Commentary Abortion

How the Bishops’ Directives Derail Medical Decisions at Catholic Hospitals

Jon O’Brien

The bishops are engaging in a public relations campaign that is more myth than fact. Here are several claims you can expect to hear from the bishops—followed by the truth about what health care under the "Ethical and Religious Directives" means for people who need care at a Catholic hospital.

On Monday, the American Civil Liberties Union (ACLU) and the ACLU of Michigan announced they had filed a lawsuit against the United States Conference of Catholic Bishops (USCCB) “on behalf of a pregnant woman who miscarried and was denied appropriate medical treatment because the only hospital in her county is required to abide by religious directives.” Written by the USCCB, the directives “prohibited that hospital from complying with the applicable standard of care in this case.”

The ACLU is taking the USCCB to task for requiring that all Catholic health-care facilities abide by the “Ethical and Religious Directives for Catholic Health Care Services,” which prevent Catholic hospitals from, among other things, offering an abortion under any circumstances, even when a fetus has little to no chance of survival and the woman’s life or health are at risk.

A recent Catholics for Choice/ACLU poll found that when it comes to abortion, nearly all respondents say doctors should not be allowed to withhold information about a fetus’ health for fear the woman may have an abortion, and majorities say doctors should not be allowed to refuse to make a referral for an abortion and that Catholic hospitals should not be allowed to refuse to provide medically necessary abortions. Nonetheless, we know that at least in the case of Tamesha Means, the woman the ACLU is representing, this made little difference.

Unfortunately, we also know that in Catholic hospitals in Michigan and across the country medical decisions are often derailed by the bishops’ directives.

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Catholic health care is big business, especially in Michigan, where Catholic health care is health care for many people. Of all hospital admissions that occur in the state, between 20 and 29 percent occur in a Catholic-run facility. In total, Michigan’s 23 Catholic hospitals care for 5,142,006 patients each year. The state’s eight Catholic health-care centers attend to 517,084 patients annually. Not all of the individuals treated by the Catholic health system are Catholic, but there are 2,008,445 Catholics in Michigan—21 percent of the state’s population. Only 17 of them are bishops. Mercy Health Partners, the hospital where the above case took place is the only one in the county.

It is worth noting that a significant percentage of the health care delivered in the United States comes from the country’s 630 Catholic hospitals, which make up 12.6 percent of the nation’s total. People in certain areas may rely upon Catholic health care because there are few other options—nearly one-third (32 percent) of all Catholic hospitals are located in rural areas. The economically vulnerable individuals served by Medicaid are often treated at Catholic hospitals, which account for 13.7 percent of all Medicaid discharges in the United States (nearly one million patients, at 978,842).

In addition, there are 56 Catholic health systems, which are enormous conglomerations made up of many separate Catholic-run hospitals. Catholic hospital systems are among the largest in the country—among the top five biggest nonprofit systems, four (80 percent) are Catholic, and all of the top three are Catholic. These three largest entities alone comprise 268 hospitals. Looking at the nation’s ten largest nonprofit health systems, six of the ten (60 percent) are Catholic. Of the group of the 25 largest nonprofit health-care systems, 11 (44 percent) are Catholic-run. When one considers the 868 hospitals affiliated with the top 25 largest hospital systems in the country, 493 of these are Catholic. All of those operate under the bishops’ directives. 

Under the directives, the reality for women who find themselves at a Catholic hospital means they have:

  • No access to abortion—even in cases of rape or incest (Directive 45)
  • No access to in-vitro fertilization (Directives 37, 38, 39)
  • No access to contraception (Directive 52)
  • No treatment for ectopic pregnancy (Directive 48)
  • None of the benefits of embryonic stem-cell research (Directive 51)
  • No respect for their advance medical directives (Directive 24)

The sole exception to the ban on contraception falls under Directive 36, which only allows the provision of emergency contraception (EC) in cases of sexual assault when it can be proven that pregnancy has not occurred. This creates an unnecessary restriction, as EC does not interfere with the implantation of a fertilized egg. Evidence also suggests that many Catholic hospitals rarely provide EC even under the circumstances approved by the directives. A 2006 study found that 35 percent of Catholic hospitals did not provide EC under any circumstances, while 47 percent refused to provide referrals to hospitals that did. Of those that provided referrals, only 47 percent of these led to a hospital that actually provided EC.

