Good afternoon, everyone. Thank you for joining us for today's webinar, Addressing GDM Disparities Preconception Care and Early Detection in Marginalized Communities. My name is Dr. Rachel Hardiman, and I have the distinct honor of moderating today's webinar and discussion. To share a little bit about myself, I am a professor in the Division of Health Policy and Management at the University of Minnesota School of Public Health, where I serve as the Blue Cross Endowed Professor of Health and Racial Equity, as well as the founding director of the Center for Antiracism Research for Health Equity. And I spend most of my days building an evidence base of research around the impact of racism and on health and well-being, particularly for moms and babies in our communities. And I'm really excited to be a part of this discussion today, as we learn more about how we can address the pervasive disparities that are experienced within many marginalized communities across the United States. We have, well, first I'll say, this activity has been funded by an unrestricted educational grant from Blue Cross Blue Shield of Minnesota, who has made this program a possibility. So we're very grateful for that generous support. Next slide, please. So here you have today's agenda. We will have some introductions, and then we'll jump right into our presentations, followed by conclusions and question and answer. So a few housekeeping items that I'd like to share with you, you know, keep in mind that the presentations are today are going to be recorded. So out of respect for our speakers and panelists, we will have microphones and cameras, microphones muted and cameras off. However, we do want to ensure that we provide all opportunities for questions and engagements after those presentations. So throughout the presentation, you will be able to access the Q&A function. You'll see that at the bottom of your screen. So if you have any questions that come out throughout the presentations or after, please feel free to utilize that Q&A function to ask your questions. I'll be keeping an eye on that and, you know, collecting questions as we go so that after the presentations are finished, we'll be able to jump right into a robust discussion. I will also note that if you prefer, you'll have the option to ask those questions or pose those questions in that function anonymously. And we will do our very best. I will do my very best to answer all of the questions that are posed in today's presentation. And if some of them are, you know, similar in some ways, I'll try to sort of summarize and make sure that we get to get through all of the important pieces of our discussion. So again, we'll begin with some introductions and then we'll jump right into those presentations. And we look forward to engaging with you in the chat box as well as in the Q&A. So now I'm excited to introduce you all to today's panelists who bring a wealth of expertise and unique perspectives from the maternal and child health space, both as practitioners and scholars. So I'm going to start by introducing Dr. Kami Wright. Dr. Wright currently serves as the president of the Indiana Market at CareSource, where she leads teams towards excellent operational and quality performance while ensuring that members receive the highest quality and highest value health care. Dr. Wright is very involved in initiating growing and fostering partnerships with all stakeholders that can contribute to and help improve the health and well-being within her community. Dr. Wright is a vocal proponent of health equity, dedicating time and efforts to mitigate health disparities in our community as well as across the nation. In her previous role as an OBGYN, Dr. Wright became a nationally recognized physician as one of Indianapolis's monthly top docs and is regarded as a passionate and exemplary medical figure. Dr. Wright served as president of medical staff, where she became known as a change catalyst due to her implementation of various innovative programs that were tied to important causes, such as lowering teen pregnancy rates. Dr. Wright also served as a teacher, a mentor, a role model, and has shaped future generations of leaders in women's health for some time now, with a focus on instilling a culture of quality and accomplishment in the implementation of treatments and diagnostic procedures. So thank you and welcome, Dr. Wright. Secondly, it's my pleasure to welcome Dr. Chloe Zera. Dr. Zera is the chief of the Division of Maternal Fetal Medicine, MFM, and the director of quality for the Department of Obstetrics and Gynecology at Beth Israel Deaconess Medical Center. She's also an associate professor of obstetrics and gynecology and reproductive biology at Harvard Medical School. Dr. Zera attended medical school at the University of Minnesota, go Gophers, and completed her OBGYN residency and MFM fellowship at Brigham and Women's Hospital, during which she also completed a master's of public health from the Harvard School of Public Health. Dr. Zera is a board certified, is board certified in OBGYN, MFM, and obesity medicine and provides comprehensive preconception and prenatal care for birthing people with complex pregnancies, particularly chronic medical, those with chronic medical conditions. She leads several ongoing clinical research and quality improvement projects that are aimed at developing better systems of care, reducing inequities and improving pregnancy outcomes. Motivated by her clinical experiences, Dr. Zera has also become a well recognized advocate for comprehensive and equitable reproductive health care policy through her leadership roles with the American College of Obstetrics and Gynecology, ACOG, and the Society for Maternal Fetal Medicine. So briefly, you can see on the screen, all of our panelists disclosures. Take a quick look before we move on and jump into our exciting content. So we are incredibly excited to have this decorated duo present today on addressing GDM disparities, preconception care, and early detection in marginalized communities. And it is our hope that by the end of today's presentation and discussion that you will walk away being able to identify the risk factors for GDM in marginalized communities, including modifiable lifestyle factors, social determinants of health and genetic predispositions with an emphasis particularly on culturally relevant or culturally centered interventions. We also hope that you will walk away with the ability to recall the importance of culturally sensitive screening during the early pregnancy stages for gestational diabetes and under-resourced populations and be able to think about how evidence-based guidelines can be adapted to improve access and equity in care. We also have the objective of recognizing being able to recognize the role of social determinants of health and exacerbating GDM disparities among marginalized communities and actionable strategies to mitigate these disparities through community-based support, culturally