Women Can’t Win: Ongoing Offensives against Maternal and Reproductive Health

By Miranda Waggoner, author of The Zero Trimester: Pre-Pregnancy Care and the Politics of Reproductive Risk

In late July of this year, the Republican-led Senate’s attempt to repeal Obamacare failed rather dramatically, punctuated by John McCain’s widely discussed—and widely viewed—thumbs-down vote. More recently, another Republican-led attempt at repeal, known as the Graham-Cassidy proposal, again disintegrated due to lack of support from several key GOP senators. For at least the foreseeable future, the spirit of President Obama’s Affordable Care Act seems here to stay, but this development does not mean that women and mothers in America are safeguarded from having key components of their health care—or dignity—stripped away.

For some time now, opponents of Obamacare have vehemently targeted family planning services, as witnessed by the Trump administration’s recent expansion of religious exemptions for contraceptive coverage. But, at the same time, GOP lawmakers have also argued that maternity care services are not “essential.” This two-pronged hostility—pointedly disregarding both maternity care and general reproductive health care—is somewhat curious because maternity care has characteristically been considered politically “safe,” while reproductive care—in its association with contraception and abortion—has been deemed politically “toxic.” I trace the trajectory of these two reproductive silos in my book, The Zero Trimester. I show how health-care professionals have sought to expand the time period of a healthy pregnancy from the typical nine months to twelve months, by creating a “zero trimester” period during which women are defined as “pre-pregnant.” In doing so, non-pregnant women’s health care is defined in terms of maternity care. The rise of the “zero trimester” was in part predicated on the assumption that policy makers care about mothers and babies—that they are in the “safe” zone. Yet, in a political environment that does not value maternity care or reproductive care, such an approach seems destined to fail.

This approach is also unfair to women. The thrust of “zero trimester” initiatives promoted by health professionals and government agencies has been public-service announcements and health campaigns aimed at alerting individual women who are of reproductive age that they inhabit a perpetual zero trimester, and must act “responsibly.” One of the most controversial of these messages was the 2016 announcement by the CDC that all women of reproductive age not using birth control should avoid alcohol.

How can we best navigate a political climate that is hostile to maternity care but that simultaneously tends to define women by their maternal capacity? Taking away women’s health care services is obviously not a step in the right direction, but neither are individual-level recommendations to women that make them feel guilty about their everyday behaviors. Comprehensive health care coverage for all potential reproducers—both women and men—across their life course is one important piece of the solution to improve health, especially maternal and child health, in America. Policies that enhance population health, such as paid parental leave or reducing toxic pollution, would also spur vast and positive change in maternal and child health in particular. The stakes are high: women in the U.S. continue to die of birth-related complications at a much higher rate than do women in other rich nations, and babies in the U.S. are more likely to die in their first year than in comparable countries.

If we cease working toward social policies that value the health of all citizens—of women and men, of mothers and fathers, and of babies and children—the most fitting image for the state of health care in this country will continue to be a thumbs-down.


Miranda R. Waggoner is Assistant Professor of Sociology at Florida State University. Her research has been supported by the National Institutes of Health and the National Science Foundation.


Trump’s Transgender Crisis

By Jack Halberstam, author of the forthcoming Trans*: A Quick and Quirky Account of Gender Variability

This guest post is part of a blog series of contributions by authors in American Studies Now, an e-book first series of short, timely books on significant political and cultural events.


At a time when the visibility and acceptance of transgender people has never been higher, when high school students openly discuss issues of gender variance and businesses boycott states without transgender bathroom policies, President Trump tweeted his intention to ban transgender people from the military. Perhaps, President Trump decided that he needed to make this bold move to win back conservative backers. No doubt even devout Trump supporters in the USA might be eyeing Trump’s health care policies with bewilderment right now and wondering why they are in bed with a one-percenter with strong ties to Russia and little interest in US businesses. For those supporters, Trump offered an olive branch yesterday—by proposing to ban transgender people from the military, he happily sacrificed a gender ambiguous lamb to the mercurial gods of conservative family values.

