Analysis Health Systems

Research Shows Philadelphia Failing UN Maternal and Infant Health Goals

Tara Murtha

Philadelphia’s dire performance can be attributed to the collision of two major factors: widespread, profound poverty and a sharp reduction in the number of hospitals providing maternity care.

A new report reveals that, on average, pregnant women and newborns in Philadelphia fare worse than in the rest of the state and country.

Led by Professor William McCool of the University of Pennsylvania and published in the journal Midwifery, the study is an evidence-based progress report on the city’s follow-through of the United Nation’s eight Millennium Development Goals (MDGs), established in 2000. The study collected data between 1997 and 2011.

“Our manuscript was submitted as evidence that the United States was not only not approaching the MDGs with regards to women’s and newborns’ health, but was actually getting further away from those goals,” McCool told Rewire.

One of the main goals of the MDGs is to reduce maternal mortality in the United States by 75 percent between 1990 and 2015. But one year away from that deadline, the data shows that maternal deaths in the United States have actually increased over the last two decades—despite operating the costliest health-care system (in terms of health per capita) of all developed nations in the world, according to the report.

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The report shows that between 1997 and 2004, the maternal mortality rate in Philadelphia is 23.8 per 100,000 live births (compared to the U.S. average of 15.2 over the same period). The difference is starker between city and state, with Pennsylvania’s average at 9.01 per 100,000 live births.

Philadelphia’s dire performance can be attributed to the collision of widespread, profound poverty and a sharp reduction in the number of hospitals providing maternity care.

Philadelphia, where 28.4 percent of all residents live in poverty, also has the highest rate of deep poverty, defined as having an income below half the poverty line.

Meanwhile, the health-care system has made childbirth unprofitable for hospitals. As a result, prenatal care and delivery options have been steadily shrinking in Philadelphia for the last 15 years. In that time, approximately two-thirds of city hospitals that offered maternity care have closed their doors, citing inadequate insurance reimbursement, rising malpractice insurance premiums, and burdensome staffing requirements.

Between 1997 and 2011, the number of obstetric units in Philadelphia has decreased from 19 to six. The remaining units include Temple University, Thomas Jefferson University, Pennsylvania Hospital, Hahnemann University Hospital, Einstein Medical Center, and the Hospital of the University of Pennsylvania. The authors of the report explain these hospitals are able to offer obstetric care because they are also teaching centers that need to conduct childbirths for training purposes.

McCool notes that preterm birth rates in Philadelphia “were as much as 40 percent higher than Pennsylvania rates and 32 percent higher” than the national average. The result is a system in which a number of hospitals now rely on income earned from serving sick and premature babies in neo-natal intensive care units to turn a profit on maternity services, creating a vicious cycle in which poverty and lack of health care lead to high rates of pre-term births and create perverse financial incentives for a system that continuously fails to address the root causes of poor maternal and newborn health.

As with nationwide and state trends, maternal and infant mortality rates in Philadelphia vary, in some cases significantly, by race. The Midwifery article found that Black mothers were 2.7 times more likely to die than were white mothers in Philadelphia.

I think it has to do with the cumulative impact of racism and stress and poor nutrition,” said JoAnne Fischer, executive director of Maternity Care Coalition in Philadelphia.

McCool agrees that diet-related issues are significant and lead to obesity, diabetes, and high blood pressure. But, he says, violence—physical and otherwise—is also a significant factor in the socioeconomic and racial disparities of maternal outcomes.

“What goes under-reported is the amount of emotional stress that women face because of either emotional violence, or physical violence, or even the stress of being a minority in a society like ours,” McCool said. “These are all socio-political issues that we don’t address head on with pregnant women.”

Like their mothers, Black babies born in Philadelphia have a consistently higher risk of death than any other group. According to the report, “non-Hispanic Black infants are at a 2-3 times greater risk of dying in the first year than any other racial/ethnic group in the city.”

