One Year Later: Protecting the Gains, Correcting the Flaws of Health Care Reform

Adam Sonfield

Reproductive health advocates must fend off repeated attacks on health reform, work on implementation and fix the flaws.

The Patient Protection and Affordable Care Act (ACA) became law in March 2010, bringing with it onerous abortion restrictions but also the promise—and in some instances already the reality—of substantial improvements in insurance coverage for various reproductive health services. Still, reproductive health advocates will face three main tasks as they seek to hold on to these gains: fending off repeated attacks from health care reform opponents, working with federal and state policymakers to implement key provisions of the law, and fixing the things that health reform got wrong.

Among the most important early provisions of health care reform that went into effect in September 2010 is one requiring all new private health plans to cover a range of preventive health services without any out-of-pocket costs to consumers. The initial list of protected services includes many related to reproductive health, including breast and cervical cancer screening, screening and counseling for HIV and other STIs, and HPV vaccination.

This list will expand later this year, when the Department of Health and Human Services issues a set of new guidelines for women’s preventive health care that may include contraceptive counseling, services and supplies. Supported by a strong body of evidence, contraceptive services have long been recognized by government bodies and private-sector experts as a vital and effective component of preventive care. Contraceptive use helps women avoid unintended pregnancy and space their births, which in turn helps improve maternal and child health. And insurance coverage without cost-sharing is an inexpensive—or even cost-saving—way of helping women overcome obstacles to effective contraceptive use.

Another notable new feature allows states to expand Medicaid coverage specifically for family planning services to women and men otherwise ineligible for the program. This provision builds on the experiences of the 22 states that have already expanded coverage via a burdensome “waiver” process—which the legislation now allows states to avoid. The potential gains for women, families and society are enormous.

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Even more significant gains are yet to be realized. Starting in 2014, the health reform law will expand insurance coverage and patient protections to tens of millions of Americans through a historic expansion of Medicaid and the establishment of new health insurance “exchanges” that will help individuals and small businesses purchase private insurance with federal subsidies. All of this should make family planning, maternity and STI services more affordable and accessible. In fact, the law has already expanded coverage for young adults by requiring private plans to extend dependent coverage to adult children younger than age 26. This provision should improve coverage and access to sexual and reproductive health care among young adults, the group most at risk for unintended pregnancy and STIs.

Yet, implementation of the overhaul faces several major, intertwined challenges. These include a historic budget crisis affecting Medicaid—which would see an influx of new participants under health care reform—and other health programs. Another major challenge is the shift in political power following the November 2010 elections, which swept into office opponents of health care reform at both the federal and state level. They have already launched a number of attacks on the legislation generally and the gains for reproductive health services specifically.

While fending off these attacks, reproductive health advocates will need to work with federal and state policymakers to promote the optimal implementation of key provisions of health care reform. This includes setting up the major infrastructures of health care reform—including the structure and authority of the upcoming health insurance exchanges, the scope of the benefits package to be required under plans for individuals and small businesses, and the expansion of Medicaid—so that it works for both individuals and safety-net providers seeking to meet the expected surge in demand.

Finally, reproductive health advocates face an uphill struggle in convincing Congress to fix problems in health care reform. In particular, extending Medicaid coverage brings with it an unprecedented expansion in the reach of the decades-old Hyde amendment, which prevents federal Medicaid dollars from going toward abortion coverage (except in the most extreme circumstances). More than two-thirds of new Medicaid enrollees are projected to be residents of states that have not countered this ban by using state revenues. Further, while private insurance plans on the exchanges may include abortion coverage, the law includes so many administrative hurdles that—combined with attacks on abortion coverage by state policymakers—it may end up dissuading insurers from offering the coverage at all.

Other shortcomings severely limit coverage options for millions of immigrants. Despite the major expansion to Medicaid under health reform, Congress refused to eliminate the long-standing policy that bars federal support for undocumented immigrants and recent legal immigrants under that program. In fact, undocumented immigrants are even barred from using their own funds to purchase private insurance plans in the new insurance exchanges.

In short, while some tangible gains for reproductive health have already been made under health care reform—and many important ones are still in the offing—these positive developments should not be taken for granted.

