New state-by-state bans on abortion will give rise to quiet pregnancy terminations elsewhere by American patients

Strict abortion ban up for Ohio governor to sign

Ohio lawmakers have passed a bill prohibiting abortions once a fetus's heartbeat can be detected — a practical ban on abortion in the state. A heartbeat can be identified as early as six weeks into a pregnancy.

The law would make it a fifth-degree felony for doctors to provide an abortion without checking for a heartbeat or for carrying out the procedure after one is found. A fifth-degree felony in Ohio is a crime that, if convicted, carries a prison term of between six and 12 months and/or a fine of up to $2,500. Crimes that are considered class 5s in Ohio include illegal gambling, breaking and entering, and the exchange or possession of illegal items. But a felony nonetheless, which would most likely cancel a license held by an Ohio medical examiner and mark him or her as a criminal.

There isn't an exception for cases of rape or incest in the measure, which now heads to the desk of Governor John Kasich. Arkansas and North Dakota have both passed similar laws, both of which were blocked by an appeals court. The Ohio measure would likely be struck down by the Supreme Court as a violation of Roe v. Wade. But if one of the more liberal justices leaves the court in the next four years, that could change. President-elect Donald Trump has promised to appoint justices who want to overturn Roe v. Wade. 

So here is where my mind wandered when I read this:

In the 1980s, when I was an OR nurse doing my internship rotation at a Catholic hospital in Ft Lauderdale, Florida, we were scheduled to perform a D&C one morning. The doctor was ready, the patient on the table, draped and with an IV in her arm. All of a sudden the Mother Superior appeared and grabbed me by the collar of my scrubs and dragged me out the door. She said, "See nothing. Hear nothing. Know nothing. Go to room 7 and help out with the cholecystectomy." And off I went just as I was ordered.

Later, in the nurses lounge, I learned that the case was cancelled. The doctor and the anesthesiologist were both dismissed from the staff and the scrub nurse and circulating nurse were suspended pending an investigation into why a D&C was being scheduled on a women with a positive HCG pregnancy test.

I predict that there will be a rise in the incidence of medical tourism D&C cases, they won't be "marketed" online as "abortions", because wherever Google shows the ad in a state such as Arkansas, Ohio or North Dakota, it would be an ad for something illegal, where the D&C might technically not be treated the same.

Dilation and curettage (D&C) is a procedure to remove tissue from inside a woman's uterus. Doctors perform dilation and curettage to diagnose and treat certain uterine conditions — such as heavy bleeding — or to clear the uterine lining after a miscarriage or abortion. The procedure does not require the use of a full operating theater. It can be done in a doctor's exam room of 9' x 12'. Prior to the 16th week, a surgical abortion procedure can be used to terminate a pregnancy. It is also referred to as suction curettage or vacuum aspiration. It is an outpatient procedure that requires a quick blood test that can be done to confirm the urine hCG preganacy test, called a "βsubunit" (hCG Quantitative: Beta-subunit Human Chorionic Gonadotropin - CPT 84702). The analysis of the units of these hormones (e.g., follicle-stimulating (FSH), luteinizing, chorionic gonadotropin, and thyrotropin) enables early diagnosis of pregnancy and/or ectopic pregnancy. The typical cost of the lab test is about $25-30 across the USA.

The typical retail (undiscounted) cost of the D&C is less than $1000 managed care plans often pay about $300 or less to a physician for a D&C performed in their private office. After the procedure, the woman remains recumbent after the procedure and relaxes for about 90 minutes and then she arises, dresses and off she goes. There is usually no restriction on flying or driving home the same day. There may be some cramping afterwards. A pathology charge is also bundled in to examine the vacuum aspirate for products of conception. A prescription for ergometrine maleate is often given after the procedure which is given for a short course and is inexpensive.

Is that where we return to? Back in the 1970s, if a girl became pregnant at high school in Florida, she took a "quick trip to New York". Today, in the Middle East this happens among those that follow Islamic law. If a single woman becomes pregnant and doesn't want to have a baby, she travels elsewhere for a quick, minimally invasive (no incision) simple procedure and come home the next day - the procedure undetected. Nobody knows unless she tells someone. It may be that the woman is not Islamic but resides where Sharia law is enforced on her because she resides there - perhaps while working as an expat or in some other situation. I need not elaborate here as to who or why or get more specific. The crux of the matter is she does not wish to remain pregnant for some reason.

This may set the whole topic in perspective and save you some time if you are a medical tourism company seeking to assist (or source) patients for D&C procedures:

Abortion illegal in all circumstances or permitted only to save a woman's life.

In these countries listed below, every day women leave quietly, without attracting a lot of attention. They go on a "short vacation away" and come back with a few problems solved. Nonetheless, they also come back with perhaps the guilt that they have gone against their life-long religious beliefs and practices, the knowledge that they have gone against what is legal in their home country, the gnawing question in the back of their mind of what "might have been" and perhaps much more untreated psychological trauma than many will ever measure. I have compassion for them. This kind of medical tourism is not full of joy.