The Misinformation Campaign

The bishops who claim that Catholic institutions care for the poor and underserved in a fashion that surpasses other nonprofit hospitals are engaging in a public relations campaign that is more myth than fact. Here are several claims you can expect to hear from the bishops—followed by the truth about what health care under the Ethical and Religious Directives means for people who need care at a Catholic hospital.

Claim: Catholics support the directives and do not want or expect their hospitals to provide services that are forbidden. “With the support of the faith community, Catholic organizations and agencies provide pastoral services and care for pregnant women, especially those who are vulnerable to abortion and who would otherwise find it difficult or impossible to obtain high-quality medical care.” – USCCB, “Pastoral Plan for Pro-Life Activities: A Campaign in Support of Life,” 2011.  

In Fact: Many Catholics do not even know about the directives and are shocked when they find out that Catholic hospitals do not provide a full range of medical services. Catholics throughout the United States rely upon their individual consciences when making decisions about which reproductive health-care services they use and want their hospitals to provide. In 2009, more than six in ten Catholic voters (62 percent) indicated that hospitals and clinics that take taxpayer dollars should not be allowed to refuse to provide medical procedures or medications based on religious beliefs, and most Catholic voters (78 percent) oppose allowing pharmacists to refuse to fill prescriptions for birth control.

Catholics use and obtain contraception and abortion at rates similar to the rest of the U.S. population and support access to these services. Sexually active Catholic women above the age of 18 are just as likely (98 percent) to have used some form of contraception banned by the hierarchy as women in the general population (99 percent), and less than 2 percent of sexually active Catholic women use the bishops’ preferred method (natural family planning) as their primary form of birth control. In 2008, a study of almost 9,500 women showed that Catholic women have abortions at the same rate as other women: 28 percent of women who had an abortion self-identified as Catholic, while 27 percent of all women of reproductive age identified as such. The facts tell the story—the majority of Catholics have rejected the USCCB’s hard-line stance, as outlined in the directives, and instead support access to comprehensive reproductive health care and need their hospitals to provide these services.

Claim: “Catholic health care does not offend the rights of individual conscience by refusing to provide or permit medical procedures that are judged morally wrong by the teaching authority of the Church.” – USCCB, The Ethical and Religious Directives for Health Services, 2011.

In Fact: The reverse is true. Catholics throughout the United States rely on their consciences to use services that are banned under the directives. Last year, Catholic hospitals employed over 600,000 full-time staff, accounting for 16.7 percent of all full-time hospital staff in the United States. Time and time again, medical professionals employed by Catholic hospitals have reported that, out of fear of theo­political retribution or out of sincere adherence to the draconian measures imposed by directives, their institutions have forced them to endanger women’s lives by denying timely and necessary reproductive health care. Catholic medical professionals have described situations in which, due to these strictures, they have provided substandard care to women seeking treatment for miscarriage or ectopic pregnancy.

While it serves neither the patient seeking care nor the dictates of conscience to force individual medical professionals to provide services they consider immoral, it goes too far to grant such blanket rights to an institution. Catholicism requires deference to the conscience of others in making one’s own decisions. Its intellectual tradition emphasizes that conscience can be guided but not forced in any direction. The directives, in their rigidity and their enforcement by the bishops, dictate to people what services they may provide and access rather than respecting the individual capacities of women and their doctors to form their own decisions.

When a young pregnant woman with pulmonary hypertension finds her life in danger and decides that it is best to defend herself by discontinuing her pregnancy, as happened in the case of St. Joseph’s, the hospital where she is treated has an ethical obligation to respect her decision. When an unemployed mother of five decides that she cannot have more children and seeks a tubal ligation, she should not have to worry about whether her right to follow her conscience will be denied. When a doctor has made the choice to save a woman on her operating table rather than waiting to perform unnecessary tests and waste precious minutes, that provider should have the ability to provide rapid, life-saving care without fear of retribution from administrators or the local bishop.

In addition, Catholic hospitals in the United States are part of a pluralistic society and have a moral obligation to respect the religious beliefs and denominations of all those whom they treat and employ, and whose taxpayer dollars they utilize, including many non-Catholics. Ultimately, when the bishops stop writing prescriptions for both individuals’ consciences and their medical care, all of us will benefit.