Trump’s pro-LGBT stance was only the latest campaign posture to find its way to the trash heap of broken promises. While fending off charges of collusion with Russia, treason, rigged elections, and incompetence, Trump has found an issue to rally his right wing fringe supporters while confusing and enraging his many detractors. In the wake of his announcement, many transgender people fired back on twitter to remind Trump and his cronies that they do not want to serve in the military anyway. Others, service members who have been honored in combat, emphasized their intention to stay right where they are, ban or no ban. America’s most famous transgender soldier, Chelsea Manning, accused Trump of cowardice and of creating a distraction with his announcement, but she also suggested that the US military had an inflated and bloated budget anyway, which should be redirected to health care. Hear, hear!

Trump’s tweeted policy change exemplifies how confused conservatives are about transgender issues. While running for office, Trump clearly stated his intentions to protect LGBT communities and to defend the rights of transgender people to use whatever bathroom they deem appropriate and, one assumes, to serve in the military. So, why this ban, why now? Is it related to the health care bill that President Trump has been trying unsuccessfully to put in place—a bill that will dispossess hundreds of thousands of people of their current health care policies? Is it part of an economic retrenchment, an attempt to cut away all unnecessary spending? Trump himself gave an economic rationale for his decision saying that the military spends millions on transgender surgeries. This is nonsense, as many journalists and researchers have pointed out—sex reassignment surgeries are a miniscule part of any military budget and in fact, as the BBC reports: “the US military spends almost $42m a year on the erectile dysfunction medication Viagra—several times the total estimated cost of transgender medical support.” By comparison, the Rand corporation estimates that expenses related to transgender soldiers fall between $5-8 million annually.

There are a few lessons to be learned from Trump’s quick turn away from his clearly stated promises to support transgender people—first, transgender issues have tended to be a safe bet for securing conservative votes. Trump may have overestimated the extent to which this is still true. Second, transgender issues continue to hold a fascination and allure that distracts people from the actual issues under discussion. Finally, transgender people are more integrated into society than ever before in history and the tide towards acceptance is unlikely to be turned back by big, dumb moves like this one. Rather than simply fight for the right for transgender people to serve in the military however, we should seize upon this issue, as Chelsea Manning did, to ask why the military has such a bloated budget in the first place and how these funds can be redirected? We should also push back in similar ways and with equal force on Trump’s attempts to: dispossess people of access to basic health care, amp up security forces and deportations, and to downsize education.

This latest measure neither reflects the current climate on transgender people in or out of the military and has no obvious purpose other than to distract from his total lack of a foreign policy, his disdain for the health of the environment, and his total inability to govern. Transgender people, many of whom have served their country selflessly, which is more than Trump and most of his cabinet can claim, will survive this latest indignity and may well see this ban overturned sooner rather than later once Trump realizes he has lost the crowd’s attention and support and has instead inspired their wrath, their pity and finally, their indifference.


Jack Halberstam is Professor of English and Gender Studies at Columbia University.

His forthcoming book Trans*: A Quick and Quirky Account of Gender Variability explores recent shifts in the meaning of the gendered body and representation, and the possibilities of a nongendered, gender-optional, or gender-queer future. Part of the American Studies Now series, Trans* will be available as an e-book first this September, months before the print edition publishes.


Health Care in the United States: How did we get here? What’s at stake?

The insurance—and lives—of millions of Americans hangs in the balance. With the final Senate health care vote looming, we’re turning to the following UC Press authors to help make sense of the current state of health care in the United States.