Click here for more information on:

Holding on to health care reform and gains for reproductive health

http://www.guttmacher.org/pubs/journals/j.contraception.2010.12.008.pdf

Commentary Contraception

The Promotion of Long-Acting Contraceptives Must Confront History and Center Patient Autonomy

Jamila Taylor

While some long-acting reversible contraceptive methods were used to undermine women of color's reproductive freedom, those methods still hold the promise of reducing unintended pregnancy among those most at risk.

Since long-acting reversible contraceptives (LARCs), including intrauterine devices and hormonal contraceptive implants, are among the most effective means of pregnancy prevention, many family planning and reproductive health providers are increasingly promoting them, especially among low-income populations.

But the promotion of LARCs must come with an acknowledgment of historical discriminatory practices and public policy related to birth control. To improve contraceptive access for low-income women and girls of color—who bear the disproportionate effects of unplanned pregnancy—providers and advocates must work to ensure that the reproductive autonomy of this population is respected now, precisely because it hasn’t been in the past.

For Black women particularly, the reproductive coercion that began during slavery took a different form with the development of modern contraceptive methods. According to Dorothy Roberts, author of Killing the Black Body, “The movement to expand women’s reproductive options was marked with racism from its very inception in the early part of [the 20th] century.” Decades later, government-funded family planning programs encouraged Black women to use birth control; in some cases, Black women were coerced into being sterilized.

In the 1990s, the contraceptive implant Norplant was marketed specifically to low-income women, especially Black adults and teenage girls. After a series of public statements about the benefits of Norplant in reducing pregnancy among this population, policy proposals soon focused on ensuring usage of the contraceptive method. Federal and state governments began paying for Norplant and incentivizing its use among low-income women while budgets for social support programs were cut. Without assistance, Norplant was not an affordable option, with the capsules costing more than $300 and separate, expensive costs for implantation and removal.

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Soon, Norplant was available through the Medicaid program. Some states introduced (ultimately unsuccessful) bills that would give cash rewards to entice low-income women on public assistance into using it; a few, such as Tennessee and Washington state, required that women receiving various forms of public assistance get information about Norplant. After proposing a bill to promote the use of Norplant in his state in 1994, a Connecticut legislator made the comment, “It’s far cheaper to give you money not to have kids than to give you money to have kids.” By that year, as Roberts writes, states had spent $34 million on Norplant-related care, much of it for women on Medicaid. Policymakers thought it was completely legitimate and cost-effective to control the reproduction of low-income women.

However, promoting this method among low-income Black women and adolescents was problematic. Racist, classist ideology dictating that this particular population of women shouldn’t have children became the basis for public policy. Even though coercive practices in reproductive health were later condemned, these practices still went on to shape cultural norms around race and gender, as well as medical practice.

This history has made it difficult to move beyond negative perceptions, and even fear, of LARCs, health care, and the medical establishment among some women of color. And that’s why it’s so important to ensure informed consent when advocating for effective contraceptive methods, with choice always at the center.

But how can policies and health-care facilities promote reproductive autonomy?

Health-care providers must deal head on with the fact that many contemporary women have concerns about LARCs being recommended specifically to low-income women and women of color. And while this is part of the broader effort to make LARCs more affordable and increasingly available to communities that don’t have access to them, mechanisms should be put in place to address this underlying issue. Requiring cultural competency training that includes information on the history of coercive practices affecting women of color could help family planning providers understand this concern for their patients.

Then, providers and health systems must address other barriers that make it difficult for women to access LARCs in particular. LARCs can be expensive in the short term, and complicated billing and reimbursement practices in both public and private insurance confuse women and providers. Also, the full cost associated with LARC usage isn’t always covered by insurance.

But the process shouldn’t end at eliminating barriers. Low-income Black women and teens must receive comprehensive counseling for contraception to ensure informed choice—meaning they should be given information on the full array of methods. This will help them choose the method that best meets their needs, while also promoting reproductive autonomy—not a specific contraceptive method.

Clinical guidelines for contraception must include detailed information on informed consent, and choice and reproductive autonomy should be clearly outlined when family planning providers are trained.

It’s crucial we implement these changes now because recent investments and advocacy are expanding access to LARCs. States are thinking creatively about how to reduce unintended pregnancy and in turn reduce Medicaid costs through use of LARCs. The Colorado Family Planning Initiative has been heralded as one of the most effective in helping women access LARCs. Since 2008, more than 30,000 women in Colorado have chosen LARCs as the result of the program. Provider education, training, and contraceptive counseling have also been increased, and women can access LARCs at reduced costs.