Claim: “Whether young or old, rich or poor, insured or uninsured, people in the US find the care they need—care always respectful of their dignity as human persons—at Catholic-sponsored health care facilities … [Catholic hospitals are] a passionate voice for compassionate care.” –Sr. Carol Keehan, CHA President and CEO, “Catholic Health Association Brochure,” 2010.

In Fact: Catholic hospitals routinely deny basic reproductive health-care services, leaving women without the respectful care that the CHA claims to provide. The Catholic health-care system indeed provides some important services in communities across the United States. The reality is, however, that the CHA and USCCB aim to highlight their commitment to human dignity and the poor while simultaneously refusing to meet the health needs of the people they serve.

By banning most services for women experiencing miscarriages, seeking to avoid pregnancy, or in need of abortion care, and turning away couples attempting to conceive a child through new reproductive technologies, Catholic hospitals in fact demonstrate a lack of compassionate understanding of peoples’ lives.

Even in instances in which the directives allow some reproductive health-care services, such as the emergency contraception provision for rape survivors included in Directive 36, many Catholic hospitals still refuse to comply with basic standards of medical care. In a 1999 survey of 589 Catholic hospitals, 82 percent stated that they did not provide EC under any circumstances. In a 2002 study, 328 of the 597 Catholic hospital emergency rooms surveyed refused to dispense EC under any circumstances.[xii] In 2006, only 37 percent of Catholic hospitals surveyed stated that EC was available for sexual assault patients at their hospital, while 35 percent stated that EC was not available under any circumstances. For the sexual assault survivor who turns to a Catholic emergency room during her time of crisis and is denied emergency contraception, the CHA’s dedication to “compassionate care” may ring false. In addition, a recent study examined the impact that the directives have on the care pregnant women receive at Catholic hospitals and concluded that women presenting with symptoms related to ectopic pregnancies were denied information about, and access to, possible treatments.

Claim: “[Catholic hospitals] operate not out of a profit motive but out of charity. In 1998, for example, the nation’s 637 Catholic hospitals’ service to the poor resulted in a $2.8 billion financial loss.” –Maureen Kramlich, US Conference of Catholic Bishops’ Secretariat for Pro-Life Activities, “The Assault on Catholic Health Care,” 2002.

In Fact: Catholic hospitals operate under the same tax laws as other nonprofit hospitals, charge market rates for health care services, receive the same government funding as non-Catholic hospitals and do not provide any more charity than other health care systems. In 2002, a MergerWatch study found that public hospitals provided twice as much free care as Catholic hospitals, based on charity write-offs.

Furthermore, directly following the “merger mania” of the mid-1990’s, some Catholic health systems actually saw double-digit revenue surges compared to previous years. In 2004, Ascension Health, the largest Catholic system and sixth-largest health-care system overall based on its number of acute-care hospitals in 2003, achieved a $10.04 billion, or 11 percent, revenue growth in the fiscal year ending in 2004.

U.S. tax dollars continue to fund Catholic hospitals, which do not provide the full range of health services. A 2002 study of over 600 religiously affiliated hospitals found that they received more than $45 billion in public funds. Approximately half of this revenue was received from Medicare, Medicaid and other government programs.

As a 501(c)(3) nonprofit organization, the CHA itself also benefits from tax breaks similar to those provided to charitable, religious, educational, literary, scientific, public safety, amateur sports, children’s and animal rights organizations such as the American Cancer Society, the Poetry Foundation and American Society for the Prevention of Cruelty to Animals. By the conclusion of the fiscal year ending on June 30, 2010, CHA had garnered over $26 million in assets.

Tax breaks and government funding to organizations that do not provide the full range of reproductive health do not bode well for the health of U.S. Catholic and non-Catholic taxpayers. During the 2009 health-care reform debate, the majority of Catholic voters (65 percent) indicated that hospitals and clinics that receive taxpayer dollars should not be allowed to refuse to provide medical procedures or medications based on religious beliefs. A majority of Catholic voters (60 percent) also believe that hospitals and clinics that take taxpayer dollars should be required to include condoms as part of HIV prevention.[xx]Women, meanwhile, disapprove of circumstances in which a Catholic hospital would become the only medical institution in their community (68 percent), while 85 percent reject the idea that Catholic hospitals receiving government money should be allowed to ban procedures because of religious beliefs.