The racial disparity in accessing maternity care reflects both financial and geographic obstacles. Philadelphia, after all, is one of the most racially segregated cities in the country. Research from 2010 reveals that even “the average black household with an income over $60,000 lived in a neighborhood with a higher poverty rate than did the average white household earning less than $20,000.”

So, although the whittling of delivery options have led the remaining six hospitals to coordinate care in what’s been called an unlikely alliance, the fact remains that the six remaining maternity hospitals are clustered in or near downtown Philadelphia, or Center City as it is known—not one of the neighborhoods suffering from poverty. This clustering leaves entire regions of the city with no maternity wards. For example, there are no such wards in South or Northeast Philadelphia.

Many of McCool’s patients, some who live in homeless shelters, rely on public transportation. He says they often take two or three buses or train connections to get to his office. Because traveling takes time, it can cost patients who have to arrange childcare more money to get to an appointment. Navigating public transportation with small children in bad weather can make it nearly impossible to keep an appointment.

“You ask them, they’ll say, ‘I just didn’t have anyone to watch my kids, and [couldn’t] cart them on [public transportation],’ or ‘It was raining,’” he said. “Anecdotally, they actually make some healthy choices that [don’t] fit in with what the system thinks is healthy.”

Another problem with the shortage of delivery options is that pregnant women who rely on public transportation are at high risk for what McCool calls a “discontinuity of service” when they go into labor.

If they go into sudden labor and don’t have the time to take multiple buses, or go into labor in the middle of the night and call 9-1-1, pregnant patients will often wind up at a hospital they’ve never been to before. In Philadelphia, 9-1-1 is handled by the fire department. “If you’re pregnant, they’ll take you to the nearest hospital that does delivery,” said McCool, “which may not be where they got prenatal care.”

One of the consequences of this de facto patchwork system is that hospitals are reporting—anecdotally, as this information isn’t formally collected—a spike in what they call “near misses.” A near miss is a situation wherein emergency intervention saves a woman who nearly died from a complication, such as executing a life-saving cesarean section for a woman who had little or no prenatal care.

While a rise in “near misses” showcases emergency room savvy, it also underscores the fault lines of the health system in which unhealthy women who have unhealthy pregnancies and few or no other interactions with health care beyond these near-death experiences.

With so many complicated factors leading to the problem—the report doesn’t dig into health insurance—there are no easy answers. But the authors of the report point to evidence that midwifery services and community-based health-care options improve the health of pregnant women.

The closure of the 13 maternity wards since the 1990s included the shuttering of at least five midwifery services associated with the hospitals, according to the report.

The authors also note that improvement can only begin when political leaders begin to look at evidence rather than rhetoric. These leaders must realize, “despite claims to the contrary,” that “they may not have ‘the best healthcare delivery system in the world.”

Analysis Politics

Advocates: Bill to Address Gaps in Mental Health Care Would Do More Harm Than Good

Katie Klabusich

Advocates say that U.S. Rep. Tim Murphy's "Helping Families in Mental Health Crisis Act," purported to help address gaps in care, is regressive and strips rights away from those diagnosed with mental illness. This leaves those in the LGBTQ community—who already often have an adversarial relationship with the mental health sector—at particular risk.

The need for reform of the mental health-care system is well documented; those of us who have spent time trying to access often costly, out-of-reach treatment will attest to how time-consuming and expensive care can be—if you can get the necessary time off work to pursue that care. Advocates say, however, that U.S. Rep. Tim Murphy’s (R-PA) “Helping Families in Mental Health Crisis Act” (HR 2646), purported to help address gaps in care, is not the answer. Instead, they say, it is regressive and strips rights away from those diagnosed with mental illness. This leaves those in the LGBTQ community—who already often have an adversarial relationship with the mental health sector—at particular risk.