respectful care, and improved access to resources. So with that, I am really excited to jump right in. Dr. Wright is going to start and then we will move directly into Dr. Zara's presentation. And again, don't forget to drop your questions in the Q&A function at the bottom of your screen. And of course, there's also the chat function that we will reserve for other types of comments. But again, those questions start, you know, sending them through as soon as you're inspired to do so. And Dr. Wright, I will pass it off to you. Well, thank you so much, Dr. Hardiman. And I'd also like to thank the American Diabetes Association for providing me with the opportunity to speak on this important topic. As highlighted earlier, I am very passionate about identifying and mitigating health disparities in our in our state as well as in our country. And certainly gestational diabetes is an area where we see very significant disparities. I'd like to start with some statistics because I love starting with numbers. And I think it's really important to understand the prevalence of this and why this is an important topic for us to discuss today. Every year, two up to 10 percent of pregnancies in the United States are affected with gestational diabetes, which I will hereafter refer to as GDM. And that's pretty significant. That means one out of every 10 pregnancies potentially has a complication of gestational diabetes. And I think that we all understand intuitively that that leads to not only circumstances that are worrisome in the pregnancy, but can lead to lifelong conditions after the pregnancy. For the mom, the risks include the likelihood of developing type two diabetes later in life, which is about 50 percent. And some will, quote, much higher than that. So there is a thought that this is a very temporary, self-limited condition and it very well can be. But many women go on to have diabetes and sequelae from that for the rest of their lives. In addition, gestational diabetes has been associated with an increased risk of developing cardiovascular disease, both in the postpartum period as well as beyond. And we certainly know that that is a very undesirable situation as well. For the infants, there are also some significant consequences of gestational diabetes. One includes macrosomia, which is having a larger body. When infants are macrosomic, there can be issues with delivery. Mothers can have significant trouble delivering vaginally, may end up requiring cesarean section, or there may be traumatic events as the delivery progresses that can have either short term or long term consequences for the infant. As well, babies oftentimes will have hypoglycemia because they have normal insulin glucose pathways, whereas the mom has significant issues with that. And so the baby will have higher insulin levels and then those higher insulin levels will lead to hypoglycemia after delivery. And that needs to obviously be monitored and addressed. I think what's most worrisome for me is number one, the incidence of gestational diabetes is increasing, similar to the fact that diabetes in general is increasing in our communities every day. And we also are seeing very significant disparities in who is experiencing this complication. And that's really what we want to highlight today. So I'm going to set the stage for what disparities exist in the space of gestational diabetes. And then Dr. Zeroh will provide some information about ways that we can address and mitigate this. So when we look at the drivers of disparity, I like to classify them in three areas. One is individual characteristics. So certainly race, ethnicity, diet, lifestyle issues like exercise, even things like culture and language, which I will go into a bit later, can be factors in terms of gestational diabetes. There are certainly some economic and socioeconomic factors. And the relationship that the individual has with the healthcare community and their likelihood of engaging with the health system certainly is a driver of disparities in terms of how that gestational diabetes is addressed. There are systemic factors. Politics, policies, and procedures certainly impact disparities. So do we have policies that are limiting someone's ability to be diagnosed, to be treated properly, to feel as though they are getting the care and the resources that they need? All of that can be linked back to the policies that we adopt as a public and in the hospital system. And then there's very painful past and present circumstance involving institutional racism, systemic racism, implicit bias. We all bring biases to our lives every day in the way that we interact with other people. When those biases are prevalent, when they're present in healthcare individuals, we can see a difference in the way that individuals are treated, in the way that they are regarded, and that can certainly lead to poor outcomes. Finally, there are some geographic issues. I think that there are very significant issues in terms of access and availability to care that can contribute to delayed or inadequate treatment, and that certainly can contribute to poor outcomes. Let's start by talking about race. And this graph is a little bit difficult to see, but it shows the rate of gestational diabetes by race. And you see on the left-hand side, non-Hispanic Black, the CDC at this point in time felt that that was the race that had the least prevalence of gestational diabetes. And you see all the way on the right-hand side, non-Hispanic Asians having the highest rate of gestational diabetes. In between, you see non-Hispanic White, you see Hispanic, non-Hispanic Native American or Pacific Islanders, and Alaska Natives. So obviously, from this chart, you can see that there are some races that have two to three times the prevalence of gestational diabetes compared to other races. I think that that's important to understand when we think about the risk factors of the patients that present, who needs to be screened, who needs to be counseled, etc. There certainly are, as I mentioned, racial and ethnic disparities, and a lot of this depends on what studies you look at and what population you're looking at. We know that by some estimates, Black individuals have less prevalence of gestational diabetes. However, there are certain studies in certain populations where the highest prevalence will be in your Black birthing parents. It is generally regarded that Hispanic individuals, Native Americans, and Asians have the highest risk of developing gestational diabetes. And we believe that that has to do with a genetic predisposition to gestational diabetes, but we also think that there are some social factors that contribute to that as well. We know that certain communities of color may have limited access to healthcare. There may be competing priorities that make it very difficult to present early or to present at the recommended schedule in order to get the care that they need. There may be social factors such as transportation, employment