Claim: Patients can go to another hospital if they need procedures that Catholic hospitals do not provide. “Those who have decided to be critical of Catholic healthcare apparently work hard to find some of those few cases in which one or more elective procedure [sic] may have been eliminated within a community. But we fail to see how they can jump to the conclusion that women have ‘no access’ to the elective procedures.” –Rev. Michael D. Place letter to Redbook Editor in Chief Lesley Jane Seymour, 2000.

In Fact: More than one third (32 percent) of U.S. Catholic hospitals are located in rural areas, and they are often the only local health-care providers in these communities. For the men and women who depend on these hospitals, however, their right to even basic reproductive health services is severely compromised. If the hospital is Catholic and will not fulfill the needs of the community it serves, then the hospital is frankly not helping people who have no other choice in health care.

In areas where Catholic hospitals are often the only health-care providers, those without the means or, in the case of emergency situations, the time to travel cannot access alternative care. In the span of one year, Catholic hospitals accounted for more than 2 million Medicare discharges (16.7 percent of the national total) and more than 900,000 Medicaid discharges. These patients, some of them the poorest of the poor, were left without access to their basic health-care needs. For example, a Medicaid patient in eastern New Orleans arriving at a hospital in the Franciscan Missionaries of Our Lady Health System and hoping to prevent an unplanned pregnancy with modern contraception will not get the care she needs. A woman in rural Nebraska who cannot take time off from work to travel many miles to a non-Catholic hospital after a potentially life-threatening diagnosis of ectopic pregnancy will also find that most treatment options are closed to her.

Even those individuals whose financial status or location may normally enable them to travel to a non-Catholic facility can find themselves reliant upon Catholic hospitals. More than 19 million emergency room visits occurred in Catholic facilities during 2009. Women experiencing medical duress due to ectopic pregnancies, miscarriages or rape may not have the time or the luxury of choosing another hospital. A woman in this situation will not have her medical wishes honored, but may instead find herself in a hospital that will allow her condition to dangerously deteriorate out of a strict adherence to the directives.

Many people are also not aware of the restrictions imposed by the directives until they are in need of the services that are banned. Often, patients believe the name of the hospital to be a name only and are unaware that it indicates a different standard of health care. Even non-Catholics who seek care at a Catholic institution are subject to the directives, and many will be surprised to learn that the care they require is unavailable.

Catholic hospitals are, first and foremost, health-care facilities—they all receive taxpayer money and they must adhere to standards of health care. This means providing comprehensive care for all patients. The USCCB and CHA aim to highlight the importance and commitment of Catholic services to the community, while at the same time downplaying the reproductive health needs of the people they serve and whose tax dollars they continue to utilize. A health-care institution should primarily provide care with a focus on its responsibility to the patients, employees and community it serves.

Catholics and non-Catholics recognize this and consistently exercise their own judgment when making decisions about which reproductive health services they want to use and want their hospitals to provide.

Catholics for Choice remains convinced of the moral capacity of men and women to make their own decisions regarding their reproductive lives. We are committed to the idea that access to reproductive health care is a matter of social justice, and that all people, Catholic or not, should be able to walk into a hospital without fear that their medical needs will not be met.

Click here for links to more than 15 years of groundbreaking research and original publications on Catholic health care, ethics, and reproductive health and rights.

Culture & Conversation Human Rights

Let’s Stop Conflating Self-Care and Actual Care

Katie Klabusich

It's time for a shift in the use of “self-care” that creates space for actual care apart from the extra kindnesses and important, small indulgences that may be part of our self-care rituals, depending on our ability to access such activities.

As a chronically ill, chronically poor person, I have feelings about when, why, and how the phrase “self-care” is invoked. When International Self-Care Day came to my attention, I realized that while I laud the effort to prevent some of the 16 million people the World Health Organization reports die prematurely every year from noncommunicable diseases, the American notion of self-care—ironically—needs some work.