“We believe that this legislation will result in outdated, biased, and inappropriate treatment of people with a mental health diagnosis,” wrote the political action committee Leadership Conference on Civil and Human Rights in a March letter to House Committee on Energy and Commerce Chairman Rep. Fred Upton (R-MI) and ranking member Rep. Frank Pallone (D-NJ) on behalf of more than 100 social justice organizations. “The current formulation of H.R. 2646 will function to eliminate basic civil and human rights protections for those with mental illness.”

Despite the pushback, Murphy continues to draw on the bill’s mental health industry support; groups like the American Psychiatric Association (APA) and the National Alliance on Mental Illness (NAMI) back the bill.

Murphy and Rep. Eddie Bernice Johnson (D-TX) reintroduced HR 2646 earlier this month, continuing to call it “groundbreaking” legislation that “breaks down federal barriers to care, clarifies privacy standards for families and caregivers; reforms outdated programs; expands parity accountability; and invests in services for the most difficult to treat cases while driving evidence-based care.”

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Some of the stated goals of HR 2646 are important: Yes, more inpatient care beds are needed; yes, smoother transitions from inpatient to outpatient care would help many; yes, prisons house too many people with mental illness. However, many of its objectives, such as “alternatives to institutionalization” potentially allow outpatient care to be mandated by judges with no medical training and pushed for by “concerned” family members. Even the “focus on suicide prevention” can lead to forced hospitalization and disempowerment of the person the system or family member is supposedly trying to help.

All in all, advocates say, HR 2646—which passed out of committee earlier this month—marks a danger to the autonomy of those with mental illness.

Victoria M. Rodríguez-Roldán, JD, director of the Trans/GNC Justice Project at the National LGBTQ Task Force, explained that the bill would usurp the Health Insurance Portability and Accountability Act (HIPAA), “making it easier for a mental health provider to give information about diagnosis and treatment … to any ‘caregiver’-family members, partners or spouses, children that may be caring for the person, and so forth.”

For the communities she serves, this is more than just a privacy violation: It could put clients at risk if family members use their diagnosis or treatment against them.

“When we consider the stigma around mental illness from an LGBT perspective, an intersectional perspective, 57 percent of trans people have experienced significant family rejection [and] 19 percent have experienced domestic violence as a result of their being trans,” said Rodríguez-Roldán, citing the National Transgender Discrimination Survey. “We can see here how the idea of ‘Let’s give access to the poor loved ones who want to help!’ is not that great an idea.”

“It’s really about taking away voice and choice and agency from people, which is a trend that’s very disturbing to me,” said Leah Harris, an organizer with the Campaign For Real Change in Mental Health Policy, also known as Real MH Change. “Mostly [H.R. 2646] is driven by families of these people, not the people themselves. It’s pitting families against people who are living this. There are a fair number of these family members that are well-meaning, but they’re pushing this very authoritarian [policy].”

Rodríguez-Roldán also pointed out that if a patient’s gender identity or sexual orientation is a contributing factor to their depression or suicide risk—because of discrimination, direct targeting, or fear of bigoted family, friends, or coworkers—then that identity or orientation would be pertinent to their diagnosis and possible need for treatment. Though Murphy’s office claims that psychotherapy notes are excluded from the increased access caregivers would be given under HR 2646, Rodríguez-Roldán isn’t buying it; she fears individuals could be inadvertently outed to their caregivers.

Rodríguez-Roldán echoed concern that while disability advocacy organizations largely oppose the bill, groups that represent either medical institutions or families of those with mental illnesses, or medical institutions—such as NAMI, Mental Health America, and the APA—seem to be driving this legislation.

“In disability rights, if the doc starts about talking about the plight and families of the people of the disabilities, it’s not going to go over well,” she said. “That’s basically what [HR 2646] does.”

