Promising a future of stronger protections and more effective treatment for patients with substance use disorders, the U.S. Department of Health and Human Services (HHS) has modified 42 CFR Part 2 (“Part 2”) to better align with the Health Insurance Portability and Accountability Act (HIPAA). Effective as of April 16, 2024, with a two-year deadline for entities subject to the regulations to comply, the new rule allows health care professionals access to necessary, but previously restricted, patient information and enforces new safeguards to patient privacy.

Part 2: 

The the health care records of any patient involved in substance use disorder programs or activities, including treatment, rehabilitation, and research, that is conducted, regulated, or assisted by any department or agency of the United States. Before the newly enacted modifications, privacy regulations under Part 2 were more stringent than those under HIPAA. These stricter regulations were intended to encourage those with a substance use disorder to seek treatment by decreasing the possible fear of legal or discriminatory repercussions that could result from an information disclosure. In practice, this system made it too difficult for providers to provide effective care, as access to important patient information was restricted. This new rule seeks to increase the privacy of substance use disorder patients while giving health care providers the proper tools to best treat patients with behavioral health challenges.

Key Changes:

1. Consent Requirements

While Part 2 previously prohibited substance use disorder patients’ records from being redisclosed (with few exceptions), under the new rule, substance use disorder patients can provide a one-time, general consent for the future uses and disclosures of their information for treatment, payment, and health care operations. This change will ensure that Part 2 health care providers have access to any and all necessary information when treating those with a substance use disorder, allowing the health care practitioner to view the patient’s entire health history and give a more holistic view of their patients.

Additionally, the substance use disorder information in a patient’s medical record received from a Part 2 program will no longer need to be segregated from the rest of the medical record once general consent is granted. While this change could benefit Part 2 programs by lowering the administrative burdens associated with segregating records, Part 2 providers will need to continue segregating records for patients yet to provide general consent.

In following HIPAA’s protections regarding psychotherapy notes, this general consent under the newly modified Part 2 will not include the disclosure of clinician notes kept separate from a patient’s treatment and medical records during substance use disorder counseling. These notes will require specific consent from the patient due to their special nature.

2. Breaches and Penalties 

HHS has also heightened its enforcement authority by replacing previous criminal penalties for Part 2 violations with the same civil and criminal enforcement authorities that apply to HIPAA violations. This change will greatly increase the repercussions for violating the new rule, as previous criminal penalties were rarely enforced by the U.S. Department of Justice.

Furthermore, Part 2 has adopted HIPAA’s Breach Notifications Rule  and the HIPAA Notice of Privacy requirements. These expanded prohibitions on the use and disclosure of patient records in civil, criminal, administrative, and legislative proceedings intend to reduce patient fear and encourage patient privacy.

While Part 2 continues to prohibit the use of substance use disorder patient information from investigative agencies without permission by court order, the new rule has adopted a Safe Harbor provision, which limits civil or criminal liability for investigative agencies that act diligently and follow certain steps if they find that they have received Part 2 records without court order permission.

By specifying and strengthening penalties under Part 2, HHS has taken a proper step in enduring that the information of patients with substance use disorders will be safeguarded.

3. Patient Requests

Included in the many benefits that substance use disorder patients gain from these modifications is the newly granted right to obtain an accounting of disclosures. From now on, each disclosure that is made with the patient’s consent will include a copy of the consent, and/or an explanation of exactly what the consent allows. In addition to this, patients can also request restrictions on some disclosures, including the option to opt out of communications regarding fundraising. In the event of a Part 2 violation, patients now can file a complaint directly with the HHS Secretary and with the Part 2 program.

Providing Part 2 patients with more rights than previously seen before, HHS has given patients with substance use disorders the chance to see a future with more personal autonomy in decision making, and more power in ensuring that their privacy is protected.

What Does This Mean for the Health Care Industry:

Amidst these new modifications to Part 2, health care organizations and providers will need to prepare for change in an effective and safe matter. To do this, proper training and education will be necessary to avoid any accidental breaches of patient privacy. Additionally, health care organizations will need to update their policies and procedures to comply with these new rules while monitoring patient records to ensure that privacy is protected during this training period.

TikTok, the wildly popular video sharing platform, has an algorithm that will occasionally push a video captioned “Pranking my kid!” or “Parenting hack!” No one watching the video will wonder if the kid(s) consented to filming and sharing their life to the Internet. However, people need to start considering the ways in which an influential online identity impacts a child’s mental health and social development.