constraints, etc. that may, again, impact one's ability to be recognized as having gestational diabetes and be treated appropriately. We also believe in addition to a genetic predisposition, there's something known as toxic stress. So some women with minority backgrounds just have a higher level of chronic stress because they are dealing with some of the social factors that we've talked about. They're dealing with potentially trauma in their lives and other things that actually affect us on the cellular level. And we believe that this toxic stress and some of the overall exposure to stress can also lead to chronic conditions. And gestational diabetes may be one of those conditions that may manifest from this toxic stress. I talked a little bit earlier about the painful history that we have in the United States regarding people of color and the healthcare system. The CDC has actually declared racism as a public health emergency. And we know that systemic racism and implicit biases exist throughout our communities. And the healthcare system is certainly no exception. We also know that there have been incidences in the past where certain racial or minority groups were not treated fairly or appropriately by the healthcare system. And those stories and those experiences are handed down over time. And that certainly leads to historical trauma and that leads to a reluctance to engage in the healthcare system. So what we have is a situation where there are people who have a higher risk of developing conditions like gestational diabetes and have a lower likelihood of presenting for care at the appropriate times because of a fear of maltreatment. I think that that's really important for us as healthcare providers to understand so that we can make sure that we are as culturally conscious and humble as possible when we are providing care for those individuals. I want to now turn to geography. As I mentioned before, geography is one of the drivers or one of the aspects of disparity that we see. In this graph, the blue represents the higher rate of gestational diabetes and the green actually is the lower rate. The lighter blue actually is the highest rate of gestational diabetes. And you can see that there are certainly states that really stand out as having higher rates of gestational diabetes. And that correlates to the diversity in the populations of those states and the communities that are at higher risk for gestational diabetes are more likely to have a higher prevalence in those states. This looks at things a bit differently and it looks at the change in the rate of gestational diabetes associated with geographic location. This looks at four years between 2016 and 2018 and in this diagram, the green actually is more worrisome than the blue. So for those states with the darkest green, there has been the most significant increase in the rate of gestational diabetes with the darkest green representing an increase of 50% or more in just four years in the rate of gestational diabetes. Again, you see that there is definitely disparities between states and where you live and where you seek care certainly is a factor here. Even within a state, you can see geographic disparities. So we know that women who are in rural areas actually have greater issues related to access and availability to care. We know that health care tends to be more sparse in rural areas and we know that the quality of health care can certainly vary depending on where you live and where you seek care. So we know that health care tends to be more sparse in rural areas and we know that the quality of health care can certainly vary depending on where you choose to seek care. You may have to travel over an hour to receive obstetrical care. Those are areas that the Marks of Dimes deem as maternal care deserts and the number of maternal care deserts are increasing over time as hospitals, particularly in rural areas, close. In Indiana, for example, about a third of our counties are considered to be maternal health deserts. So that means in a third of our counties, women have to travel great distances to seek care. Obviously, when that is the case, you can imagine that that makes it very, very difficult to present in a timely fashion, to receive your ongoing care on the schedule that's recommended, and really can provide hindrances for women in rural communities to experience the best care during their pregnancy. If you have gestational diabetes, obviously that is a factor. We also know that the infrastructure in rural areas can be limited. So broadband access is one big area that people will make note of. In rural areas, there's what we call the digital divide. There's less access to broadband. So while there is a role for telehealth as an option, that may oftentimes not be available in rural areas with limited broadband. We also know that while there is some access issues with primary obstetrical care, there is huge access issues to specialty obstetrical care. So should you need an endocrinologist or a maternal fetal medicine specialist, like Dr. Zara, or a dietician, or some advanced provider, it may be very difficult to find that in rural areas. Socioeconomic factors are certainly an issue. So women of lower socioeconomic status, regardless of their race, have a higher likelihood of developing gestational diabetes. We know that there are multiple factors involved with that. We also know that lower health literacy, should someone develop gestational diabetes, may impair outcomes. There may be limited knowledge of how to take care of oneself. There may be limited understanding of what it means to have gestational diabetes, and what the potential consequences are for both mom and baby. And there may be a limit in the ability to follow the recommendations that are provided by the healthcare provider, because of financial issues, or because again, of that lack of understanding. There are other factors that go along with socioeconomic challenges, which include inadequate insurance, inadequate transportation, issues with social support, childcare, employment, et cetera, that exacerbate all of these conditions that I mentioned. If you are struggling to make ends meet, and you're struggling to maintain stable housing, maintain adequate basic needs, you may not have access, or the ability to afford the type of diet, or the type of dietary choices, that your provider is recommending. And so that certainly can impair your outcomes. And finally, those individuals who are in lower wage jobs, oftentimes have just less ability to advocate for themselves. So you may not have the flexibility that other people may have to see the doctor regularly, to be able to come in for a problem visit during the standard eight to five hours, et cetera. And so we know that, again, individuals of lower socioeconomic status will oftentimes experience worse outcomes. Finally, culture and language actually can create disparities and challenges in gestational diabetes. We know women who