Rodríguez-Roldán’s concerns extend beyond the potential harm of allowing families and caregivers easier access to individuals’ sensitive medical information; she also points out that the act itself is rooted in stigma. Rep. Murphy created the Helping Families in Mental Health Crisis Act in response to the Sandy Hook school shooting in 2012. Despite being a clinical psychologist for 30 years before joining Congress and being co-chair of the Mental Health Caucus, he continues to perpetuate the well-debunked myth that people with mental illness are violent. In fact, according to the Department of Health and Human Services, “only 3%-5% of violent acts can be attributed to individuals living with a serious mental illness” and “people with severe mental illnesses are over 10 times more likely to be victims of violent crime than the general population.”

The act “is trying to prevent gun violence by ignoring gun control and going after the the rights of mentally ill people,” Rodríguez-Roldán noted.

In addition, advocates note, HR 2646 would make it easier to access assisted outpatient treatment, but would also give courts around the country the authority to mandate specific medications and treatments. In states where the courts already have that authority, Rodríguez-Roldán says, people of color are disproportionately mandated into treatment. When she has tried to point out these statistics to Murphy and his staff, she says, she has been shut down, being told that the disparity is due to a disproportionate number of people of color living in poverty.

Harris also expressed frustration at the hostility she and others have received attempting to take the lived experiences of those who would be affected by the bill to Murphy and his staff.

“I’ve talked to thousands of families … he’s actively opposed to talking to us,” she said. “Everyone has tried to engage with [Murphy and his staff]. I had one of the staffers in the room say, ‘You must have been misdiagnosed.’ I couldn’t have been that way,” meaning mentally ill. “It’s an ongoing struggle to maintain our mental and physical health, but they think we can’t get well.”

Multiple attempts to reach Murphy’s office by Rewire were unsuccessful.

LGBTQ people—transgender, nonbinary, and genderqueer people especially—are particularly susceptible to mistreatment in an institutional setting, where even the thoughts and experiences of patients with significant privilege are typically viewed with skepticism and disbelief. They’re also more likely to experience circumstances that already come with required hospitalization. This, as Rodríguez-Roldán explained, makes it even more vital that individuals not be made more susceptible to unnecessary treatment programs at the hands of judges or relatives with limited or no medical backgrounds.
Forty-one percent of all trans people have attempted suicide at some point in their lives,” said Rodríguez-Roldán. “Once you have attempted suicide—assuming you’re caught—standard procedure is you’ll end up in the hospital for five days [or] a week [on] average.”

In turn, that leaves people open to potential abuse. Rodríguez-Roldán said there isn’t much data yet on exactly how mistreated transgender people are specific to psychiatry, but considering the discrimination and mistreatment in health care in general, it’s safe to assume mental health care would be additionally hostile. A full 50 percent of transgender people report having to teach their physicians about transgender care and 19 percent were refused care—a statistic that spikes even higher for transgender people of color.

“What happens to the people who are already being mistreated, who are already being misgendered, harassed, retraumatized? After you’ve had a suicide attempt, let’s treat you like garbage even more than we treat most people,” said Rodríguez-Roldán, pointing out that with HR 2646, “there would be even less legal recourse” for those who wanted to shape their own treatment. “Those who face abusive families, who don’t have support and so on—more likely when you’re queer—are going to face a heightened risk of losing their privacy.”

Or, for example, individuals may face the conflation of transgender or gender-nonconforming status with mental illness. Rodríguez-Roldán has experienced the conflation herself.

“I had one psychiatrist in Arlington insist, ‘You’re not bipolar; it’s just that you have unresolved issues from your transition,'” she said.

While her abusive household and other life factors certainly added to her depression—the first symptom people with Bipolar II typically suffer from—Rodríguez-Roldán knew she was transgender at age 15 and began the process of transitioning at age 17. Bipolar disorder, meanwhile, is most often diagnosed in a person’s early 20s, making the conflation rather obvious. She acknowledges the privilege of having good insurance and not being low-income, which meant she could choose a different doctor.

“It was also in an outpatient setting, so I was able to nod along, pay the copay, get out of there and never come back,” she said. “It was not inside a hospital where they can use that as an excuse to keep me.”