Social media revolutionized global connection, information delivery, and creative expression. Many would argue that these sites and apps brought immense good to the world, but social media also introduced new problems. Some parents are profiting by turning their children into social media influencers, a practice that could be damaging to youth mental health. It is difficult to regulate any content, let alone content created by parents featuring their own children. However, it is possible to regulate the labor of monetized child influencers, and this is currently the most accessible approach to curbing harms brought by social media to youth mental health.

In May 2023, the U.S. Surgeon General released an Advisory on Social Media and Youth Mental Health. The Advisory compiled research and statistics on the matter and addressed the benefits of social media use among youths, like building positive community, sharing information, and creating space for self-expression. The rest of the Advisory studied the potential harms of social media use. Exposure to extreme, inappropriate, and harmful content can create risks of fatality, physical injury, body image issues, and low-self-esteem. In addition, excessive use of social media can create risks of insomnia, addiction, attention deficits, depression, and anxiety.

Next, the Advisory identified five groups—policymakers, social media companies, researchers, parents, and youths—and provided recommendations to each group on effectuating maximum benefits and minimal harms from social media, and “creat[ing] safer, healthier online environments for children.”

Recent lawsuits have claimed that the lack of safe, healthy online environments for children is a consequence of profit-motivated social media companies prioritizing engagement over safety. Social media companies have been condemned for the addictiveness of their platforms, including the constant, compulsive engagement of children which has led to negative effects on their physical and mental health. The goal of these lawsuits has been to hold these companies accountable for knowingly, intentionally, and deceptively designing algorithms that harmed youth mental health.

Social media companies certainly hold some of the blame for their part in this crisis, but they are hardly the sole perpetrators. Content creators—particularly parents who monetize videos or images of their children—must also be taken seriously for their role in harming youth mental health beyond the screen.

The U.S. Surgeon General’s Advisory recommends that parents mitigate the potential harms of social media by modeling responsible social media behavior to their kids. However, variation of social media use by parents, caretakers, and guardians makes it difficult to determine exactly what it looks like to “model responsible social media behavior” and protect children from harms.

In her 2017 article entitled Sharenting: Children’s Privacy in the Age of Social Media, law professor and children’s privacy expert Stacy Steinberg addresses the social media behaviors of parents who share content of their children online, using the term “sharenting” to describe this behavior. Sharenting serves as an outlet for parents to express their true feelings on the realities of raising children, particularly the hardships brought on by raising children with chronic mental health or developmental needs. By sharing these stories, parents build supportive communities of similarly situated parents and advocate for greater awareness and education around the raising of children with mental and developmental needs.

The dark side of sharenting lies in parental oversharing that invades a child’s privacy, agency, and safety. Some parents go viral for videos of them disciplining their children, for example, where a child is forced to stand in public with a sign describing his misbehavior. These parents are trying to effectuate behavior changes in their child through public shaming. Once shared, some in the online community approve of the disciplinary video, finding the post entertaining and authentic. However, others point out that this kind of online discipline is disrespectful and humiliating to a child. Unlike traditional offline forms of discipline, a viral video leaves a digital footprint beyond the child’s control.

Parents who share content of their kids with little regard for short-term and long-term repercussions may be just as harmful to youth mental health and development as the social media platforms. While litigation has the potential to protect children from the harms dealt by social media companies, it is a less viable option when the offender is a child’s own parents. Other methods must be used to protect children from their parents’ harmful use of social media.

Steinberg suggests a public health model of child protection. The public health model proved effective with the secondhand smoke campaign, where pediatricians warned parents of the dangers of secondhand smoke and encouraged parents to not smoke around children. When parents continued to do so, some state legislatures enacted laws to prohibit the discouraged behavior. The public health model prevails by identifying a crisis and disseminating appropriate warnings and education to the public, with state legislature available as a fallback measure.

Steinberg proposes a draft of the public health model for protection of youth mental health, organized by the best practices to be advised to the public. It mirrors the Advisory, listing educational points for parents like giving their child veto power over online posting, considering the effect that sharing has on the child’s current and future sense of well-being, and sharing anonymously.

For some parents engaged in sharenting, anonymous posting defeats the entire purpose of sharing because anonymity is counterproductive when the goal is to build a career as an influencer.

Melanie Fineman has discussed commercialized sharenting in her 2023 note Honey, I Monetized the Kids: Commercial Sharenting and Protecting the Rights of Consumers and the Internet’s Child Stars. She argues that commercial sharenting has negative effects on child influencers, or “kidfluencers,” and that more support for regulations of commercial sharenting might be earned by reframing the issue as “foster[ing] misleading content online” or “implicat[ing] child labor concerns.”