The commitment to LARCs has apparently yielded major returns for Colorado. Between 2009 and 2013, the abortion rate among teenagers older than 15 in Colorado dropped by 42 percent. Additionally, the birth rate for young women eligible for Medicaid dropped—resulting in cost savings of up to an estimated $111 million in Medicaid-covered births. LARCs have been critical to these successes. Public-private partnerships have helped keep the program going since 2015, and states including Delaware and Iowa have followed suit in efforts to experience the same outcomes.

Recognizing that prevention is a key component to any strategy addressing a public health concern, those strategies must be rooted in ensuring access to education and comprehensive counseling so that women and teens can make the informed choices that are best for them. When women and girls are given the tools to empower themselves in decision making, the results are positive—not just for what the government spends or does not spend on social programs, but also for the greater good of all of us.

The history of coercion undermining reproductive freedom among women and girls of color in this country is an ugly one. But this certainly doesn’t have to dictate how we move forward.

Commentary Abortion

Latinx Must Use Votes to Fight Hyde Amendment

Cristina Aguilar, Jessica González-Rojas, Laura Jimenez & Maria Teresa Kumar

More than 27 million Latinx are now eligible to vote, and that number can help determine who takes office and what abortion policies they enact.

The first woman known to die of an unsafe illegal abortion after the Hyde Amendment was a Latina. A struggling 27-year-old college student with a young daughter, Rosie Jimenez died from septic shock in October 1977—with a scholarship check earmarked for school in her purse. Jimenez had been refused coverage because, just months before, Congress had enacted the Hyde Amendment banning use of federal Medicaid funds for abortion except in cases of rape, incest, or life endangerment.

As we enter this Latina Week of Action for Reproductive Justice (today through August 7), the Hyde Amendment continues to deny pregnant people the chance to make the best decision for themselves and their families. And because our communities are hard-hit by abortion restrictions, Latinx must play a role in our electoral process to repeal Hyde and replace other anti-abortion measures with policies that truly support all families.

A 2011 study found that more than 70 percent of Latino registered voters believe that we should not judge someone who feels they’re not ready to be a parent. Unfortunately, this sentiment is not echoed by many legislators in Congress and throughout the country, who too often design policies precisely to put abortion care out of reach.

While the recent Whole Woman’s Health v. Hellerstedt Supreme Court struck down medically unnecessary restrictions in Texas, abortion access remains a challenge for many Latinx across the country. The Hyde Amendment has a disproportionate impact on low-income people of color who already face numerous health-care disparities and often do not have the money to compensate for insurance gaps.

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Withholding Medicaid coverage for abortion has an especially devastating effect in our communities, where enrollment is high; in 2012, 29 percent of Latinx adults and children nationwide received benefits from the program, and in some states such as Texas, more than half of Medicaid participants were Latinx.

Whether it’s public or private, health insurance must cover the services we need. When it doesn’t, the scramble to pay for an abortion has the potential to push families further into poverty. Already, too many of us are just scraping by while living with the stresses of a broken immigration system that divides families, structural racism, and lack of educational and employment opportunities.

Our communities need laws to ensure that health plans provide abortion coverage—not the Hyde Amendment nor legislation that claims to protect women while closing clinics or shaming those who provide and seek abortions.

Abortion is health care. And the ability to obtain health care should not be predicated on what type of insurance benefits you have, how much money you make, or whether you live in a state that allows public funds to pay for abortions.

It is time that we push back. Together, we can harness our power to advance positive policies that will make a difference. Latinx comprise a critical voting bloc that can significantly influence electoral outcomes; according to the Pew Research Center, an unprecedented number—27.3 million—of Latinx will be eligible to vote in the upcoming election.

But this only matters if we show up at the ballot boxes. We need to hold our elected officials accountable when they don’t consider the needs of our families. By lifting our collective voices and our votes, we can sway who holds office and makes policies.

This election, the health, rights, and dignity of our families are at stake. We cannot afford to sit out voting. It is an opportunity to make sure that those who are charged with representing us stand with our families. We owe it to Rosie Jimenez and the daughter she left behind. We owe it to ourselves.

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