• South America: Brazil, Colombia, Chile, Dominican Republic, El Salvador, Guatamala, Haiti, Honduras, Mexico, Nicaragua, Panama, Paraguay, Venezuela,
• Sub-Saharan Africa: Angola, Benin, Central African Rep.Chad, Congo, C?te d'Ivoire, Dem. Rep. of Congo, Gabon, Guinea- Bissau, Kenya, Lesotho, Madagascar, Mali, Mauretania, Mauritius, Niger, Nigeria, Senegal, Somalia, Tanzania, Togo, Uganda.
• Middle East and North Africa: Afghanistan, Egypt, Iran, Lebanon, Libya, Oman, Sudan, Syria, United Arab Emirates, Yemen.
• Asia and Pacific: Bangladesh, Indonesia, Laos, Myanmar, Papua New Guinea, Philippines, Sri Lanka.
• Europe: Ireland, Malta.

Abortion legally permitted only to save a woman's life or protect her physical health.

• The Americas and the Caribbean: Argentina, Bolivia, Costa Rica, Ecuador, Peru
• Sub-Saharan Africa: Burkina Faso, Burundi, Cameroon, Eritrea, Ethiopia, Guinea, Malawi, Mozambique, Zimbabwe
• Middle East and North Africa: Kuwait, Morocco, Saudi Arabia
• Asia and Pacific: Pakistan, South Korea, Thailand
• Europe: Poland

The "other" consequences - the ones that remain long after the procedure is over?

1. What will happen if the woman requires therapy for the psychological consequences of abortion that plague many women after the procedure? If they disclose that they did this and the therapist or psychiatrist documents that she had an "illegal abortion", are the notes subject to discovery by law enforcers? If so, what will the penalty be? What are the statutes of limitation? Will the Ohio, Arkansas or North Dakota doctor be prosecuted? Will the woman be prosecuted?
2. Now that we have mental health parity laws, will the counseling service be a "covered service" or result in a disallowed claim if the notes are requested? Is the workaround going to be telepsych counseling with a therapist from outside of the state where it is illegal? Is it self pay? or Covered? If the therapist is licensed in say, California and Ohio, could the therapist lose their license in Ohio if they counsel a woman after an illegal procedure in Ohio from California?
3. If the woman is a participant in a managed care plan with a national wraparound benefit (meaning that she is considered "in network" at any clinic, anywhere in the country where the provider is a participating provider), and her plan from her self-insured employer does not specifically exclude D&C for the purpose of pregnancy termination, will the claim be payable to a provider outside the state where it is considered illegal?
4. If the procedure is illegal in Ohio, Arkansas and North Dakota, but still allowed elsewhere nationally, will the service be an includable service under IRC 213D? Will a woman be able to deduct the lab test, pathology charge, procedure and travel to have the procedure as a medical expense? If documented as a D&C will the charge be questioned by the IRS and other regulators? How would regulators afford to maintain this process and at what cost?
5. Will there be a consequence to medical tourism facilitators who knowingly aid and abet women to plan a trip and find a provider for the procedure? After all, a professional medical tourism coordinator is going to ask about pregnancy and transfer medical records, if they exist to the treating provider. So the information of date of LMP, and "are you currently pregnant" is a question asked of all women planning ANY surgical procedure or procedure involving certain medications or x-rays. You cannot simply do a "don't ask, don't tell" in this case.

Right now, this is what users of medical marijuana face in reverse. Decriminalized in their state, but still nationally "illegal", the expense of the medical marijuana purchases are not deductible as a medical expense on their taxes even though they pay 100% out of pocket for a medically-indicated treatment that gives relief from a number of chronic conditions. Currently in the case of medical use of cannabis, only the patent medicine (Marinol) is deductible and only indicated for certain conditions. Marinol (dronabinol) is a man-made form of cannabis (also known as marijuana). Marinol is used to treat loss of appetite that causes weight loss in people with AIDS. It is also used to treat severe nausea and vomiting caused by cancer chemotherapy.

My post is not meant to judge or opine on abortion. I don't want to get into philosophical issues or position issues for or against. This is not a place to share my personal views on abortion and women's rights, Sharia law, or other religious beliefs.

I simply wanted to bring to light the recent developments associated with this rollback of Roe v Wade on a state-by-state basis, or even a national basis. My intent is to highlight that interesting dilemma created by the proposed legislation and to see how it will evolve as a medical tourism or telepsych procedure - a procedure which is essentially a "side effect" of taking the morning after pill or many other abortifacient drugs, or a suction curettage procedure commonly referred to as a "D&C".

Your thoughts?

About the author

Maria Todd is an international healthcare industry consultant, author, and innovator recognized worldwide for her work in managed care, health delivery systems integration, concierge medicine and health tourism. She works as the CEO of Mercury Healthcare International in Denver, Colorado and directs its consulting firm, Mercury Advisory Group and its Corporate Medical Travel Administration program at Mercury Health Travel.

Maria is also the director of the Managed Care Institute and the Center for Health Tourism Research. She oversees publication of Medical Tourism Destinations of Distinction, a new travel, lifestyle and wellness quarterly publication that will begin digital distribution in March 2017. Her knowledge of surgery and medicine comes from working in the industry for more than 35 years and professional work experience as an EMT/Firefighter and an OR nurse.