How All Politics Became Reproductive Politics:
From Welfare Reform to Foreclosure to Trump
by Laura Briggs

Today all politics are reproductive politics, argues esteemed feminist critic Laura Briggs. From longer work hours to the election of Donald Trump, our current political crisis is above all about reproduction. Households are where we face our economic realities as social safety nets get cut and wages decline. Briggs brilliantly outlines how politicians’ racist accounts of reproduction—stories of Black “welfare queens” and Latina “breeding machines”—were the leading wedge in the government and business disinvestment in families. With decreasing wages, rising McJobs, and no resources for family care, our households have grown ever more precarious over the past forty years in sharply race-and class-stratified ways. This crisis, argues Briggs, fuels all others—from immigration to gay marriage, anti-feminism to the rise of the Tea Party.


Uninsured in America:
Life and Death in the Land of Opportunity
by Susan Sered and Rushika Fernandopulle

Uninsured in America goes to the heart of why more than forty million Americans are falling through the cracks in the health care system, and what it means for society as a whole when so many people suffer the consequences of inadequate medical care. Based on interviews with 120 uninsured men and women and dozens of medical providers, policymakers, and advocates from around the nation, this book takes a fresh look at one of the most important social issues facing the United States today.


One Nation under AARP:
The Fight over Medicare, Social Security, and America’s Future
by Frederick Lynch

A fresh and even-handed account of the newly modernized AARP (formerly the American Association of Retired Persons)—the 40-million member insurance giant and political lobby that continues to set the national agenda for Medicare and Social Security. Frederick R. Lynch addresses AARP’s courtship of 78 million aging baby boomers and the possibility of harnessing what may be the largest ever senior voting bloc to defend threatened cutbacks to Social Security, Medicare, and under-funded pension systems. Lynch argues that an ideologically divided boomer generation must decide whether to resist entitlement reductions through its own political mobilization or, by default, to empower AARP as it tries to shed its “greedy geezer” stereotype with an increasingly post-boomer agenda for multigenerational equity.


Jailcare
Finding the Safety Net for Women behind Bars
by Carolyn Sufrin

Thousands of pregnant women pass through our nation’s jails every year. What happens to them as they carry their pregnancies in a space of punishment? In this time when the public safety net is frayed, incarceration has become a central and racialized strategy for managing the poor. Using her ethnographic fieldwork and clinical work as an ob-gyn in a women’s jail, Carolyn Sufrin explores how jail has, paradoxically, become a place where women can find care. Focusing on the experiences of incarcerated pregnant women as well as on the practices of the jail guards and health providers who care for them, Jailcare describes the contradictory ways that care and maternal identity emerge within a punitive space presumed to be devoid of care.


Blind Spot
How Neoliberalism Infiltrated Global Health
by Salmaan Keshavjee & Paul Farmer

Neoliberalism has been the defining paradigm in global health since the latter part of the twentieth century. What started as an untested and unproven theory that the creation of unfettered markets would give rise to political democracy led to policies that promoted the belief that private markets were the optimal agents for the distribution of social goods, including health care.

Provocative, rigorous, and accessible, Blind Spot offers a cautionary tale about the forces driving decision making in health and development policy today, illustrating how the privatization of health care can have catastrophic outcomes for some of the world’s most vulnerable populations.


Repeal and Replace is a Women’s Issue

By Susan Starr Sered, co-author of Uninsured in America and Can’t Catch a Break

In recognition of Women’s History Month, this post is republished with permission from the author. #RepealAndReplace #WomensHistoryMonth

The Republican plan to eliminate or change substantial portions of the Affordable Care Act is likely to have a disproportionately deleterious impact on women. This is why.

Women compared to men use more medical services and spend more on health care. Thus, any reduction in government support for health care will affect women more than men.

Women make more visits each year to primary care physicians than do men and are more likely than men to take at least one prescription drug on a daily basis.  According to the Health Care Cost Institute, “In 2015, spending was $5,684 per woman and $4,581 per man. …  From 2012 to 2015, the difference in spending between genders rose from $1,071 per capita to $1,103 per capita.  Per capita spending for women was higher than for men on every type of service, except brand prescriptions.”