Sharenting fosters misleading content because parents often instruct their children to talk and react for the camera in ways that prioritize profit and engagement over authenticity. One mother told her Internet-famous twins to “say Oshkosh!” when asked about their favorite brand at an Oshkosh promotional event, though the twins later indicated they did not know what Oshkosh was. Followers on social media were influenced to support Oshkosh because of the twins’ uninformed endorsement, but the endorsement only occurred because Oshkosh incentivized their mother to do so.

Sharenting also implicates child labor concerns. A kidfluencer’s advertisements or sponsorships on social media could bring is so much money that running the account becomes a full-time job and income source for the parent. Content featuring the child becomes the key to the parent’s commercial success, increasing the risk of parents exploiting their children and harming their mental health.

An apt comparison might be child reality TV stars from shows like Toddlers and Tiaras or even Kendall and Kylie Jenner in their earliest years on Keeping up with the Kardashians. Children develop a different sense of self when they’re put in the public eye from a young age, lacking the agency to control their own image. Dissolving the boundary between portrayed character and personal self puts the child in a position to believe he or she is a commodity in the parents’ eyes, always expected to perform in a money-earning, content-worthy manner and creating pressure, stress, and negative mental health outcomes in the child.

Exploiting a child’s presence on social media for the parents’ financial gain is a difficult issue to address due to legal protection of parental rights. A parent’s right to control and shape their child’s life historically outweighs the child’s rights to privacy or autonomy. Thus, the law is unlikely to compel parents to stop sharenting and grant children autonomous control over their own digital footprints. Limitations also exist in regulating what is posted, rather than who is posting. Steinberg notes that a parent’s social media posts may be considered free speech protected by the First Amendment, and therefore, insulated from state regulation. However, states are permitted to regulate the monetization of a child on social media and mitigate damages of commercial sharenting by approaching the matter as a labor issue.

Fineman describes California’s Coogan Law, which ensures that a portion of money earned by child actors be put in a trust until the child turns eighteen. The intent is to protect children from exploitative employment, where earnings are spent by parents and not the child. It returns a degree of control to the child, diminishing the risk of the child believing he or she is a commodity in the parents’ eyes. Coogan’s Law has since been mimicked in other states like New York, New Mexico, Louisiana, and Illinois.

Illinois is the first state in the nation to pass legislation amending its Child Labor Law to include protections for child influencers on social media. The amended act defines vlogs, family, and online platforms, and mandates that profits from online content featuring a child’s name, image, or likeness must be directed to a trust fund account for the child. Children will have the right to sue their parents for failing to direct profits to the trust fund in violation of the amended Child Labor Law.

The amended Illinois act goes into effect on July 1, 2024, so it remains to be seen whether it successfully mitigates the harms to child influencers posed by commercial sharenting. In the meantime, the public health model could serve as a means of protecting the mental health of child influencers by disseminating education to parents and raising awareness of the privacy, health, and safety risks of sharenting.

Višegrad is a town in eastern Bosnia and Herzegovina (Bosnia). As a child, I would frequently visit this town. Višegrad is struggling with protecting its natural aesthetic and the health and well-being of its inhabitants. The Drina River flows through Višegrad, renowned for its emerald color and historical significance. It symbolizes the struggles of the Bosnian war and underscores urgent environmental and public health challenges requiring immediate intervention.

Before delving into the challenges facing Višegrad today, I would be remiss to not mention and acknowledge the struggles of Bosnia that continue to affect many war-torn families today. Bosnia as a whole has been the victim of unspeakable atrocities and genocide. In 1992, Muslims of Višegrad faced a siege; they were deliberately attacked, tortured, and murdered by Serbs. Serbs, individuals from Serbia, inhabit both Serbia and Bosnia. In Serbia, they operated under the direction of Slobodan Milošević, and in Bosnia, they were led by Radovan Karadžić. They actively promoted Serbian nationalism and pursued the creation of a “…Greater Serbia.” Their goal encompassed the “…disappearance of Bosniaks [Bosnians].” They executed this agenda by ordering Serb forces to “…ethnically purify the territory…” of Bosnian Muslims. The International Criminal Tribunal for the Former Yugoslavia investigated some of the crimes that took place in Višegrad, but many attacks and murders remain unprosecuted. They are unlikely to ever be prosecuted, resulting in zero closure for many families of Višegrad.