The fear of having freedom and other rights stripped away came up repeatedly in a Twitter chat last month led by the Task Force to spread the word about HR 2646. More than 350 people participated, sharing their experiences and asking people to oppose Murphy’s bill.

In the meantime, Sen. Lamar Alexander (R-TN) has introduced the “Mental Health Reform Act of 2016” (SB 2680) which some supporters of HR 2646 are calling a companion bill. It has yet to be voted on.

Alexander’s bill has more real reform embedded in its language, shifting the focus from empowering families and medical personnel to funding prevention and community-based support services and programs. The U.S. Secretary of Health and Human Services would be tasked with evaluating existing programs for their effectiveness in handling co-current disorders (e.g., substance abuse and mental illness); reducing homelessness and incarceration of people with substance abuse and/or mental disorders; and providing recommendations on improving current community-based care.

Harris, with Real MH Change, considers Alexander’s bill an imperfect improvement over the Murphy legislation.

“Both of [the bills] have far too much emphasis on rolling back the clock, promoting institutionalization, and not enough of a preventive approach or a trauma-informed approach,” Harris said. “What they share in common is this trope of ‘comprehensive mental health reform.’ Of course the system is completely messed up. Comprehensive reform is needed, but for those of us who have lived through it, it’s not just ‘any change is good.'”

Harris and Rodríguez-Roldán both acknowledged that many of the HR 2646 co-sponsors and supporters in Congress have good intentions; those legislators are trusting Murphy’s professional background and are eager to make some kind of change. In doing so, the voices of those who are affected by the laws—those asking for more funding toward community-based and patient-centric care—are being sidelined.

“What is driving the change is going to influence what the change looks like. Right now, change is driven by fear and paternalism,” said Harris. “It’s not change at any cost.”

Analysis Politics

Conservative Attacks on Voting and Abortion Rights Share Tactics, Goals

Ally Boguhn

The pushes for voting and abortion restrictions use similar tactics, slowly eroding the rights of women, people of color, and those with low incomes in particular.

During a May interview with the Texas Observer‘s Alexa Garcia-Ditta, Planned Parenthood President Cecile Richards didn’t skip a beat when pointing to the likely effect of voting restrictions.

“One of the greatest challenges, absolutely, in the state of Texas is the enormous hurdles that people have to go through to vote, and the fact that in the last election, we were 50th in voter turnout of 50 states,” said Richards. “That’s appalling. When 28 percent of the voters go to the polls, the democratic process isn’t working, it’s completely broken. I believe we have to completely address voting rights in this country, and in Texas.”

Texas is one of 17 states to implement new voting restrictions, such as voter identification laws and reduced early voting, for the first time during the 2016 presidential election, according to the Brennan Center for Justice, a nonpartisan law and policy institute at New York University’s School of Law. Those states include Alabama, Arizona, Georgia, Indiana, Kansas, Mississippi, Nebraska, New Hampshire, North Carolina, North Dakota, Ohio, Rhode Island, South Carolina, Tennessee, Virginia, and Wisconsin.

Voting and Abortion Restrictions

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“This is part of a broader movement to curtail voting rights, which began after the 2010 election, when state lawmakers nationwide started introducing hundreds of harsh measures making it harder to vote,” explains the Brennan Center’s website. “Overall, 22 states have new restrictions in effect since the 2010 midterm election.”

The Republican-led charge to roll back voting rights has been fairly transparent in its goal of suppressing Democratic votes, specifically targeting voters of color and those living in poverty—a goal only made easier after the Supreme Court gutted parts of the Voting Rights Act (VRA) that safeguarded against these strategies in a 2013 decision.

In April, Rep. Glenn Grothman (R-WI) told a local news network that his state’s new voter ID law would make “a difference” in electing members of his party in November. And he is hardly the first Republican to admit that the party is utilizing this strategy in order to gain power.