I propose a shift in the use of “self-care” that creates space for actual care apart from the extra kindnesses and important, small indulgences that may be part of our self-care rituals, depending on our ability to access such activities. How we think about what constitutes vital versus optional care affects whether/when we do those things we should for our health and well-being. Some of what we have come to designate as self-care—getting sufficient sleep, treating chronic illness, allowing ourselves needed sick days—shouldn’t be seen as optional; our culture should prioritize these things rather than praising us when we scrape by without them.

International Self-Care Day began in China, and it has spread over the past few years to include other countries and an effort seeking official recognition at the United Nations of July 24 (get it? 7/24: 24 hours a day, 7 days a week) as an important advocacy day. The online academic journal SelfCare calls its namesake “a very broad concept” that by definition varies from person to person.

“Self-care means different things to different people: to the person with a headache it might mean a buying a tablet, but to the person with a chronic illness it can mean every element of self-management that takes place outside the doctor’s office,” according to SelfCare. “[I]n the broadest sense of the term, self-care is a philosophy that transcends national boundaries and the healthcare systems which they contain.”

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In short, self-care was never intended to be the health version of duct tape—a way to patch ourselves up when we’re in pieces from the outrageous demands of our work-centric society. It’s supposed to be part of our preventive care plan alongside working out, eating right, getting enough sleep, and/or other activities that are important for our personalized needs.

The notion of self-care has gotten a recent visibility boost as those of us who work in human rights and/or are activists encourage each other publicly to recharge. Most of the people I know who remind themselves and those in our movements to take time off do so to combat the productivity anxiety embedded in our work. We’re underpaid and overworked, but still feel guilty taking a break or, worse, spending money on ourselves when it could go to something movement- or bill-related.

The guilt is intensified by our capitalist system having infected the self-care philosophy, much as it seems to have infected everything else. Our bootstrap, do-it-yourself culture demands we work to the point of exhaustion—some of us because it’s the only way to almost make ends meet and others because putting work/career first is expected and applauded. Our previous president called it “uniquely American” that someone at his Omaha, Nebraska, event promoting “reform” of (aka cuts to) Social Security worked three jobs.

“Uniquely American, isn’t it?” he said. “I mean, that is fantastic that you’re doing that. (Applause.) Get any sleep? (Laughter.)”

The audience was applauding working hours that are disastrous for health and well-being, laughing at sleep as though our bodies don’t require it to function properly. Bush actually nailed it: Throughout our country, we hold Who Worked the Most Hours This Week competitions and attempt to one-up the people at the coffee shop, bar, gym, or book club with what we accomplished. We have reached a point where we consider getting more than five or six hours of sleep a night to be “self-care” even though it should simply be part of regular care.

Most of us know intuitively that, in general, we don’t take good enough care of ourselves on a day-to-day basis. This isn’t something that just happened; it’s a function of our work culture. Don’t let the statistic that we work on average 34.4 hours per week fool you—that includes people working part time by choice or necessity, which distorts the reality for those of us who work full time. (Full time is defined by the Internal Revenue Service as 30 or more hours per week.) Gallup’s annual Work and Education Survey conducted in 2014 found that 39 percent of us work 50 or more hours per week. Only 8 percent of us on average work less than 40 hours per week. Millennials are projected to enjoy a lifetime of multiple jobs or a full-time job with one or more side hustles via the “gig economy.”

Despite worker productivity skyrocketing during the past 40 years, we don’t work fewer hours or make more money once cost of living is factored in. As Gillian White outlined at the Atlantic last year, despite politicians and “job creators” blaming financial crises for wage stagnation, it’s more about priorities:

Though productivity (defined as the output of goods and services per hours worked) grew by about 74 percent between 1973 and 2013, compensation for workers grew at a much slower rate of only 9 percent during the same time period, according to data from the Economic Policy Institute.

It’s no wonder we don’t sleep. The Centers for Disease Control and Prevention (CDC) has been sounding the alarm for some time. The American Academy of Sleep Medicine and the Sleep Research Society recommend people between 18 and 60 years old get seven or more hours sleep each night “to promote optimal health and well-being.” The CDC website has an entire section under the heading “Insufficient Sleep Is a Public Health Problem,” outlining statistics and negative outcomes from our inability to find time to tend to this most basic need.