are immigrants have a unique set of challenges, which may include language barriers. If English is not their first language, there may be lack of familiarity with the healthcare system, the way that we practice it here. They may be used to a different way of interacting with the healthcare community. They may be used to different providers. And so when it is time for them to obtain prenatal care, there may be challenges with communication, with understanding what is being said, with understanding the diagnosis, and more importantly, understanding what needs to be done. While interpretation services are oftentimes provided, they may be inadequate, they may be inappropriate, they may not be meeting the needs of that individual. We know that medication errors, for example, are highest in individuals for whom English is not the first language. And so all of these barriers exist, and again, can impair outcomes with GDM. I think I've painted a bit of a dismal picture here, and so I'll turn it over to Dr. Zahra to tell us what we can do about this. I hope that I can give us some hope at the end of this, although we'll see. So first of all, I also just wanna thank the American Diabetes Association for inviting me to participate today. I think this is an incredibly important topic, and I'm incredibly honored to be asked to speak about it. So one thing that I wanted to highlight is that it's not just that there are disparities in who develops gestational diabetes, it's that once you diagnose gestational diabetes, there are inequitable outcomes. So this is a heat map that demonstrates the differing rates of selected maternal outcomes by race and ethnicity. So specifically, you can see that the rates of cesarean delivery are the highest among black birthing people, also in primary cesarean delivery. That rates of preeclampsia, which is a significant contributor to severe maternal morbidity and fatality in this country, are highest among black birthing people. That the rates of ICU admission are the highest among black birthing people, and the rates of transfusion are very high. The other group that really has notably worse outcomes are American Indian individuals. You look at neonatal outcomes, you see similar patterns in the risks for preterm birth, NICU admission, large for gestational age is probably the one outlier, macrosomia, and small for gestational age. But particularly, I think it's worth highlighting this morbidity of preterm birth and NICU admission is really significant. So why talk about preconception care? I think by definition, gestational diabetes is diagnosed during pregnancy, right? I think what I wanna hopefully lay out very clearly is that if we wanna be targeting disparities in gestational diabetes and eliminating as much gestational diabetes, much of the preventable morbidity of gestational diabetes as possible, we have to start way upstream of the individual clinician and patient interactions. So we're gonna talk a little bit about that preconception care. Why focus then? Because that gives people time to address social determinants. I'm imagining there are a lot of clinicians in the audience here who know just how difficult and how many visits it takes to really navigate things like housing insecurity, food insecurity, transportation difficulties. As Dr. Wright mentioned, people who have jobs where they can't come to visits, right? So we need time to build up relationships with our patients to really address those things. Preconception care is obviously a great opportunity for prevention. Some amount of gestational diabetes is probably preventable, but most importantly, preconception care improves pregnancy outcomes and it improves the worst pregnancy outcomes, specifically severe maternal outcomes. And for that reason, I think we can't talk about eliminating disparities without talking about that. So the first point that I think is worth making is that gestational diabetes, again, by definition is diabetes first diagnosed in pregnancy. But for a lot of people, they don't know that they have diabetes before they're pregnant because pregnancy is the first time they get care. So there's a population level problem with undiagnosed diabetes in the United States. Data from NHANES that uses laboratory criteria estimates that the prevalence is about 1.3% overall. And if you limit that just to reproductive aged women, it's about 650,000 is the estimate of the number of people who are walking around with undiagnosed diabetes. The risk factors that came out of that study, poverty, particularly a family income that was less than their federal poverty limit, Hispanic ethnicity, and I'll get into some theories of why that is, and lack of insurance, right? So lack of having access to care. You're much less likely to carry a diagnosis of pre-gestational diabetes if you don't have care. If you do have pre-gestational diabetes or pre-existing diabetes, pre-conception care is probably among the highest impact interventions we can offer. So we know that this was data from a meta-analysis. Pre-conception care is associated with a much lower first trimester hemoglobin A1C, like 2% at least, with earlier presentation for prenatal care, with a lower risk for congenital malformations, preterm delivery, and perinatal mortality. And these numbers needed to treat here are small. So the number of people that you need to give pre-conception care to to prevent one death in their offspring is 32. So when we think about where is the bang for our buck in terms of intervention, pre-conception care is a very, very impactful intervention. At the population level, there have been a couple of interesting studies that have estimated what could be. So congenital heart defects, I think many of us know that diabetes is a potent risk factor for congenital anomalies, and specifically congenital heart disease. There are about 32,000 cases of those per year in the United States, and there's a three to fourfold increased risk in sort of everybody with diabetes. Obviously that's impacted by glycemic control, but it's a risk factor. And so it accounts for about one in 12 of the cases of CHDs per year. So the estimates are if we could give 50% of the people who had diabetes, pre-pregnancy glycemic control, we would prevent a lot of those cases of congenital heart defects. So that in and of itself is probably worth it. But universal pre-conception care would also prevent a large number of preterm births, birth defects, and perinatal deaths. The estimates in the 2015 dollars, now 10 years ago, pre-inflation were a lifetime cost savings of more than 4 billion, with an additional 1.2 billion if those with undiagnosed diabetes also got the care they needed. And unfortunately in this country, pre-conception care delivery is incredibly imperfect. So this is data from a national sample of Medicaid claims from about 10 years ago. Notably that is pre-implementation of the Affordable Care Act. So this is before there was a contraceptive mandate in