Efforts to enact voting restrictions have begun to gain steam, increasingly in many of the same places where abortion restrictions are also being passed. And reproductive rights and justice advocates are taking notice. NARAL Pro-Choice America in 2012 noted that efforts to chip away at voting rights effectively silence the ability of many to weigh in on decisions regarding their bodies.

“Americans defend the right to choose by lobbying their elected officials, taking action in their communities, and participating in the public debate, but no single deed is as central to the civic process as the simple act of casting a vote,” Nancy Keenan, then president of NARAL, said in a statement announcing the decision. “That is why recent efforts to restrict citizens’ access to the ballot box are so dangerous. These measures threaten to deny millions of Americans the right to vote, silencing their voices as the nation debates our most cherished freedoms, including the right of every woman to make personal decisions regarding the full range of reproductive choices.”

Ilyse Hogue, NARAL’s current president, reaffirmed this commitment after the Supreme Court’s 2013 decision on the VRA, explaining in a statement that year that the organization believes “that participation in the political process is a constitutional right that empowers Americans to elect leaders who represent their interests in important areas such as reproductive rights.”

When thousands joined the Moral March in Raleigh, North Carolina in February 2014 to protest conservative policies such as the state’s restrictive voter suppression laws, Planned Parenthood was among the event’s 150 coalition partners. In a piece for the Huffington Post, Richards explained why it was imperative for her organization to get involved.

“For Planned Parenthood, the ideology behind these measures is all too familiar. They were put in place by politicians who would rather transport us through a time warp where only the privileged few have access to fundamental American rights,” wrote Richards. “Many of those states [passing voting restrictions] are the same ones passing restriction after restriction on women’s access to health care.”

“The history of our country shows that we are better off when everyone has a voice in our political process. We continue to stand with our partners in calling for laws that make it easier—not harder—to vote,” Richards continued.

As the aftermath of the 2010 midterm elections brought a wave of voting restrictions, a crush of anti-choice laws similarly swept the country. Since those elections, an unprecedented 288 state-level abortion restrictions have been enacted.

“To put that number in context, states adopted nearly as many abortion restrictions during the last five years (288 enacted 2011-2015) as during the entire previous 15 years (292 enacted 1995-2010),” Guttmacher researchers explained in a recent report outlining the state of reproductive rights in the country.

The pushes for voting and abortion restrictions use similar tactics, slowly eroding the rights of women, people of color, and those with low incomes. “It’s a ‘death by 1000 cuts’ strategy,” Heather Gerken, a professor at Yale Law School, told MSNBC of the two issues in 2014. “For both of these rights, you’re not allowed to ban it. So in each instance you’re just making it harder than it would be otherwise.”

Conservatives have been able to do this by leveraging misinformation about the two issues. Abortion and voting restrictions “both address manufactured problems,” Sondra Goldschein, director of advocacy and policy at the American Civil Liberties Union (ACLU), told Rewire. “They have thinly veiled excuses for introducing them. Whether it’s unproven voter fraud or concerns about women, the legislation is clearly about taking away rights, particularly in marginalized communities.”

For example, many voting restrictions are implemented based on false claims about the prevalence of voting fraud. In Wisconsin, where as many as 300,000 registered voters stand to be disenfranchised by the state’s restrictive voter ID law, Republican Gov. Scott Walker justified suppressing the vote by citing instances of fraudulent voting. When challenged in court, the state was unable to come up with a single case of voter impersonation.

That is likely because in Wisconsin, like in the rest of the country, voter fraud is virtually nonexistent. Study after study has found little to no evidence to support the claim. An analysis conducted by the Washington Post‘s Justin Levitt in 2014 found just 31 instances of voter fraud in the more than one billion ballots cast between the years 2000 and 2014.

