So that's going to be critical. For patients, some of the cons may be. I think they're going to have more administrative work, unfortunately, and they already have a lot. But it's here, I think, harder to predict what that sort of the total reimbursement is going to be over time. Okay.

[00:10:36] So, you know, you have talked about how diagnosis and treatment have changed in the last 20 years. Is this going to help? Yeah, I'm not so sure in that sense. I don't think so, right? I mean, so, you know, if we sort of move over to kind of like, you know, sort of like what are the changes as it relates to diagnosis and so on?

[00:11:03] I don't think that necessarily is a bundling issue, right? Now, for sure. No doubt. You mentioned the fact that, you know, I've treated many, many patients with gynecologic patients with conditions and maternal health. And I can tell you that, you know, overall, even just with or without bundling, for me, you know, having left clinical practice about 20 years ago, not much has changed, honestly. Overall, I'm saying just for women's health, right?

[00:11:33] You know, think about oncology. That's really, there's basically two areas, I think, where things really have changed. Oncology for women, especially breast care, I think is so much better than ever before. Needs more. But, and now, you know, with menopause, I think we're now finally, you know, patients are getting diagnosed, they're getting treated better. We do have some actual new solutions for them.

[00:11:59] But for like diagnosis of like endometriosis, fibroids, PCOS, all that is still taking years and years and years for women. And I'm sure that Satiria will talk about that. We still see a lot of stigma, you know, poor treatment of patients, patients not listening to, you know, or believed. There's a lot of lack of, you know, physician education and issues. And of course, the healthcare system needs so much better.

[00:12:25] So yes, I think that, you know, not much has changed as it relates to sort of overall treatment and diagnosis for women at all. So, you know, you talked about years and years. And Jessica, you know, if someone is on a fertility journey, that too can take years and years. And, you know, you've talked about how we spend a lot of time talking about infertility, but much less time talking about fertility.

[00:12:53] Can you talk a little bit about why that distinction matters? Absolutely. I mean, it's so interrelated to what Elizabeth just shared. I mean, I think what the reality is here is, you know, once we diagnose somebody with infertility, you know, that's when someone starts trying to conceive. In reality, the challenges have started many, many years earlier.

[00:13:15] And, you know, I think at some point it felt like infertility was rare, but the stats absolutely prove that it is not. It used to be one in eight struggle with infertility. Now it's one in six. And actually in the U.S., it's one in five. But again, many of the causes of infertility are identifiable years earlier. And I'm definitely one of those people. PCOS, endometriosis, thyroid disease, diminished omerian reserve, male factor.

[00:13:42] And I think the challenge that we have today is these topics don't tend to come up until someone is, again, struggling and says, I want to have a baby within the year. Well, if you bring that up when you're 39, 40, 41, 42, again, the reality is you're going to have a harder time. But also those underlying conditions that Elizabeth just mentioned that have not been diagnosed have also not been treated. So it complicates the whole path.

[00:14:09] So, you know, it's not really about how do we treat infertility only. It's how do we identify fertility risk earlier and preserve fertility before infertility develops? Could we make prevention or early detection the standard of care? Oh, I obviously love this concept and idea. Yeah, it's obviously really challenging, too, as we see, you know, preconception counseling be the standard of care, to your comment.

[00:14:39] But it is billed as a problem visit, not preventative care. Right. And so, again, reimbursement doesn't align with the philosophy that we all know is important here. And you're definitely seeing some other countries take more proactive approaches, whether that's, you know, France or parts of Asia. They're starting to do this testing earlier and cover it and make sure that when things are identified, there are options, you know, embryo freezing, whatever it might be.

[00:15:03] So to your comment, you know, again, we know that this needs to happen, but the system has not been set up to reimburse or provide support so that these conversations can happen and be covered appropriately. So I think you're sort of touching on my next question. You know, it's problematized. So first, we view this as a problem.

[00:15:25] And so if most women first seek fertility guidance from their PCP, perhaps, or their gynecologist, given what we know, why are we still in a situation where so many conditions are diagnosed so late? Yeah. Yeah, it's to your comment. I mean, the stats show that 84% of people have this conversation with a PCP or OBGYN first. And so to your comment, that's often the first time that any type of problem is ever surfaced.

[00:15:54] And it's a lot of times the first time that people are really interacting with the health care system in a more meaningful way. And so I think to your comment, you know, we don't see that visit or conversation get enough time. There's often not a lot of training provided to these different medical providers about the depths of fertility. Again, there's not appropriate reimbursement for a further conversation versus the last two minutes of your annual well-woman visit packed with everything else.