As aforementioned, the Drina River flows through Višegrad. The town boasts the  Mehmed Paša Sokolović (Sokollu Mehmed Pasha) bridge, designed and built by the Ottoman architect, Mimar Sinan, in the sixteenth century. It spans 179.5 meters in length. Despite being regarded as a historical treasure and even being added to the UNESCO World Heritage List, victims were taken to the bridge and murdered. In 1992, a Višegrad local reported, “They [Serb militiamen] took them [Muslim men] from the trucks and to the railing of the bridges,” and “…they would shoot them,” and throw “…them all into the river.” The war in Bosnia lasted until 1995 when the Dayton Accords were signed. If earlier action had been taken, the staggering loss of 250,000 lives and displacement of over 2 million Bosnians could have been prevented.

You may be asking yourself: How did the war cause the environmental degradation that is still evident today? Is Bosnia taking any action to rebuild its environment? If these questions are on the forefront of your mind, let me pose a simple one: If you witnessed murder and genocide, would rebuilding the green landscape be your top priority? Since scars of the war persist in the region, they have resulted in environmental degradation and even a potential public health crisis.

The Drina River begins at the confluence of the Tara and Piva rivers, flowing for 215 miles until it runs into the Sava river. The Drina serves as a boundary between western Bosnia and eastern Serbia, originating in the northwestern part of Montenegro. Over twenty years ago, individuals built a hydro-power plant with old oil drums to protect the dam from debris that flowed with the river. However, today, after heavy rain and snow, you can nearly find everything under the sun in the Drina. There are reports of finding dead animals, car parts, medical waste, and plastic bottles. The waste can accumulate to around 5,000 cubic meters since garbage flows into Višegrad at least twice a year. The waste piles up behind the barrier that was installed by the hydro-power plant. Consequently, a floating landfill has formed in what was once a picturesque emerald river.

The waste is not generated by the locals of Višegrad, but they are forced to deal with its consequences. The floating landfill results from waste originating in the towns surrounding Višegrad; waste from these surrounding towns flow upstream through the Drina, and accumulate in Višegrad. Despite attempts by workers at the hydro-power plant to clear the waste, Višegrad struggles with an ongoing cycle. Even though they remove and burn 10,000 cubic meters of waste each year in the town’s landfill, the effort has not proven to be highly effective. Fears are materializing not only regarding the river’s ecosystem, but also what the impact will be on locals when the waste is burnt. Burning waste releases toxic chemicals that pollute the air; it is inhaled by both humans and animals, and can also make its way into soil and plants. Ultimately, the toxic chemicals can make its way into the human food chain through crops and livestock.

Fears surrounding the effects on the Drina’s ecosystem are also well-founded. With plastic water bottles being the primary type of waste found in the Drina, many species mistake the waste for food and ingest it; once ingested, it can lead to starvation and/or death. Further, it is no secret that plastic is not fully biodegradable. In fact, the waste can generate even more bacteria and spread disease.

The piled-up waste has drastically harmed the tourism of Višegrad since many tourists make their way to the town to visit the Mehmed Paša Sokolović bridge. It is difficult to market a town that is engulfed with waste that can negatively affect the health of individuals. Since the town heavily relies on outdoor tourism, owners of hotels and restaurants have become devastated and are actively suffering from the sight of the waste.

In March, the Eko Centar Višegrad started taking water samples. However, the problem is long-term, and finding a solution will not be easy nor cheap. It has been proposed that towns upstream of the Drina should implement their own waste collection to prevent the waste from ultimately accumulating in one town, Višegrad.

Although the locals of Višegrad are not currently pursuing any legal actions, it may be worth considering. Whether actions are directed against the government as a whole for failing to implement more effective interventions, or against the surrounding towns that ultimately contribute to the floating landfill, legal action could serve as an effective tool in revitalizing the Drina in Višegrad. However, as Bosnia continues to heal its wounds from the war, it may not be surprising if locals encounter opposition when they express their desire to revitalize a river.

Despite the wounds of the war and the public health challenges that face Bosnia, it continues to strive for healing and renewal. Although locals of Višegrad continue to confront the tragedies of the war whilst facing public health challenges, they take it upon themselves to do it with a commitment of resilience and remembrance. I dream of the moment I can visit an emerald-colored Drina again, but ultimately, a nation whose wounds of the war are healed is something every Bosnian yearns for. Together, we envision a future where peace and prosperity flourish through our green landscape and the Drina River.