Given women’s higher healthcare needs, the ACA protected women by requiring all plans to meet a minimum level of coverage that includes a basic basket of necessary services. The Trump administration has announced that they will reduce the price of premiums so that Americans can have more “choice” to select less expensive insurance.  Less expensive insurance typically covers less, which disproportionately hurts people who have need of more medical services. Lower premiums also may come with higher annual deductibles, meaning that people need to spend a large sum of money out-of-pocket before insurance will pay. Again, this places a particularly heavy burden on people who need more healthcare services.

In particular, women are more likely than men to suffer mental health challenges and women make substantially greater use of mental health services. Beginning in 2020, the GOP plan would eliminate the current requirement that Medicaid cover basic mental-health and addiction services. This roll back of mental health parity requirements will disproportionately hurt women.

Women are less able than men to afford health care.

According to the Department of Labor, women earn less than men. In 2014, for example, women who worked full time in wage and salary jobs had median usual weekly earnings of $719, which was 83 percent of men’s median weekly earnings ($871).

The Republican plan emphasizes tax credits and health savings accounts, both of which are irrelevant to low-income Americans.

According to the Department of Labor, women are more likely than men to be among the working poor. This is the group that has the most to lose with the Republican plan to decrease subsidies and eventually eliminate the Medicaid expansion.

The Republican approach to Medicaid disproportionately impacts women.

Nationally, women make up 56% of Medicaid recipients (in 2015). In states that did not expand Medicaid under the ACA, women are an even greater proportion of Medicaid recipients. In South Carolina, for example, 67% of Medicaid recipients are women. In Nebraska 66% are women. Thus, phasing out the Medicaid expansion will disproportionally hurt women.

The ethos of suspicion directed at Medicaid recipients will further hurt women. For example, the Republican plan requires states to re-determine Medicaid eligibilities “no less frequently than every six months.” Given that women bear the greater share of responsibility for arranging health care in American households, the need to frequently recertify eligibility will place an increased time burden on women to keep track and show evidence of eligibility.

Near elderly women are at particular risk of losing coverage under the Republican plan.

Women are less likely than men to be insured through their own job (35% vs. 44% respectively) and more likely to be covered as a dependent (24% vs. 16%), a disparity that reflects the fact that women are more likely than men to work at part-time jobs in order to carry out duties as primary caregivers for children, sick and disabled family members, and elderly parents.

At the same time, many American women are married to men who are slightly or significantly older than they. This means that when the husband retires and becomes eligible for Medicare, the wife loses the “dependent” coverage she had while her husband was employed, but she herself will not yet be Medicare eligible.

This age group has particularly high healthcare needs that may become exacerbated while waiting for Medicare eligibility.

Under the A.C.A., plans can charge their oldest customers only three times the prices charged to the youngest ones. The Republican plan allows insurers to charge older customers five times as much as younger ones and gives states the option to set their own ratio.

Planned Parenthood

The Republican plan singles out Planned Parenthood, prohibiting federal funding for Planned Parenthood for one year beginning with the enactment of the law. This will have a disproportionately negative impact on women.

Two and a half million women and men in the United States annually visit Planned Parenthood affiliate health centers for a variety of healthcare services. Most of these people are women who would stand to lose a wide range of primary healthcare services including, but not limited to, contraception.

Abortion

Under the Republican plan, qualified health plans cannot include abortion coverage except for pregnancies that present life-threatening physical risks (not mental health risks) and pregnancies that resulted from rape or incest.

This provision not only reduces access to a needed medical procedure, but it also seems to require some sort of process for determining whether a pregnancy is life-threatening or confirming that a pregnancy is a result of rape or incest. This potentially could force women to prove (to the satisfaction of an insurance company) that she indeed was raped, and it certainly would delay performing the abortion – a delay that in and of itself presents health risks to women.