[00:16:21] And even now we know as these problems come up in your annual well-woman visit, it's no longer a preventative care visit. It's now a problem visit. And now you're paying for it. So, again, everything kind of snowballs from there. And the other sad thing here is say you then need a referral to a specialist. 8% of U.S. counties have a specialist. There are 1,200 reproductive endocrinologists and infertility specialists in the entire country. So, again, even then when we need to go a layer deeper, we don't have enough.

[00:16:51] So, again, many levels of kind of system challenges here. One thing, Linda, maybe if I could just quickly just say is also the stigma problem, right? Patients don't necessarily want to tell anyone that they're having a problem. Would you say that's true, Jessica? Oh, goodness. I am one of those people, right? Especially when you're struggling to conceive. Unfortunately, it feels like you did something wrong. And that is really sad that that is the way people feel. But I definitely lived that myself.

[00:17:21] And you feel shame. You feel like you must have missed something. You didn't understand something. And, again, it is not your fault at all. It is the system not being able to care for these challenges earlier. And now you are in a situation where it feels like it must have been me. It must have been something I did wrong to be 39 and in a doctor's office and learning this for the first time. Thanks. So, you know, you're talking system issues.

[00:17:46] You know, what is one issue about this or some, you know, one misconception you want to clarify about infertility that you wish policymakers better understood? Since this is where we get our systems from. Yeah. I mean, there's so many. But the other one I thought about just clarifying here is, you know, infertility isn't simply a women's issue. It's a reproductive health issue that affects couples and families.

[00:18:11] And the reality is, again, I'm not trying to say we shouldn't provide more care for women because we absolutely should. But the problem is actually 40 to 50 percent of infertility cases are related to male factor. And so as a result, we're also kind of dragging the female through all of this testing when in a lot of situations it relates to the male factor challenge. But we're also not testing there either.

[00:18:33] And so, again, if we had better screening mechanisms, which we actually know what they are, but if they were covered and woven into the standard of care better for females and for males, we'd be more likely to address these things earlier. And actually, male factor challenges are far easier to treat as well, too. Yeah. Okay.

[00:18:52] So, Soteria, talking about identifying things early, I know you could go on at length about how long women suffer when they have fibroids and they're undiagnosed. You know, you've talked many times about fibroids being the most common gynecologic condition. And yet here we are, underdiagnosed, missed, dismissed. The stigma factor, women are socialized to, you know, it's just heavy periods.

[00:19:23] You know, why do you think fibroids continue to be missed or minimized by health care, by the health care system or providers? And, you know, please talk about what that means for patients. Yeah. I'm nodding my head because you all have touched on two key words, which is stigma and suffering. And when I started the Fibroid Foundation after my third of what unfortunately would be four fibroid surgeries, I thought I was just advocating for fibroids.

[00:19:51] But I soon came to learn that there is an expected stigma of suffering that's not just U.S.-based. It's worldwide from menarche all the way through menopause. And when I hit menopause, I really thought like I was having, you know, a flashback moment to launching the Fibroid Foundation because, again, there were the same issues. Women should suffer. There's not enough information.

[00:20:18] And it's just a really sad spiral. So I think it's more in the way that we comprehend the needs of women that is really what we need to shape through our policies and in demanding better layered care. The overall cost is upwards of $40 billion a year for fibroid surgeries.

[00:20:42] So when you consider that, and we have no tally on missed days at work and women who are at work suffering. So these are key issues that, you know, when I think about advocacy, what the goal is to stop that suffering. Yeah. And you have been on Capitol Hill.

[00:21:08] You've been in state houses, D.C., you know, talking about this. If you could get one policy change enacted, maybe it won't be this year, but let's say in the next year, research funding, insurance coverage or even provider education. What would it be? Where would you start? We know research funding is pivotal because women's health has not been studied.

[00:21:33] And I'd like to offer that one of the biggest catalysts that is the reason why 300,000 women per year have a hysterectomy due to fibroids is because minimally invasive gynecologic surgeries are not taught in medical school. It requires a fellowship.

[00:21:53] And so when you have that caveat, that is why we get calls all the time at the Fibroid Foundation with a woman saying she has one fibroid and the doctor told her to have a hysterectomy. Where on the polar opposite of that, we have medical advisory board members who say who have removed over 50 or in some cases 60 fibroids from women and kept her uterus intact.

[00:22:19] And community wide, there's no knowledge that that's even possible because people are listening to their doctors. And I will offer this. Jim Seegers, Dr. James Seegers, who heads the Seegers Lab at Johns Hopkins and also headed the fibroid program at NICHD for many years. I asked him why he became a gynecologist and he said the uterus is the most fascinating organ, in his opinion, in the human body, male or female.