We also don’t get to the doctor when we should for preventive care. Roughly half of us, according to the CDC, never visit a primary care or family physician for an annual check-up. We go in when we are sick, but not to have screenings and discuss a basic wellness plan. And rarely do those of us who do go tell our doctors about all of our symptoms.

I recently had my first really wonderful check-up with a new primary care physician who made a point of asking about all the “little things” leading her to encourage me to consider further diagnosis for fibromyalgia. I started crying in her office, relieved that someone had finally listened and at the idea that my headaches, difficulty sleeping, recovering from illness, exhaustion, and pain might have an actual source.

Considering our deeply-ingrained priority problems, it’s no wonder that when I post on social media that I’ve taken a sick day—a concept I’ve struggled with after 20 years of working multiple jobs, often more than 80 hours a week trying to make ends meet—people applaud me for “doing self-care.” Calling my sick day “self-care” tells me that the commenter sees my post-traumatic stress disorder or depression as something I could work through if I so chose, amplifying the stigma I’m pushing back on by owning that a mental illness is an appropriate reason to take off work. And it’s not the commenter’s fault; the notion that working constantly is a virtue is so pervasive, it affects all of us.

Things in addition to sick days and sleep that I’ve had to learn are not engaging in self-care: going to the doctor, eating, taking my meds, going to therapy, turning off my computer after a 12-hour day, drinking enough water, writing, and traveling for work. Because it’s so important, I’m going to say it separately: Preventive health care—Pap smears, check-ups, cancer screenings, follow-ups—is not self-care. We do extras and nice things for ourselves to prevent burnout, not as bandaids to put ourselves back together when we break down. You can’t bandaid over skipping doctors appointments, not sleeping, and working your body until it’s a breath away from collapsing. If you’re already at that point, you need straight-up care.

Plenty of activities are self-care! My absolutely not comprehensive personal list includes: brunch with friends, adult coloring (especially the swear word books and glitter pens), soy wax with essential oils, painting my toenails, reading a book that’s not for review, a glass of wine with dinner, ice cream, spending time outside, last-minute dinner with my boyfriend, the puzzle app on my iPad, Netflix, participating in Caturday, and alone time.

My someday self-care wish list includes things like vacation, concerts, the theater, regular massages, visiting my nieces, decent wine, the occasional dinner out, and so very, very many books. A lot of what constitutes self-care is rather expensive (think weekly pedicures, spa days, and hobbies with gear and/or outfit requirements)—which leads to the privilege of getting to call any part of one’s routine self-care in the first place.

It would serve us well to consciously add an intersectional view to our enthusiasm for self-care when encouraging others to engage in activities that may be out of reach financially, may disregard disability, or may not be right for them for a variety of other reasons, including compounded oppression and violence, which affects women of color differently.

Over the past year I’ve noticed a spike in articles on how much of the emotional labor burden women carry—at the Toast, the Atlantic, Slate, the Guardian, and the Huffington Post. This category of labor disproportionately affects women of color. As Minaa B described at the Huffington Post last month:

I hear the term self-care a lot and often it is defined as practicing yoga, journaling, speaking positive affirmations and meditation. I agree that those are successful and inspiring forms of self-care, but what we often don’t hear people talking about is self-care at the intersection of race and trauma, social justice and most importantly, the unawareness of repressed emotional issues that make us victims of our past.

The often-quoted Audre Lorde wrote in A Burst of Light: “Caring for myself is not self-indulgence, it is self-preservation, and that is an act of political warfare.”

While her words ring true for me, they are certainly more weighted and applicable for those who don’t share my white and cisgender privilege. As covered at Ravishly, the Feminist Wire, Blavity, the Root, and the Crunk Feminist Collective recently, self-care for Black women will always have different expressions and roots than for white women.

But as we continue to talk about self-care, we need to be clear about the difference between self-care and actual care and work to bring the necessities of life within reach for everyone. Actual care should not have to be optional. It should be a priority in our culture so that it can be a priority in all our lives.

Commentary Politics

Democrats’ Latest Platform Silent on Discriminatory Welfare System

Lauren Rankin

The current draft of the 2016 Democratic Party platform contains some of the most progressive positions that the party has taken in decades. But there is a critical issue—one that affects millions in the United States—that is missing entirely from the draft: fixing our broken and discriminatory welfare system.

