Bending Toward Health Justice

By Amy Allina, NWHN Policy Director

"The arc of history is long, but it bends toward justice.” – Martin Luther King, Jr.

Martin Luther King, Jr., has been on my mind a lot as I’ve reflected on the women’s health victories and losses in the new health reform law. King was an advocate for health care reform – in 1966, he famously named injustice in health care as the most shocking and inhumane form of inequality in society.  And in the 44 years since he made that assessment, the United States has done shamefully little to address this inhumanity.

Despite clear evidence that access to health care in the United States was getting worse every year, and despite the warning sounded by health experts that the country was falling behind the rest of the developed world in health outcomes, we failed again and again to muster the political will to make health care available to everyone in this country. Anne Kasper, a founding member of the National Women’s Health Network board, came to Washington, D.C. in 1970 to work for the Committee for National Health Insurance, a labor-led advocacy campaign for health reform.  But that campaign ended without success, and Kasper went on to work on several similar efforts during the four decades that followed, including as leader of the Campaign for Women’s Health during the years of the Clinton reform initiative.  What sustained her through those disappointments, she says, was a steadfast belief that “the people of this country were capable of making important change.“

This long period of repeated failures is what Dr. King was talking about when he said that the arc of history is long. But, as King forecast, we saw that arc bend toward justice when President Barack Obama signed the Patient Affordable Care Act into law on March 23, 2010.

The new law doesn’t do everything we hoped it would (see our Women’s Vision for Quality, Affordable Health Care for All at www.raisingwomensvoices.net/storage/pdf_files/RWV-Principles-4.07.08.pdf for a description of the kind of reform we set as our goal). It includes restrictions on access to abortion care and care for immigrants that will cause definite harm to people’s health and wellbeing. At the same time, however, it is a major victory that will make a real and significant difference in the lives of millions of women, our families, and our communities.  By now, you’ve probably read many recaps of the changes the new law will make, and we don’t have space to spell out all the improvements here, but we do want to share with you the NWHN’s take on how health care reform will affect women’s health.

A historic advance for women

There’s a huge gain from the Medicaid expansion: 16 million women will be newly eligible for Medicaid in the next nine years. And it will be easier for states to provide Medicaid coverage for family planning care to even more women because states are no longer required to go through the time-consuming, costly waiver process that had been required before now. Medicaid-eligible women will get comprehensive reproductive health services (though not abortion, except in the 15-17 states where state funds support it), and free-standing birth centers will be eligible for Medicaid reimbursement as well, giving low-income women a wider range of choices in childbirth.

Under the new insurance exchanges that will start in 2014, maternity care coverage will be required. Many women insured by individual and small group policies haven’t been able to get maternity coverage, so this is a big advance that is expected to affect about 4.8 million women. Additionally, insurers in the exchanges will be required to contract with essential community providers like community health centers, HIV/AIDS clinics, and family planning centers. This will make it possible for women to get care in their own communities if they want to, and to have that care covered by insurance.

By 2011, all women who have insurance under a new policy – whether they get insurance through the exchange or some other way – will be covered for women’s preventive health and screening services without cost-sharing: no copays, and no charges against the deductible. Senator Barbara Mikulski (D-MD), who added this women’s health provision to the bill, has said it is intended to ensure women can get the preventive health care we need to stay healthy —  including contraceptive services and supplies and screening for cervical cancer and sexually transmitted infections -- without insurers imposing financial obstacles that discourage women from seeking care. Prenatal care will likely be covered this way as well.

Families will be able to keep children on their parents’ insurance policies through their 26th birthdays. This will help increase insurance coverage among young people, who often start work lives in jobs that neither offer health insurance nor pay enough to make individual health insurance policies affordable.

Finally, the bill allocates new money for important women’s health programs:

• $75 million per year over five years for evidence-based, age-appropriate and medically accurate programs that educate adolescents about preventing pregnancy and sexually transmitted infections. The money will be distributed in grants to states but if a state doesn’t participate, after two years its funds will revert to local entities providing these services..
• $1.5 billion over five years for home visitation programs designed to improve prenatal, maternal, and newborn health, including pregnancy outcomes.
• $11.5 billion for community health centers that are required to provide family planning services and other basic reproductive health care.
• $50 million per year for school-based health centers, which often provide contraceptive care to students in need.
• A new program at the Centers for Disease Control and Prevention (CDC) to fund community health workers in medically underserved communities through a model very similar to that used by promotoras who have worked throughout Latin America for decades and have been active, more recently, in U.S. communities with large immigrant populations.

A huge victory, at a great cost

On the negative side of the ledger, Congress wasn’t able to pass a health reform bill that treats abortion the same way as women’s other basic health care needs. The new law continues and extends unjust restrictions that prevent health programs from using Federal tax dollars to pay for abortion care except in cases of rape, incest, or threat to the life of the woman. This restriction has long affected Medicaid beneficiaries, Federal employees, women in the military and Peace Corps, and women who receive care through Indian Health Services. Now, women getting health insurance through the new exchanges will also be cut off from needed medical services by these restrictions and the threat they pose to our health and the health of our families.

States can prohibit abortion coverage entirely in the new exchanges, and some have already initiated legislation to do that. In states that don’t, anyone in the exchange who wants abortion coverage will have to make two insurance payments: one for abortion coverage and one for everything else. Insurers are required to segregate Federal funds from private payments used to pay for abortion services. Experts predict these burdensome requirements could lead insurance companies to drop abortion coverage rather than develop the complicated systems necessary to comply with the law.

The law also includes a one-sided “conscience clause” that requires health insurers to protect providers who refuse to provide or refer for abortions but doesn’t protect those who do. And there is $50 million in annual funding to continue the dangerous, ineffective abstinence-only-until-marriage sex education program for five more years.

As if that weren’t bad enough, some people won’t see improvements in any aspect of their health care. Many immigrants will continue to be denied access to health care despite the new law.   Legal immigrants will still have to wait five years to become eligible for Medicaid unless they live in a state that provides coverage, as some do, especially for pregnant women and children. And undocumented immigrants, including women of reproductive health age, are excluded entirely. They are not eligible for Medicaid or Federal subsidies to help them buy insurance and are even prohibited from using their own money to buy health insurance through the exchanges.

Making health justice a reality

Last fall, NWHN’s Executive Director Cindy Pearson wrote in this newsletter about the ways that passing health care reform was like giving birth. That comparison is still revealing. The first weeks and months after a baby is born is when new parents are first able to focus on the fact that they’ve got a child to raise! Implementing this new law is going to take just as much hard work and careful attention as passing the legislation did. Over the next two to four years, we’re going to monitor and partner with officials in the states and at the Department of Health & Human Services as they put the new regulations and structures in place for health reform. We’re also going to be working hard to change the political climate for abortion funding and get rid of restrictions preventing Federal health programs from paying for abortion care. And we’ll partner with our allies in the immigrant rights community to extend health access to everyone living in the United States.  The NWHN will keep you posted about changes as they come, and we’ll be looking to you for help in holding state and Federal officials accountable for delivering on the promise of the new law and working to fix the problems that remain.

As Kasper and King and thousands of others who worked over so many years to make health reform happen have told us, health justice won’t come fast or easy, but we can make it a reality.