[00:22:49] And then he said, and if you know Jim, he has like just a straight face most of the time. He said something that really made me giggle but want to cry at the same time. He said, can you imagine? He said that the uterus has the potential to grow 20 fold and shrink back to its original size. He said, can you imagine if men's testes grew 20 fold and wouldn't shrink back down? We would have had a cure decades ago. And that is the truth.

[00:23:16] So we have a slogan that says someone you know has fibroids. So when I'm on Capitol Hill, I say, who do you know in your family who has fibroids? And behind closed doors, invariably on both sides of the aisle, someone will say, my sister, I didn't know my mother had a hysterectomy due to fibroids. My wife had issues. But then when it's time to hit the floor and vote, then there are, you know, just the partisan drama.

[00:23:45] So that has to be unacceptable. And that's really where I stand on that. Like think of your family members. And that's universal. So it's fair to say we all know someone who has fibroids. Absolutely. So, you know, just real quick. And this question is not a quick question, but there is a disparity in fibroids and how they're diagnosed.

[00:24:13] A racial disparity may be income as well. Can you sort of briefly talk about what's driving that gap and why Black women are more likely to have their fibroids diagnosed when they're very severe? Sure. Absolutely. So I want to start by saying that all ethnicities get fibroids. And the reason we're talking all the time just about women of European descent and women of African descent is because we have very little data.

[00:24:43] And the data that we have focuses on mostly on those two ethnic groups. But as we start to learn more, there was a study at the end of last year that showed that 47% of Asian women have fibroids. It's really starting to open the door and reveal a much wider footprint. We are launching a database where we're going to heat map incidences of fibroids across the country by zip code that hopefully will be available next year.

[00:25:11] Because we really need there to be an understanding district by district of the impact. And, you know, it's really the lack of training and the lack of really just care around women's suffering that has led to these delays. And also the Southeast United States has the highest hysterectomy levels for fibroids. So that's another disparity that we are looking at as well.

[00:25:39] And we really have to ask ourselves why someone like me could walk into a doctor's office who is, I think, maybe perhaps a more informed patient and let the provider know, you know, that I am and ask questions. And it's been dismissed on more than one occasion. So I feel for those women and menstruators who don't have the confidence to research or advocate for themselves.

[00:26:06] And it's really upon the community at large to be an advocate for them to help them to preserve their health and well-being. And it's also a heart health issue, severe anemia. And I've walked around with half the blood in my body. And women have had heart attacks and died from fibroids.

[00:26:33] So that's something that is not discussed as well. I meet women all the time who say they can't bend over and stand up because they'll get dizzy because they have that little blood in their body. So, Soteria, you may have provided an answer. But, you know, as we kind of wrap up this session, you know, we've got advocates, researchers, clinicians, policymakers listening.

[00:27:00] You know, what is in sort of one sentence, what is the one thing you want folks to walk away from this conversation with? We need a multi-billion dollar, multi-annual investment in understanding why there's something that affects 26 million plus women across the United States that we don't understand the origins of it. Yeah. Jessica, I would put the same question to you.

[00:27:29] What is the one takeaway? I mean, I think there's so many great takeaways already shared, but I would say you have to treat fertility, not just infertility. Yeah. And Beth, I'll give you the last word. What is that one thing we all need to take away from this conversation? Yeah. I mean, it's really hard, as she just said. It's, you know, there's just so much. But I would say for me, I'm sort of around what Satira just said.

[00:27:59] I think we need to better understand the science that underlines all of these conditions, right? All of these. We don't understand pretty much any of them, right? And so we must get that funding and get the science. Yeah. Well, thank you all very much. I mean, we obviously could have spent another two hours having this conversation.

[00:28:18] I mean, clearly, you know, what you've talked about today is that the barriers women and menstruators face in accessing timely and accurate care for fertility and gynecologic conditions and the gaps need significant funding, need research, need understanding, and that these things are not accidents. What you are talking about today is really the product of policy choices that were made without women at the table. And one might argue without even considering women's health at all.

[00:28:48] So the system works exactly as it's designed. Our job is to change the system so it works for all of us. So thank you, Dr. Beth Garner. Thank you. Jessica Bell-Vanderwall and Satira Venable so much for participating in this conversation. I really appreciate it. Thanks a lot. Take care.

[00:29:10] While we're transitioning panels, I just want to remind the listeners that on September 23rd is Breast Cancer Early Detection Coalition Hill Day on the 22nd. I think it's Menopause Hill Day. So go to womenshealthadvocates.org to register if you can attend. You know, it'll be a great time, a great way to bring these issues to lawmakers. And the final webinar in this series is Advocacy and Voting, Putting It All Together.

[00:29:39] And it's at noon Eastern time on October 22nd. We must all vote like our health depends on it because it does. So our next panel, we're going to be discussing maternal health access and contraception. So it's a natural flow from the first panel.