Medicaid. This was about 1.5 million births. And nearly 80% of these births did not have any kind of pre-conception care based on claims data. But if they did have pre-conception care of any kind, there was a notable reduction in severe maternal morbidity. So what I wanted to show you here was just that there are disparities in who gets pre-conception care. So it was interesting, there were differences in the rate of pre-conception care by race and ethnicity, but nobody is getting, you know, this is huge amount of the population that is not getting the pre-conception care they need. And they did do a sensitivity analysis limiting it to people with diabetes or hypertension, sort of people who should be getting primary care and found that there was no increased rate of pre-conception care in that group. So what would it take for us to do better? Like how would we actually get universal pre-conception care at the individual level? If you think about your interactions with your patients, like to really get things working, you know, to make a difference here, do lifestyle treatment, all the things we need to do, you need an engaged patient. You need to engage providers who are motivated and knowledgeable and able to take care, take this on. You need effective and affordable treatments. I think, you know, it's outside the scope of what we're gonna talk about today, but diabetes medications are incredibly expensive. I will talk a little bit about insulin, but what I will say is that the newer generation of diabetes medications, things like SGLT2 inhibitors and GLP-1 agonists are incredibly effective. They are not affordable. Access to care is probably the single biggest determinant of pre-conception care. So you need insurance. That's the prerequisite. You need provider availability. As Dr. Wright highlighted, we actually don't have maternal health care across this country. There are huge parts of the country that don't have any access. You need transportation. In a lot of situations, you need childcare. And what I would argue is that you also need the ability to plan a pregnancy. And so family planning services and contraception are a crucial aspect of access to pre-conception care. So why even talk about policy? Because I think, you know, it is very important to acknowledge that some of the individual level care that we are delivering is causing inequitable outcomes. So interpersonal racism is a factor. Sort of culturally, not culturally concordant care or not culturally responsive care probably does, definitely does impact outcomes. And policy probably has the largest amount of impact at the population level. And when we think about, again, what is the most impactful intervention that we can deliver? I think it's really crucial that we talk about the policies that in the end are so far upstream, are so hugely determinant of whether or not people can get any care at all, that if we don't change them, we probably aren't going to move the needle very much. So first of all, how many people are uninsured? It's one in 10. And so that's relatively recent data. This is all data from the Kaiser Family Foundation. This is as of 2022 among reproductive age women, 10% uninsured, about 20% have Medicaid, 7% have an individually purchased plan, and about 60% have employer sponsored insurance. The employer sponsored insurance, as many of us know, is fragile. And so the fact that Medicaid isn't universally available across this country is a major issue. It's also true that the rate of uninsurance is actually the highest among black individuals in this country, and there are big racial and ethnic disparities in who doesn't have insurance. Now, since the implementation of the Affordable Care Act, there have been marked decreases in the number of uninsured. However, I'm going to show you some data that says that we may have hit the floor and unfortunately are going to start increasing the number of people who are going to be uninsured. I want to talk a little bit about the difference between health insurance during pregnancy and health insurance before pregnancy. So there are 10 states that haven't expanded Medicaid yet. You can take North Carolina off this list. This is a little bit older, this is from 2021, but there's 10 states that still haven't expanded Medicaid. As of 2021, the median income eligibility, these numbers change slightly year to year, was about 40% of the federal poverty limit. So if you look at a state like Texas, I believe that they're cut off as 17 or 18% as of last year. For somebody who hasn't yet had children, you have to make 17% of the federal poverty limit to qualify for Medicaid. So that's a very, very small income. The federal poverty limit for one person is 14,580 as of last year. So if you think about less than 20% of that, we're talking very small, very low income people to qualify for Medicaid. The implications of this are in states that have opted not to expand Medicaid, which unfortunately is most of the South. Very modest and temporary increases in income in a given year can bump somebody off of their eligibility for Medicaid. So there are real difficulties in it for a lot of people in accessing Medicaid and where people live in this country is not equitable. And so it turns out that if you live in a non-expanded state or more likely to, the people who are black are more likely to live in a non-expanded state than people who are white. And so there's not equitable access to Medicaid in this country. It's also true that people are losing access to Medicaid. I think during the pandemic, there was a stop to sort of what they call procedural disenrollment or administrative disenrollment. So if you had Medicaid, you didn't have to re-enroll every year during the pandemic. And that stopped on March 31st of 2023. And so this has been called the federal unwinding. And what happened is each state was able to decide how they wanted to handle the re-enrollment. So many states actively went out and said, hey, you have Medicaid, you need to re-enroll to be able to get it or to keep getting it. But there are some states that actually have not done any sort of outreach to their membership. And the results of this is that millions of people, it's about like about 11 million people have lost their insurance coverage since 2023. When that happens, it has an impact. And so disenrollment from Medicaid means that you're probably gonna be uninsured for some period of time, even if your income hasn't changed and your eligibility hasn't changed, just getting disenrolled and having to do the paperwork again means you have this period of time where you don't have access to care. So again, I think it's really important So again, it is really crucial in the United States to talk about where do you live? Each state has their own policy and their own access to care issue. And where do you access care? And I think that getting people continuous healthcare coverage is a huge priority if we really wanna move the needle on maternal