The Republican plan does allow insurance to pay to treat “any infection, injury, disease or disorder that has been caused or exacerbated by the performance of an abortion.” Since legal abortions performed by a qualified medical provider in a suitable medical setting are extremely safe, this provision seems to be set up for women who have resorted to “backstreet” abortions. While it is unlikely that the plan’s intent is to encourage illicit abortions, this provision seems to acknowledge that an increase in unsafe abortions may be a consequence of the plan.

This analysis was prepared by Susan Sered on March 8, 2017. Healthcare legislation currently is highly volatile with many changes proposed. Stay tuned – I will come back and update this analysis as more information becomes available.


Susan Starr Sered is Professor of Sociology and Senior Researcher at the Center for Women’s Health and Human Rights at Suffolk University in Boston. She is the author of Uninsured in America: Life and Death in the Land of Opportunity and Can’t Catch a Break: Gender, Jail, Drugs, and the Limits of Personal Responsibility. Read more on Susan’s blog at http://susan.sered.name/blog/.


The UC Press Guide to the Affordable Care Act

Inside National Health Reform

In light of the Supreme Court’s recent decision to uphold most of the provisions of the Affordable Care Act, you may want to take a look at Inside National Health Reform, John McDonough’s firsthand account of the intense effort required to bring this legislation into law. McDonough served as Senior Advisor on National Health Reform to the U.S. Senate Committee on Health, Education, Labor, and Pensions between 2008 and 2010, and served as an advisor to the late Senator Edward Kennedy.

In the book, McDonough describes the ACA’s inner workings, revealing the rich landscape of the issues, policies, and controversies embedded in the law yet unknown to many. Taking us through the Act’s ten titles, he clearly explains what the law means for most Americans’ health coverage, and what changes we can expect to see over the next few years.

For more from McDonough, listen to this interview with him on Public Radio’s KERA, or read this discussion of the role he played in the legislation in The New Republic.

And once you’ve become an expert on national health reform, dig into UC Press’s entire list of books on Health Care Policy!


An American in Paris

How's Europe Doing? logoAmidst French labor protests over the increase in retirement age, Steven Hill, author of Europe’s Promise: Why the European Way Is the Best Hope in an Insecure Age, searches for an American counterpart to this sort of populist demonstration. In his recent dispatch from the Continent, Hill asks where American anger is over flat wages, lack of health care coverage, and the widening gap between rich and poor. Read his post from Washington Monthly below:


FRENCH PROTESTERS: “WHERE ARE YOU AMERICANS?”

The headlines are ablaze with reports of strikes in France, and the strikes are getting increasingly intense. As the date arrived for the Senate to vote on the legislation to increase the retirement age (the lower house, the National Assembly, already had passed it), things began coming to a head. Protesters blockaded Marseille’s airport and strikers shut down fuel depots, which in turn caused a quarter of the nation’s gas stations to run out of fuel. More young people joined the fray, barricading high schools and taking to the streets nationwide. Some of them were masked and hooded, raising fears of a replay of the banlieue youth riots back in November 2005 in which 10,000 cars were burned. Vehicles have been set on fire and overturned. Police turned to teargas and helicopters to try and control the situation as the Senate vote loomed (update: the Senate passed the legislation on Friday October 22, but the unions, students, and other protesters say their direct actions will continue).

A couple of weeks ago, when I was in Paris, things were not quite this heated but you could feel the momentum building, could see that the kindling piling up. I witnessed one protest of sorts; I was standing on a street corner, on a beautifully sunny fall day in Paris, when all of a sudden the boulevard was filled with hundreds of rollerbladers! They whisked by in earnest, chanting slogans, some of them were dressed in colorful wigs, brightly painted faces, theatrical props and costumes. Their protest didn’t feel threatening, in fact the mood mostly was festive. It was kind of like watching a Critical Mass bicycle ride in San Francisco or other US cities. The faces of the protesters reflected a mixture of joy and determination, but the carnival atmosphere in no way diminished the seriousness of their challenge to the political authorities. The street was paralyzed and motorists were honking their horns.

Read the full post at Washington Monthly.