[00:30:00] We're going to sort of move across the full arc of reproductive health care from mental health challenges that can follow childbirth to coverage and policy decisions that shape whether those who are expecting get the care they need to the barriers that still stand between patients and the contraceptive care that they need to make informed decisions. These aren't separate issues.

[00:30:24] They are three points on the same continuum of whether our health system actually provides maternal health care as it's needed. So we're really fortunate to have three panelists who bring very different vantage points to that continuum. Dr. Rashmi Raghavendra is CEO of Dionysus Health, whose work centers on maternal mental health. Chad Turner, vice president of marketing for Maine Pharma, is going to bring the market innovation lens to contraceptive access.

[00:30:54] And Dr. Sophia Yen, co-founder and CEO of Pandia Health, will push us on access itself over the counter contraception telemedicine access across state lines and the joy and friction patients and physicians face with insurance. So, Rashmi, let's begin with you.

[00:31:14] You've talked about maternal mental health as an emerging public health challenge, particularly as younger generations become parents. Do you have a sense of sort of the root cause? And, you know, what about maternal mental health should policymakers pay attention to? Thank you. Thank you, Linda. And what a fantastic panel that was earlier. Learned so much, as I always do.

[00:31:42] I want to start with saying maternal mental health is not a side issue of maternity care. It is one of the most significant issues that most women deal with. And if you're following the news, following the Clancy versus Massachusetts, state of Massachusetts, you know what it can look like in the worst case scenario.

[00:32:07] And this is just going to get worse, primarily because our research and independent research has demonstrated that if you've had one major depressive episode, MDD, you are 67% more likely to develop postpartum depression.

[00:32:31] And as you look at the younger generation, girls between the ages of 15 to 25 years have already been diagnosed with one major depressive episode.

[00:32:53] That is 51% population and 57% of a segment already has had one major depressive episode. That is the generation that is going to become others. And so this is an impending public health crisis. And it is aggravated primarily because today the standard of care is what is called as Edinburgh postnatal depression screening.

[00:33:23] It's a self-reported form that a mom gets if she is lucky because only 33% of women even get screened. And this is done at week six postpartum, that last wellness visit that they have with their OBGYN before care moves to pediatric care. So Linda, you said the system is working exactly as it should.

[00:33:47] And that is exactly what is going to break in five years from now when all of these young girls begin to become mothers, which should be a joyful, most joyful experience of their lives. Instead, it can end up not just being traumatic, but putting extreme pressure on the system that is not equipped to support it. Yeah. You know, it's interesting. You know, there are the depression scales.

[00:34:16] And even if you go see your PCP, you'll often get a depression questionnaire. But doctors aren't always asking the questions early or what I've heard many PCPs say is, you know, we want to know, we want to ask the questions, but then we don't know what to do with the answer. So it's better not to know. You know, how do we address that? I think that is the most important question. And this, and I feel super fortunate to be doing the work that I'm doing right now.

[00:34:45] What we are working on is a blood test that can predict postpartum depression 10 weeks before the baby is born. You're not asking a mother when she's in labor for the first time if she wants an epidural, if she wants a C-section. That is not the first time you're having that conversation because you know very well that she's not in the right frame of mind to have that discussion, make those decisions.

[00:35:13] That is not how maternal and mental health is treated. What we want to do is change the narrative. There was a lot of talk about stigma in the previous panel as well. There is a lot of stigma with reporting, the issues that you see, you know, infanticide, just a lot of intrusive thoughts. You don't want to share this. You truly do not want to share this even with yourself sometimes, right?

[00:35:37] And so the only way that we can remove the stigma but also prepare the system is by predictive care. And so we are working on MyLuma, which can give you a predictive risk score for postpartum depression 10 weeks before. And then we've partnered with several navigation companies. So even under Medicaid today, there is $3,500 in existing CPT codes that cover postpartum care.

[00:36:04] They are underutilized, grossly underutilized because the mother is not in a place to even access that care. And so being able to not do a reactive when the symptoms emerge, but predict and create a fourth trimester care plan that the woman can be administered to when they are in crisis. The other important aspect you brought is OBGYN saying we don't know what to do, which is true because they're never, they're trained surgeons.

[00:36:33] They're not trained to be mental health professionals. So giving a predictive blood test, something that they can do in a standard week 28 blood panel will help them provide the care, transfer it to experts that can actually take care of the mother. And that's the only way to do this.

[00:36:54] From a policy perspective, one of the things that I'm very, very, very excited about is the Medicare extension for coverage for first 12 months postpartum versus just the first 60 days. I think it's a step in the right direction. We don't have services because we've never thought of postpartum care long enough.