health outcomes. Lack of insurance leads to poor glycemic control. That has something that has been seen again and again, but costs impact everyone. I just wanted to share some data that's out there. These are data that the American Diabetes Association put out from a survey done in 2020, as well as some other data that's been published, but not having insurance is associated with obvious, this is probably obvious, but fewer office visits with physicians, fewer medication prescriptions, more utilization of the emergency room and a higher hemoglobin A1C. For people with diabetes during the pandemic, when people were facing a lot of economic stress, one in three were not checking blood sugars due to the cost of test strips. One in four were rationing their insulin. One in 10 people, these are people with type one diabetes put off getting a pump or a CGM due to cost. And people were choosing between food and diabetes management supplies. And so it's not a small number of people who reported this on this survey. And I think when we just think about how much it costs to take care of diabetes, so this is the cost per 1500 unit equivalent prescription or a month's worth of insulin. So the out-of-pocket cost is pretty variable. The total costs, these are non-negotiated costs from 2020. So these costs have gone up. The out-of-pocket costs at that time were the highest among people who are uninsured, obviously. Medicaid is great. So if you have Medicaid, awesome, you get affordable insulin. But people with private insurance or people facing even a one month gap where they're looking at COBRA to be able to continue their coverage have to pay out-of-pocket. We know that many states have now implemented the insulin cost caps. It is not clear that those caps will continue in the next administration, that the federal mandate that Medicare has will continue in the next administration. And each state, like I said, has their own sort of policy for their state Medicaid products and for their state private insurers, and only about half the states in the country have put a cap on insulin prices for private insurers. I just wanted to, I pulled out this last week, so this is them today prices, 100 test strips. And if you think about how we treat gestational diabetes, I think, again, many clinicians here probably, but if we're asking people to check their blood sugars four times a day, this is a 25 day supply, right? $186 out of pocket. If you don't have insurance or you have a high deductible health plan, or you have a health plan that doesn't cover medical equipment or supplies, you really might be having to ration these. These are Libre sensors, similarly, pretty expensive, a month long supply, $200 in diabetic outlet. Oops, sorry. And difficulty affording diabetes medications is common, so particularly for those who are uninsured or have high deductible plans. Medicaid, again, is great. Medicaid covers a lot. It allows us to access medications and equipment for our patients, but private plans do have variable sort of caps on medication costs, caps on the kinds of costs that go along with equipment, and people who have no insurance obviously can't afford any of this. So if we wanted people to have a diagnosis prior to pregnancy or an early pregnancy and have access to the kind of care that they would need to really improve their outcomes, we would need to start talking about getting them probably enrolled in Medicaid or some sort of similar plan earlier, and that is a huge barrier to good outcomes. So I think if we really wanna eliminate disparities in pre-conception care, we absolutely need to be looking at that top of the population health pyramid where we're talking about individual level solutions. But at the end of the day, lack of insurance is a barrier to care. Cost is a barrier to care. Geography in this country is a barrier to care, both because of rurality, but also because of state level policy decisions. And so solutions are going to require both political will and investment. And I would argue as providers, we're probably the most well-positioned to argue on behalf of our patients. And so if I can give you one piece of information here that's useful, it's that us doing advocacy as providers on behalf of our patients and access to care is really, really important and probably something we should be talking about more. Thank you both so much for those informative presentations. I've been like scribbling down questions I personally have because this has brought up a lot of different thoughts for me, but I wanna make sure and encourage our audience to please go ahead and drop your questions in the Q&A function, not the chat function, but the Q&A on the bottom sort of towards the right hand of your screen. And while folks do that, maybe I will jump in with a few of my own questions. And actually there was one that was already posed that maybe I'll start with that. One of the participants, and I think this fits with your closing, Dr. Zara, around the political will to move this work forward. And the question that was posed in the chat was, do you think, and feel free Dr. Wright also to answer this, but do you think the number of uninsured will increase in 2025? Yes. Short answer. I think if any of campaign promises are followed through on then what we can anticipate is fewer people with access to Medicaid, fewer people with caps on insulin coverage, because I don't think that those will necessarily continue, and fewer people whose immigration status is uncertain, in particular having access to care of an income. I would echo that. And I would say coming from the payer side, we already see it, right? So we've seen a huge decrease in eligibility after the public health emergency. And while that's starting to stabilize a little bit, we still have many less people in our ranks as is. But even on the marketplace side, which is the Affordable Care Act, we're seeing less individuals. I expect that to get worse. The incoming administration has proposed some changes to the Affordable Care Act. We don't yet know what those changes might be, but I do think that they might make it more difficult for people to maintain that coverage. The other issue is that Medicaid is based on income. If you happen to not meet those income, that criteria, and you don't have employer-sponsored healthcare, you're looking at marketplace, which can be prohibitively expensive. And so I think that will be out of reach for an increasing number of individuals over time. Thank you. Again, I'll encourage folks to drop your questions in the chat. And in the meantime, I appreciated both of your presentations because I think they offered a really important, comprehensive understanding of not just gestational diabetes, but actually what maternal health, I mean, I wouldn't even say maternal health, but just health across the life course for women. And I noticed in the work I do and the circles I'm having these discussions in as a maternal child health researcher, we're