Women’s reproductive rights have always been topics of contentious political and legal debates in the United States. And in the wake of the U.S. Supreme Court’s decision in Dobbs v. Jackson Women’s Health Org.—which held that the federal Constitution does not confer a constitutional right to abortion—reproductive rights will continue to have polarizing political salience for years to come. But there is an inescapable scientific and public health fact that lies at the heart of this debate, one which has no political allegiance: the alarming rates of maternal morbidity and mortality. To alleviate this disturbing issue, a new maternal health care model has been announced. The model has been dubbed the “Transforming Maternal Health Model,” or TMaH Model for short.

Data from the U.S. Centers for Disease Control and Prevention (CDC) speak to the sad state of affairs regarding maternal health in the United States. In 2018, the maternal mortality rate was 17.4 deaths per 100,000 live births. However, as of 2021, the rate had climbed to a shocking 32.9 deaths per 100,000 live births. Compared to other wealthy nations, the United States ranks last when it comes to maternal mortality; a perplexing acknowledgment given the cost and sophistication of the U.S. health care system. Many of these deaths were preventable, of course. According to data from Maternal Mortality Review Committees—”multidisciplinary committees that convene at the state or local level to comprehensively review deaths that occur during or within a year of pregnancy (pregnancy-associated deaths)”—an estimated 80% of pregnancy-related deaths in the United States between 2017 and 2019 were preventable. Disparities between racial and ethnic groups are especially worrisome. For example, based on 2021 data, non-Hispanic Black women had 2.6 times the rate of pregnancy-associated deaths than non-Hispanic White women. Nevertheless, amidst all these horrendous trends and statistics, not all hope is lost.

On December 15, 2023, the U.S. Department for Health and Human Services (HHS), through the Centers for Medicare and Medicaid Services (CMS), introduced the new model for maternal health care. The goal is to combat the maternal health crisis for those enrolled in Medicaid and Children’s Health Insurance Programs. CMS announced that the Biden Administration is focusing on maternal health disparities as well as the improvement in the postpartum health outcomes of mothers and the infants. This model could be a promising start to addressing maternal morbidity and mortality in the United States, however, many issues will require careful attention.

A CMS overview of the Model explains the ten-year plan to address the high rate of negative pregnancy results. The first three years of that plan will be dedicated to pre-implementation, and the remaining seven are dedicated to implementation and proper execution. The complete Model addresses three main pillars: access, quality improvement, and delivery.

Pillar I – Access to care, infrastructure, and workforce capacity: Many mothers do not have proper access to health care, both pre- and postpartum. Proper access for these mothers may include regular visits to doctors, prenatal care (such as prescribing of prenatal vitamins), and postpartum check-ups. In considering the previously discussed statistics, Pillar I displays the proposing parties’ hope that the rate of complications will decrease with the introduction of the proper access to maternal health care, and it may be likened to a gateway to the success of the overall Model.

Pillar II – Quality Improvement and Safety: The TMaH Model will be state-based. Participating State Medicaid Agencies will be collaborating with their local hospitals and health systems to implement the goal-based protocols, which will be “evidence-informed”. In reviewing the quality and safety protocols, which have been labeled “patient safety bundles,” it appears that the key to Pillar II is consistency.

Pillar III – Whole-person care delivery: Pillar III aims to provide customization and specialized care based on the mother and child. Each pregnancy is unique in nature and Pillar III aims to ensure that complications do not occur due to the failure of the health care system.

Data from 2019 provided by the National Library of Medicine offers that 98.4% of women in the United States gave birth in a hospital. Given that a vast majority of births occur in this setting, it makes sense that the procedures may be standardized. However, the mother and child would be at a disservice if these procedures were not tailored to the patients undergoing them.

The TMaH Model seems to show an understanding that a case-by-case approach may not be practical. However, it also demonstrates the desire by federal and state health authorities to utilize the data obtained to address the systemic failures at hand, while providing the specialized care needed for each patient.

Adjusting the procedures to each mother’s unique needs provides them the best possible chance at survival without complication. For example, one birth may require closer attention postpartum due to mother’s hypertension or history of substance use than another. This “closer attention” may take the form of increased postpartum check-ups or more careful prescription of medications for a mother that has known substance abuse issues.

The TMaH Model should be praised for its holistic approach to each pregnancy, keeping firmly in mind the “physical, social, and mental health needs” of the patients. In a time where women are losing control over whether they should be mothers, it is encouraging to see the health system try to provide those that are expecting with accessibility to proper care. One may argue that this overall goal is far-fetched given the increasing rate of complications. While this is a lofty goal, it is far from unattainable. The proposed pillars, timeline, and overall Model are all feasible if they are combined with the proper funding.

Funding opportunities for the TMaH model will be announced to state Medicaid agencies beginning Spring of 2024 and which hopefully provide the Model with the means to enact change.