[00:37:17] But hopefully it doesn't just become an eligible for care, but there are actually services in the postpartum period that can help support the mother. But that, you know, as of July 15th, this year, 2026, 49 states have adopted the extension for the 12 month extension coverage of Medicare postpartum, which I think is a huge win. But it also speaks to what policy and advocacy can do for us. Yeah.

[00:37:46] So I'm going to ask you to predict the future a little bit. If we could identify women at a higher risk, let's say that this blood test was the standard of care, what could the fourth trimester look like? Absolutely. So there is just one therapy today that is approved for postpartum depression, zuranolone. And, you know, given giving that prescription that's very specific to postpartum depression, it's not SSRI based.

[00:38:16] It's actually a new class of mood disorder drugs that are coming up on the market. This is the first of its kind, which uses an allopregnant alone pathway, an allopathway to treat women. And it's safe in periods of breastfeeding and postpartum. And it does not have side effects. And it can, it shows symptom relief in under 48 hours.

[00:38:38] All of this is important when you actually start thinking of what is the mother going through in those first four weeks, first six weeks, first three months postpartum. Right. And so that, that is available, accessible today. But, you know, to do that, you need to have a system that actually cares enough, has time to react, has time to plan for that.

[00:39:04] Apart from that, there are fantastic organizations that are doing care navigation therapy. That is top therapy that is specific to postpartum. It's very unique. It's very specific. And so I do see all of them as a part of, you know, the care plan. Dula services are being covered. All of those, I think, can become a package, a fourth trimester package.

[00:39:27] And there are some very good health systems, Linda, that are beginning to think in this way and are beginning to offer the fourth trimester care plan for their mothers. Wow. So I'm hearing some innovation in this. Chad, you know, we were talking about mental health, but I can't help thinking about the many stressors people who want to conceive or don't want to conceive are facing.

[00:39:54] You've talked about contraception as an issue that almost everyone agrees should be covered across the political spectrum. It doesn't matter your party affiliation. So if we've got this broad agreement on, you know, the accessibility of contraceptive care, why are we still seeing companies struggle with innovation, with bringing new contraceptive options to the market? Yeah, great question.

[00:40:21] Right. And really, it distills it down to really being a kind of a twofold issue. Right. The good news is innovation is happening. Right. We've got the Rashmi's of the world. We've got others, Dr. Sophia Yen, who we'll hear from in a second, who's got an entire disintermediation platform. Right. To sort of break up the traditional model. And we've got research happening from NIH, not enough money, obviously, biotech, pharma. They're all doing that. Right. But the issue really comes down to two things. Right.

[00:40:50] Unfortunately, women's health, a lot of the heavy lifting to commercialize these products and deliver them to the patients that need them, unfortunately, is falling to our small to midsize pharma companies that don't necessarily have the resources or the deep pockets to to weather the two to three to five years it takes to create the demand so that the payers will ultimately step in and actually apply coverage.

[00:41:18] I think the other piece of it really is that coverage arm. Right. So, you know, to get a product approved is one thing. Currently today, the Affordable Care Act, the final contraceptive mandate that came down in 2012 states that if you have an innovative product, if you've got something that does not have an A-B rating, which means does not have a generic equivalent, it should be covered at zero dollars. And unfortunately, that's not always happening. Right.

[00:41:46] And so what ultimately is required of that small to midsize pharma company is they need to pay that delta between what's not being covered for the patient and buy that copay down either to zero dollars or to buy it down to something that's that, you know, a consumer or a patient can afford.

[00:42:06] So if, you know, sort of the payer dynamics are a root obstacle and you're talking about this delta, what specifically has to change in how we structure coverage? Because, you know, let me just say it just seems like this also is a men's health issue, but maybe that's another conversation. You know, how do we look at how reimbursement is that or, you know, what are the policy issues to actually make it viable for these smaller companies you're talking about to invest in contraceptive innovation?

[00:42:35] And Linda, I love the fact that you said that it's also a men issue. I would say it's a societal issue. Right. So family planning is not a partisan issue. Right. It's literally 80-20 across almost every single question, regardless of what side of the aisle that you're on. Being able to control the timing of when in the ultimate cost benefit analysis that's been done a multitude of times. Right. Shows about for every dollar spent on contraceptive, we're getting from four to nine dollars in return.

[00:43:02] So, look, back to your question. As we sit here, our uninsured or truly uninsured still have backstops with Title 10, Medicaid waivers, federal state programs. So really, out of the 40 million women that are currently contraceptive, the vast majority of them have some sort of coverage, whether it's under the Affordable Care Act or some sort of commercial coverage.