not thinking, we're treating these as very separate sort of parts of the life course, right? And we're not thinking across the life course. And even I've been engaging with discussions around the perimenopause period and how we can begin to really talk about all of this within the scope of women's health and reproductive health. And so, I agree that the preconception care piece is incredibly important. And I'm wondering if you both can talk about how you see that happening more effectively, right? Because I think that there's an education issue, right? Where there are, I think most, a lot of women, a lot of people aren't thinking about preconception. They're just, we're just out there trying to live our lives. And I think about this also, when I have an 11-year-old daughter and when my husband and I decided to start planning for a family, I did seek out preconception care. And I remember the first physician I had an appointment with being very surprised or taken aback that I had even taken the sort of initiative to do that. And so, and it's certainly not the norm. So as we think about sort of how to educate the public on the importance of preconception care and also marrying that with the access issues and the health policy challenges, I think about the fact that we offer now, and in some states, postpartum care for up to a year for those who are on Medicaid, what would it look like? And what would it look like to leverage health policy to create opportunities for both education awareness and access to preconception care? So I think we've seen a little bit of that already in the postpartum space because postpartum care used to be six weeks, which is an extremely short amount of time and you cannot adequately address all of the needs of a birthing individual in the first six weeks. And so many states have expanded that to a year and that really gives us that interconception time to address any conditions that may have been uncovered during pregnancy, make sure that family planning has been adequately addressed, follow that woman from a cardiovascular standpoint, from a mental health standpoint, et cetera. I think we need to, first of all, we need to make that ubiquitous, right? Because only certain states have that. So that to me is table stakes. But then we also need to go beyond to what does a woman do when she's not pregnant and she's not postpartum because the income restrictions for Medicaid, for example, become much more stringent. And so oftentimes women will lose their insurance until the next time they get pregnant. And so I think we need to understand is there a role for Medicaid when you're not pregnant? Can we make just for women the bar a little lower so that she can maintain coverage throughout her lifespan? So that's one policy opportunity, I think. I'll let Dr. Zara jump in. Yeah. Yeah, I agree. I'm like Medicare for all, Medicaid for all. That's the easy answer. No, I do think that leveraging that interconception period, I think if many states that haven't opted to expand Medicaid also have some of the highest rates of maternal mortality. I heard someone say the road to maternal health equity runs through the South. And I think we have to be thinking about what is doable there. And if we tackle it through maternal morbidity and mortality, infant morbidity and mortality, there is, if we all agree, we can all agree that that's something we all care about. Then continuous coverage during a reproductive life seems like the way to do it. Some sort of floor of continuous coverage in the name of improving infant outcomes, improving maternal health outcomes. And building that political will in a way, I have a lot of feelings right now. I will say that. Fair. Building the political way. Clearly, I am rethinking how I communicate about this. Let me put it that way. And I think trying to find common ground across political ideologies and focus specifically on the health outcomes. It's just so very clear that you can't have good health outcomes without continuous access to care. And that we have a crisis within maternal health care in this country. And so I think if we can have real conversations around that, that's a start. I do worry a lot about the contraceptive provision of the ACA specifically being knocked out. And I think if we lose that, that's gonna be a major blow to women's health because so much of this is, can you plan a pregnancy effectively? Not just can we get you healthy, but can we actually let you time when you wanna do it? And I think that that's extremely important. Maybe reframing the issue so that everybody can get behind it. I think everybody wants healthy moms, healthy babies. So regardless of your political allegiance, et cetera, I think that's something that everybody can get around. I think we need to look at reproductive health. Contraception is part of that. And we know that that's a polarizing issue, but it's so much more than that. I think reproductive health is this interconceptual care that we're talking about. How do we keep women healthy all the time, right? So that if she happens to get pregnant, she is in the best frame of health to have a healthy baby. I think that's something that is nonpartisan that we can all get around. So I'm with you, Dr. Zara, we have to start using different language, different arguments that resonate with people who are at different points on the spectrum of reproductive thoughts. But I think that that is something that we can start to build policy and procedures around. I have to say, I'd love to see us do the cost-effectiveness analysis of also preventing the transition to type 2 diabetes or delaying that. What does that do for your state Medicaid budget, your state Medicare budget in 10 years? Like if we could do that, we have so little cost-effectiveness work across the lifespan to draw on when we talk about this. But I think that that's low hanging fruit that maybe some of our research friends can help us with. Because I think having those numbers and being able to say, look, this is like an easy few billion dollars to knock off your eventual budget. Maybe that also speaks to a different segment of the population that otherwise wouldn't be moved. You both keep responding to like the questions that I like have in my head. So I appreciate that. Cause I was going to ask where are the gaps from a research perspective? Where do we need to be focusing the development of new and important evidence, particularly now? And so I appreciate you sharing the cost-effectiveness piece. And Dr. Wright, I think you were going to comment. So I'll let you do that. And then we do have a question in the chat that I'll raise as well. I was just going to say that we have to remember that legislators are not clinicians, right? So really effectively engaging them and connecting those dots. Because I do not think that everybody knows that gestational diabetes is a precursor to type two diabetes and that there are ways that we can intervene and manage that that