While the Republican Party has adopted one of the most regressive, punitive, and bigoted platforms in recent memory, the Democratic Party seems to be moving decisively in the opposite direction. The current draft of the 2016 Democratic Party platform contains some of the most progressive positions that the party has taken in decades. It calls for a federal minimum wage of $15; a full repeal of the Hyde Amendment, which prohibits the use of federal Medicaid funding for abortion care; and a federal nondiscrimination policy to protect the rights of LGBTQ people.

All three of these are in direct response to the work of grassroots activists and coalitions that have been shifting the conversation and pushing the party to the left.

But there is a critical issue—one that affects millions in the United States—that is missing entirely from the party platform draft: fixing our broken and discriminatory welfare system.

It’s been 20 years since President Bill Clinton proudly declared that “we are ending welfare as we know it” when he signed into law a sweeping overhaul of the U.S. welfare system. The Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996 implemented dramatic changes to welfare payments and eligibility, putting in place the Temporary Assistance for Needy Families (TANF) program. In the two decades since its enactment, TANF has not only proved to be blatantly discriminatory, but it has done lasting damage.

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In one fell swoop, TANF ended the federal guarantee of support to low-income single mothers that existed under the now-defunct Aid to Families with Dependent Children (AFDC) program. AFDC had become markedly unpopular and an easy target by the time President Clinton signed welfare reform legislation into law, with the racist, mythic trope of the “welfare queen” becoming pervasive in the years leading up to AFDC’s demise.

Ronald Reagan popularized this phrase while running for president in 1976 and it caught fire, churning up public resentment against AFDC and welfare recipients, particularly Black women, who were painted as lazy and mooching off the government. This trope underwrote much of conservative opposition to AFDC; among other things, House Republican’s 1994 “Contract with America,” co-authored by Newt Gingrich, demanded an end to AFDC and vilified teen mothers and low-income mothers with multiple children.

TANF radically restructured qualifications for welfare assistance, required that recipients sustain a job in order to receive benefits, and ultimately eliminated the role of the federal state in assisting poor citizens. The promise of AFDC and welfare assistance more broadly, including SNAP (the Supplemental Nutrition Assistance Program, commonly known as food stamps) benefits, is that the federal government has an inherent role of caring for and providing for its most vulnerable citizens. With the implementation of TANF, that promise was deliberately broken.

At the time of its passage, Republicans and many Democrats, including President Bill Clinton, touted TANF as a means of motivating those receiving assistance to lift themselves up by their proverbial bootstraps, meaning they would now have to work while receiving benefits. But the idea that those in poverty can escape poverty simply by working harder and longer evades the fact that poverty is cyclical and systemic. Yet, that is what TANF did: It put the onus for ending poverty on the individual, rather than dealing with the structural issues that perpetuate the state of being in poverty.

TANF also eliminated any federal standard of assistance, leaving it up to individual states to determine not only the amount of financial aid that they provide, but what further restrictions state lawmakers wish to place on recipients. Not only that, but the federal TANF program instituted a strict, lifetime limit of five years for families to receive aid and a two-year consecutive limit, which only allows an individual to receive two years of consecutive aid at a time. If after five total years they still require assistance to care for their family and themself, no matter their circumstances, they are simply out of luck.

That alone is an egregious violation of our inalienable constitutional rights to life, liberty, and the pursuit of happiness. Still, TANF went a step further: It also allowed states to institute more pernicious, discriminatory policies. In order to receive public assistance benefits through TANF, low-income single mothers are subjected to intense personal scrutiny, sexual and reproductive policing, and punitive retribution that does not exist for public assistance recipients in programs like Social Security and Supplemental Security Income disability programs, programs that Democrats not only continue to support, but use as a rallying cry. And yet, few if any Democrats are crying out for a more just welfare system.

There are so many aspects of TANF that should motivate progressives, but perhaps none more than the family cap and forced paternity identification policies.

Welfare benefits through the TANF program are most usually determined by individual states based on household size, and family caps allow a state to deny welfare recipients’ additional financial assistance after the birth of another child. At least 19 states currently have family cap laws on the books, which in some cases allow the state to deny additional assistance to recipients who give birth to another child. 