[00:43:24] The issue is that ultimately what we're dealing with is payers that, for whatever reason, you know, are not willing to cover these innovations out of the gate the way the Affordable Care Act is currently written.

[00:43:42] So that ultimately stymies the investment that can actually go back into investment research and commercializing great athletes, you know, that folks like Rashmi and other brilliant folks that are part of this coalition are working on. And unfortunately, I sit here today, 29 years from when I joined pharma exclusively in women's health that entire time. And we're still sitting here talking about fibroids, endometriosis, PCOS, PCOM.

[00:44:11] But the issue is big pharma, the margins are so small for contraceptive products that they're not willing to necessarily dip their toe into the space, leaving it to the smaller companies to try to, you know, carry the torch on behalf of women. So, I mean, there's so much that could be done here. I mean, you've pointed to companies that are running out of cash.

[00:44:36] You talked about, you know, in a previous conversation, the vaginal vein product made by like the Anovera that was created. But I mean, what can we do? What does this look like in practice? Because we don't want to stymie innovation. We want there to be more innovation. So what happens like to this range of options when you've got something that may work, but then you've got a company that says, well, I can't sustain it. And so then we lose something that can be really valuable. How can we sustain this commercially? Yeah.

[00:45:06] Well, fortunately for the Anovera ring, I do know a company that was able to pick up that asset. Right. And so we were fortunate enough to have the resources to pick up that entire portfolio. But you're correct. You know, prior to the Affordable Care Act around 2011, 2012, there were approximately 20 companies that were in pharma that were heavily investing in innovating in women's health. Unfortunately, now we're probably down to a handful of those. Right.

[00:45:36] And there are a couple that are not in great positions. And I worry that I don't necessarily worry about some of the on-market assets, although there's some very good ones. I worry about the pipelines that those companies were investing in doing the research in because there are some incredibly, incredibly innovative things behind it. So, look, the bottom line question you have, right, is what do we do? Right. So I think, number one, we need to continue to reach out to our legislatures. Right.

[00:46:05] Legislators. I think writing letters, reaching out to your congressmen and women absolutely is a critical piece to us ultimately having a system that works. Typically, Linda, what we see is women of color are disenfranchised when it comes to our health care system.

[00:46:31] Ironically, when it comes to understanding the Affordable Care Act and the zero cost that they should be paying or should not be paying, women of color actually are more informed than other ethnic groups. So what that shares to me is that we also have an awareness issue. Right. We need to make people aware. Maybe you're happy to pay that $20 copay for your monthly contraceptive or that $50 copay for your monthly contraceptive because you have the means to do it.

[00:47:00] But you should not have to. There are products now, innovative products, whether it be a natural estrogen, whether it be a contraceptive ring, whether it be the innovation that we see with the intrauterine systems that we have today. There are significant advancements, yet I constantly hear stories from physician colleagues who tell me like, wow, you wouldn't believe that I saw a woman on a 50 microgram pill today. That screams 1980s to me, right?

[00:47:27] We have come so incredibly far and there's so many advantages to these innovative products, but it's being limited, obviously, by the lack of enforcement. So really, I say we have to raise our hand and we have to make sure that we are asking our legislators to potentially step in. So, Sophia, politics.

[00:47:52] You've argued contraceptives should be available over the counter. What a thought. And you've pointed to lingering legal confusion from the Comstock Act to IUD still being mischaracterized as abortifacient. You know, you heard what Chad said.

[00:48:13] How does that combination of outdated, what did you say, so 1980s, outdated law and misinformation actually shape what patient can get access to and what they even know about? I think it's so important for every person on this call to realize that we have an activist administration with respect to laws that restrict women's rights.

[00:48:39] And specifically the Comstock law, if you don't all know, it says you can't mail abortifacients or things that do abortions by mail. And it's unfortunate when legislators who are not physicians are writing laws that can have unintended consequences. And so specifically the drug mifepristone is being used for breast cancer, is being used for fibroids, is being used for brain cancer, is being used for so many other things other than abortion.

[00:49:09] And if you restrict it, then it can't be used for this research to improve these people's lives. But also that it is safer than penicillin, Viagra and Tylenol. So if you're going to make this drug gone, then I suggest you take Viagra too, to be fair, one on each side. But know that we don't want the Comstock law enforced. It wasn't enforced. It was assumed to be a dead law because we had Roe v. Wade.

[00:49:37] But because Dobbs was overturned, then this law is called a zombie law and it reemerged. And it is now becoming an issue. So please check out, and I'll drop in the thing, stopcomstock.org. It's a coalition. It's education. It's petitioning. It's calling your legislators to make sure they understand that. The other thing you alluded to, Linda, I just want to reemphasize because this is my wish.