will offset long-term costs. We know that type two diabetes is probably the largest cost driver right now in health, certainly in Medicaid. And when you're thinking about the fiscal impact of that is huge. And so those are things that really resonate with legislators and regulators. And I think we as healthcare community need to develop effective arguments to say, yes, we need continuous care throughout the continuum. I like how you put that. So that we can prevent some of these very costly consequences down the road. I have a very cynical follow-up question to this. So, Dr. Zara, I think you said, or maybe both of you mentioned the high cost of the newer diabetes or type two diabetes medications, right? And we're seeing ads and discussions for them all over the country and the world right now. And part of me has to wonder where that, what's the lever to pull, right? Because there is money certainly to be made on making sure that there is a need for these medications. And also, I think to your, both the points both of you all have made around the sort of lead, the potential for gestational diabetes to lead to type two diabetes and sort of how do we address that in a way that feels like politically sound and from a policy standpoint, while ensuring that, I don't know, we might be treading into waters that we don't wanna go past, we don't wanna go now. But I do think that there's a lot of work to be done. And I think that clinicians in particular can have an important role to play in having those discussions. And also, and like you said, Dr. Wright, legislators are not clinicians. And so, but understanding sort of where big pharma lives in this space, where folks like the two of you who are caring for patients every single day are in this space, and then what the policy levers are. So maybe that's not a question and more of a comment, but go ahead, Dr. Zero. Do you think that there's a way we could, and this is, I think, through research and maybe something just to throw out to this kind of group, including the audience at large, which is how do we tell the story that connects the dots between gestational diabetes, the pregnancy episode, pre-pregnancy, postpartum, lump that into one thing. And you're a 70-year-old with diabetes who's driving a lot of Medicare expenditure, you know? Yeah, yep. And just sort of tracing somebody's journey across that continuum at various income categories, various like sort of what's a common life transition. You know, people leave their jobs after pregnancy. They lose their, we know there's a ton of churn, right? So even people with employer-sponsored insurance often have a little period of uninsurance postpartum because they're switching to their partner's plan or they're going on to Medicaid or they're finding something new. So I think being able to really trace that journey and sort of what it means not, you know, in the clinical life where like, yeah, you haven't seen a doctor in three years since you were last pregnant. And now you have type two diabetes after having gestational diabetes last time. It's a story we know. To your point that legislators, that's not obvious. Like how do we have kind of a couple of archetypes that are well-researched where we can say, here's again, what the cost-effectiveness of starting here at age 19 would be like, and is it, you know, if you don't wanna pay for the GLP-1 and you're a 50-year-old patient, like maybe we need to be thinking about, I mean, school lunch is for all, but I mean, it truly is, how do we sort of make the financial argument across the lifespan more obvious around, I think, specific conditions like gestational diabetes and then transition into type two diabetes. Thank you. I think the other part of that is, you know, economic stability. So the new administration is very concerned about the economy, right? Well, when women are sick, they're not contributing to the economy. So if we want people to be at their jobs and doing all the things, then we want a population that is healthy as possible, right? So I think, you know, thinking in terms of arguments that resonate on both sides of the aisle, having people be well, having people not contribute to exorbitant healthcare expenses and having people positively contributing to the economy are all arguments that we need to make. Absolutely. I think we are at a point where we need to wrap up. There is one question that I want to get to in the Q&A from Melissa, where she states, as a care manager for pregnancy, I rarely see a planned, quote unquote, planned pregnancy, especially in lower socioeconomic areas. Is there a relationship between first-time pregnancy and increased incidence of gestational diabetes complications? I'd say there's a risk between first-time pregnancy and all complications. So I'm sure that that exists. Although interestingly, I haven't seen any sort of population-based studies that look just at the first pregnancy as opposed to sort of people with GDN at large, but it's the highest rate of preeclampsia, right, which is the biggest morbidity, most significant morbidity in people with gestational diabetes. So I'm sure that it is highest in people having their first pregnancy. Another research question to explore further, for sure. Well, I want to thank you both again for sharing such informative and engaging presentations. I have like 10 bajillion other questions, so maybe we can chat offline one day soon. But again, really appreciate everything you've shared. I think we have a lot of work to do, but I think there's a lot of potential, especially as the two of you talked about, thinking about just the framing and the language around how to move this work forward, particularly on a policy level. So as we wrap up, we want to provide you with some resources for your reference. And these resources will also be provided via email following the webinar today. So diabetes and pregnancy, including gestational diabetes is, as we know, and as we just learned even more about, a growing problem in the United States. And the American Diabetes Association recognizes women's health deserves individualized study, care, and advancement. So we invite you to learn more about the women's health initiatives at the ADA by visiting the page on our website on gestational diabetes. That concludes today's program. I think we are at time, which I apologize. We might be a little bit over time. Again, we want to thank the presenters as well as Blue Cross Blue Shield of Minnesota for making this program a possibility. And also we want to extend a huge thank you to all of you for taking the time to join us today and to participate in today's learnings. And we certainly look forward to connecting with you all again soon in the future. Thank you so much for your time and have a wonderful afternoon.

gestational diabetes mellitus

GDM disparities

marginalized communities

preconception care

early detection

racial equity

systemic barriers

healthcare access

maternal health

policy change