Many abortion restrictions are similarly based on the perpetuation of misinformation, which are often based on conservatives feigning concern for women’s health. Wisconsin provides yet another prime example of this with its 2013 targeted regulation of abortion providers (TRAP) law, which required all doctors performing abortions in the state to obtain admitting privileges to hospitals within a 30-mile range, justified by claims of safeguarding women’s health. But when the Seventh U.S. Circuit Court of Appeals ruled the law unconstitutional in 2015, Judge Richard Posner, writing for the majority, noted that the medical necessity for such laws is “nonexistent” and the regulations were instead meant to impede abortion access.

“They may do this in the name of protecting the health of women who have abortions, yet as in this case the specific measures they support may do little or nothing for health, but rather strew impediments to abortion,” wrote Posner.

Though it’s often clear that legislation to restrict access to the polls and abortion share similar goals and tactics—employing misinformation, attempting to dissuade people from access by making doing so too expensive or burdensome, and so on—in some cases, states are borrowing from the exact same playbooks to make laws to get their way. In Texas, where there is already a strict voter ID law, the state passed another law in 2015 requiring abortion providers to ask for “valid government record of identification” from patients to prove they are 18 before providing care. The process of obtaining a valid form of ID is often difficult, time-consuming, and expensive, especially for those in marginalized communities.

Much like the case for voting restrictions, abortion restrictions help white men maintain the status quo of power across the country. Drawing connections between between voting restrictions and TRAP laws in Texas, then-Rewire reporter Andrea Grimes, who now works for the Texas Observer, noted on the RJ Court Watch podcast that both conservative restrictions help ensure those in power maintain their positions.

“We [in Texas] have some of the strictest TRAP (targeted restrictions on abortion providers) legislation in the country. At the same time we have what one federal judge straight up called racist and unconstitutional voter ID requirements that prevent people from being able to get out to the polls and cast their votes,” said Grimes. “And these two things together kind of ensure that power stays with the powerful. That’s what we’re seeing right now here.”

“[B]oth voting rights and abortion access involve fundamental rights,” added Jessica Mason Pieklo, Rewire‘s vice president of law and the courts. “In theory, fundamental rights are fundamental. They are things that we all hold but really what we’re talking about is access to power. So when we place restrictions on those rights, we make it harder to exercise them—which makes it harder to effectively engage our civic power.”

When framed as a desperate attempt by the GOP to maintain a hold on their power dynamics, it comes as no surprise that many of the very same states pushing through voting restrictions are also moving to restrict abortion access. During 2015 alone, 57 abortion restrictions were enacted across the country. Of the massive push to restrict abortion since 2010, ten states enacted more than ten restrictions: Arizona, North Dakota, South Dakota, Kansas, Oklahoma, Texas, Arkansas, Indiana, Alabama, and North Carolina.

These lists have remarkable crossover with the states that have enacted new voting restrictions in that same period of time: Alabama, Arizona, Florida, Georgia, Illinois, Indiana, Iowa, Kansas, Mississippi, Nebraska, New Hampshire, North Carolina, North Dakota, Ohio, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Virginia, West Virginia, and Wisconsin.

The end result for both kinds of restrictions is the same: a massive sweep of nationwide changes chipping away at the fundamental rights of Americans and disproportionately affecting women, communities of color, and those living in poverty.
Those pushing through these laws “are not just focusing on one state, but they are looking at creating change across the whole country, through each individual state-by-state attack on these fundamental freedoms,” explained Goldschein.

Goldschein went on to note that conservatives’ success in pushing these restrictions demonstrates the importance of voting, especially for down-ballot seats in the state legislature where many of these decisions are made. “State legislatures are ground zero in the fight for civil liberties, and they do not always attract as much attention as the debates in Congress or arguments in the Supreme Court, but in fact they are really the source of unprecedented assaults on our most fundamental rights,” she explained.

“This year … 80 percent of our state legislature seats are up for re-election, and we need voters to be paying attention to what is happening in those state legislatures and then to hold politicians accountable and vote as if their liberties depend on it—because they do—because this is where these fights are taking place.”