[00:50:03] So know that one birth control pill is over the counter. But this pill was taken off market ages ago because everything else was better. It has a three-hour window. And my joke is if you go watch Oppenheimer or some movie that's crazy long, then you might literally be screwed because you took your pill late by three hours. And then you have to remember, did I have sex five days ago? And then I can't have sex for two to three days until the hormone level gets up.

[00:50:33] It's just a lot to ask of people. But what I'm asking bipartisan, both sides, let's take all birth control pills over the counter, including the pill, the patch, the ring, the injection. And I say don't make them all go through the FDA process. For those people that don't understand, taking a pill or patch or ring over the counter from prescription takes five to seven years and five to $10 million.

[00:51:02] And there are 40 different pills. And it shouldn't just be the pill that happened to be off patent and available for sale. It should be all the pills so that we have access to all of them. And the American College of Obstetricians and Oncologists have said over and over and over again that birth control pills and thus patch and ring should be safe and over the counter. And in China, they get it over the counter. So why can't we have the same rights as China? Yeah.

[00:51:30] So, you know, you're talking about access. Let's just make it accessible. And, you know, as you think about what you kind of term the 50-state problem, you've argued for a national telemedicine license rather than having this state-by-state. You know, it's not like we can throw people over a state border to continue their care. What does a state-by-state licensure cost patients and providers in practice today? I mean, you know, the fact that we don't have this. And, you know, what could it look like?

[00:52:00] What would happen if the barrier actually came down? So I want to make sure everyone understands that physicians take a national exam. We are not like lawyers who practice differently state-by-state. Medicine should be practiced the same at least throughout the United States and even throughout the world. We have standards. We have practices. We have protocols. And so we don't need a state-by-state exam or licensing. I think this is a residual of the old days.

[00:52:28] But that is currently the law. And so by not having a national medical license, or you could have it specific telemedicine would be my proposal, then you have to get licensed state-by-state that you want to open up your telemedicine. And the impact for patients is you don't get care to somebody at Stanford, Harvard, UCSF, Hopkins. You have to fly there. And some things, yes, we absolutely should see you in person so we can examine you and whatnot.

[00:52:58] But other things, wouldn't it be amazing to get that second consult from Stanford or Harvard or UCSF or Yale or Mayo Clinic? I have to touch everybody and make sure they aren't offended. But that is what you're missing out on. And what I'm really proud of my company is we bring better than UCSF and Stanford care to wherever you have internet and a mailbox. But we had to pull out of certain states because certain states restricted asynchronous telemedicine.

[00:53:27] So they required a video or they required a phone call. But would that change my management in birth control? No. Would that change my management with respect to basic HRT? No. So I say leave medicine to the physicians. But part of this is the medical boards. And the medical boards should make note that some things are low risk and should be set free. Birth control, HRT, dermatology, psychiatry. I think psychology can be done by video. It doesn't have to be done in person.

[00:53:57] And so much more access, so much better flexibility for physicians, less burnout. But access to care and cost of care will be totally brought down. We charge $35 once a year, unlimited access to a doctor about the pill patch ring. Beat that. So you talked about the problem. And you've called insurance the bane of your existence. We just have a couple minutes left.

[00:54:26] But talk about what it means to have someone who's not even in the same specialty make a decision about how you're treating patients and what you can and cannot do. What does that look like? My daughter says I complain so much about the three hours that I work at an academic institution in Palo Alto. And because I walk in and the nurse hands me a stack of prior authorizations. And I'm like, did I go to medical school to fight these people?

[00:54:56] I'm here to help people. And why won't they give me the medications that I want? And it's not like I'm trying to go for something crazy expensive, though GLP ones are crazy expensive. But they're worth it for what they do and the stuff that they protect against. And so this is causing severe doctor burnout. But what is insulting is that they don't even have the giant ovaries to put their name to the denial. They put RPH. And so that means pharmacist.

[00:55:26] So it's not even a doctor. And then sometimes they'll have a doctor. But it's not a doctor who understands obesity. It's not a doctor who understands women's health. It's an eye doctor. Why is an eye doctor telling me how to handle obesity? Why is an eye doctor telling me what I can and cannot prescribe for birth control? That I'm one of the world's premier specialists in obesity.

[00:55:52] And who are you to override me when you won't even tell me your name? And you won't even tell me your specialty? And I just want to call out Optum and Medi-Cal of California doesn't even have a peer-to-peer review. So they're like, nope, sorry. And then my next level is I have to contact my state representative? That is ridiculous. What the heck happened here? We at least have the decency to have a doctor-to-doctor chat.