Ultimately, this means that if a woman on welfare becomes pregnant, she is essentially left with deciding between terminating her pregnancy or potentially losing her welfare benefits, depending on which state she lives in. This is not a free and valid choice, but is a forced state intervention into the private reproductive practices of the women on welfare that should appall and enrage progressive Democrats.

TANF’s “paternafare,” or forced paternity identification policy, is just as egregious. Single mothers receiving TANF benefits are forced to identify the father of their children so that the state may contact and demand financial payment from them. This differs from nonwelfare child support payments, in which the father provides assistance directly to the single mother of his child; this policy forces the fathers of low-income single women on welfare to give their money directly to the state rather than the mother of their child. For instance, Indiana requires TANF recipients to cooperate with their local county prosecutor’s child support program to establish paternity. Some states, like Utah, lack an exemption for survivors of domestic violence as well as children born of rape and incest, as Anna Marie Smith notes in her seminal work Welfare Reform and Sexual Regulation. This means that survivors of domestic violence may be forced to identify and maintain a relationship with their abusers, simply because they are enrolled in TANF.

The reproductive and sexual policing of women enrolled in TANF is a deeply discriminatory and unconstitutional intrusion. And what’s also disconcerting is that the program has failed those enrolled in it.

TANF was created to keep single mothers from remaining on welfare rolls for an indeterminate amount of time, but also with the express goal of ensuring that these young women end up in the labor force. It was touted by President Bill Clinton and congressional Republicans as a realistic, work-based solution that could lift single mothers up out of poverty and provide opportunities for prosperity. In reality, it’s been a failure, with anywhere from 42 to 74 percent of those who exited the program remaining poor.

As Jordan Weissmann detailed over at Slate, while the number of women on welfare decreased significantly since 1996, TANF left in its wake a new reality: “As the rolls shrank, a new generation of so-called disconnected mothers emerged: single parents who weren’t working, in school, or receiving welfare to support themselves or their children. According to [the Urban Institute’s Pamela] Loprest, the number of these women rose from 800,000 in 1996 to 1.2 million in 2008.” Weissmann also noted that researchers have found an uptick in “deep or extreme poverty” since TANF went into effect.

Instead of a system that enables low-income single mothers a chance to escape the cycle of poverty, what we have is a racist system that denies aid to those who need it most, many of whom are people of color who have been and remain systemically impoverished.

The Democratic Party platform draft has an entire plank focused on how to “Raise Incomes and Restore Economic Security for the Middle Class,” but what about those in poverty? What about the discriminatory and broken welfare system we have in place that ensures not only that low-income single mothers feel stigmatized and demoralized, but that they lack the supportive structure to even get to the middle class at all? While the Democratic Party is developing strategies and potential policies to support the middle class, it is neglecting those who are in need the most, and who are suffering the most as a result of President Bill Clinton’s signature legislation.

While the national party has not budged on welfare reform since President Bill Clinton signed the landmark legislation in 1996, there has been some state-based movement. Just this month, New Jersey lawmakers, led by Democrats, passed a repeal of the state’s family cap law, which was ultimately vetoed by Republican Gov. Chris Christie. California was more successful, though: The state recently repealed its Maximum Family Grant rule, which barred individuals on welfare from receiving additional aid when they had more children.

It’s time for the national Democratic Party to do the same. For starters, the 2016 platform should include a specific provision calling for an end to family cap laws and forced paternity identification. If the Democratic Party is going to be the party of reproductive freedom—demonstrated by its call to repeal both the federal Hyde and Helms amendments—that must include women who receive welfare assistance. But the Democrats should go even further: They must embrace and advance a comprehensive overhaul of our welfare system, reinstating the federal guarantee of financial support. The state-based patchwork welfare system must be replaced with a federal welfare assistance program, one that provides educational incentives as well as a base living wage.

Even President Bill Clinton and presumptive Democratic presidential nominee Hillary Clinton both acknowledge that the original welfare reform bill had serious issues. Today, this bill and its discriminatory legacy remain a progressive thorn in the side of the Democratic Party—but it doesn’t have to be. It’s time for the party to admit that welfare reform was a failure, and a discriminatory one at that. It’s time to move from punishment and stigma to support and dignity for low-income single mothers and for all people living in poverty. It’s time to end TANF.