[00:56:20] And the horrifying thing is I think it's going to be AI versus AI. My AI versus your AI. When really it should just be a let me prescribe what I need to prescribe and know that I will save you money to the best of my ability. Yeah. So, you know, with that, I mean, we could, you know, as with the previous panel, continue this forever. But we're going to have to wrap up. You know, you've got a bunch of people who I think just got charged up listening to you, Sophia.

[00:56:48] But advocates, policymakers, you know, researchers, scientists, providers. You know, what's that one thing you want them to walk away with? What do you want them to do tomorrow that they didn't do today? We'll start with you, Sophia. I would like birth control over the counter, but we need to deal with this prior off thing. Oh, pay me for my time. That's my hashtag. I spend two to three hours on the phone arguing with people about this and just like this. Why I hate going into clinic every week.

[00:57:18] So, like, if you're going to waste my time, you at least should pay me for it. And I should be able to bill you. Just like lawyers, when you lose a suit, you got to pay the lawyer that you wasted or whatever. As a physician, if I'm going to spend time fighting, no one's paying for this time. And this is why doctors are burnt out. Yeah. And, Ted, what do we need to do tomorrow that we didn't do today? Look, I think we all have a role, right?

[00:57:42] So, I would submit that we all need to channel our inner Sophia Yen MD, right? And make our voice heard, right? And so, I think the WHA is an unbelievable forum for that. We've seen the black box warning come off, you know, menopause hormone therapy. You know, there's still conversation about taking local estrogen over the counter. And I think we can combat some of these issues that we've touched on today if we just make sure that our voices are heard. So.

[00:58:13] Yeah. Thank you. And Rashmi, you get the last word. What are we doing tomorrow? We didn't do today. Just recognize that maternal health is generational health. And healthy babies start with healthy mothers before, during, and after pregnancy. And for lawmakers and policy makers in this group, take care of your mothers. The rest of it will follow. The rest of it will follow.

[00:58:44] Yeah. Well, thank you all. You all made clear today that we've got science. We've got the will. They don't always go together. So, what's missing is getting this will to turn into action and policy. Whether we're catching depression risk or getting new contraceptive options to the market or getting a prescription through the door without a fight. The work ahead isn't about proving these problems matters.

[00:59:11] It's about getting policymakers and payers to pay attention and finally build the infrastructure that actually matches what patients and physicians need in the way that they need it. I want to thank you all. You've been an amazing panel. Dr. Rashmi Raghavendra, CEO of Dionysus Health. Chad Turner, Vice President of Marketing for Maine Pharma. And Dr. Sophia Yen, Co-Founder and CEO of Pandia Health. Thank you all so much for participating in this conversation.

[00:59:41] And before we close, I'll just remind you again, Women's Health Advocates has the Breast Cancer Early Detection Hill Day in Washington, D.C. on the 23rd. The Menopause Day is the 22nd. Go to Women's Health Advocates and register. And don't forget to join us for the final webinar in this series, Advocacy and Voting, Putting It All Together, at noon Eastern time, October 22nd. We must vote like our health depends on it because it does. Thank you all so much.

[01:00:13] I hope you enjoyed the conversation with these great expert voices. What struck me is how many of these problems seem different on the surface and how similar they become when you look underneath. For example, a woman may spend years getting a diagnosis for fibroids or endometriosis. Someone may first learn about her fertility risks when she's already struggling to conceive. A new mother may be screened for depression only after symptoms have appeared.

[01:00:40] A patient may have an effective contraceptive prescribed but still be unable to get it covered. And an innovative company can develop a better solution and then discover that the reimbursement system makes it difficult to get that solution to patients. Different conditions, different stages of life, but again, the same policy questions emerge. What studies do we choose to fund? What services and benefits do we choose to pay for? What do we make easy to access?

[01:01:09] And what do we make unnecessarily difficult? And who gets to make those decisions? This is why these issues belong in a series about elections. Women's health policy isn't confined to one issue, one political party, or even one moment in a woman's life. It stretches from research funding to medical education, from insurance coverage to telehealth, from contraception and fertility to pregnancy, postpartum care, midlife, and beyond.

[01:01:36] As the midterm elections approach, we hope this series encourages you to go beyond the headlines. Find out where candidates sit on the health issues that matter to you and your family. Ask what they support, not only in principle, but in funding, legislation, coverage, and implementation. Because advocacy doesn't end with an election, but elections help determine who will be making these decisions on our behalf. Your health is shaped by policy. Your voice can help shape policy.

[01:02:06] For more information, go to womenshealthadvocates.org. And for more podcasts and information on women's health, visit beyondthepapergown.com. And while you're there, sign up for our newsletter. Our podcast was produced by me and our audio engineer is Patrick Shambayati. Our associate producer is Kyla McMillian. Until next time, take good care.