Reproductive Justice in Law and the Clinic

Harold Pollack address at the Reproductive Justice & Health Care Reform ConferenceBy Dianna Douglas

The Affordable Care Act is nearly one and a half years old, but the complexity of its reforms and their gradual roll-out have made it difficult to grade. Different disciplines are still parsing the legislation, attempting to figure out how it will change the future of their field. Experts in the field of Family Planning and Contraceptive Research has been puzzling over an enormous and perhaps unanswerable question: How will health care reform affect the reproductive lives of women and girls?

That was the primary question at the section’s spring conference, “Reproductive Justice and Health Care Reform: the Impact of Reform on the Reproductive Health of Underserved Women and Youth.” The phrase “reproductive justice” connotes the activism to give women and girls of all races and incomes the access to the same choices and education for controlling their reproduction. Panelists argued that some aspects of the bill, particularly the expansion of insurance coverage, would benefit this cause. But there were also warnings about the political resistance, exemplified by Representative John Boehner’s statement that he doesn’t think reproductive health care services are the business of the federal government: “How can you spend hundreds of millions of dollars on contraceptives? How does that stimulate the economy?” he asked in 2009.

Speakers at the conference, which was co-sponsored by UChicago’s Center for the Study of Race, Politics and Culture, posed many unanswered questions about how the Affordable Care Act will affect women and girls in America. Some expressed hope that it could close the gap between black and white and rich and poor in all areas of maternal health, unintended pregnancy, intimate partner violence, and infant mortality.

But Harold Pollack, PhD, professor at the School of Social Service Administration, gave both sides of the story. He argued that the Affordable Care Act is not only health care policy, but it is the defining document of America’s public policy on reproductive health care.

“Near-universal health insurance coverage will reduce disparities in health,” Pollack said. One of the goals of the Affordable Care Act, passed by Congress and enacted by President Obama in 2010, was to stop people from skimping on health care when they couldn’t afford it. If enacted properly, the health care plan would extend reproductive health care to millions of women.

Under the law, Pollack said, insurers can no longer require a referral to see an obstetrician or gynecologist, and must offer women direct access to these specialists. They are required to pay for some preventative services, like screenings for breast and cervical cancers and sexually transmitted infections. Insurers are required to pay for certain vaccines for women. They have to pay for preventive care for children and adolescents, including screenings for pregnancy. And, insurers may be required to pay for contraception and other family planning services.

All of these requirements were designed to improve women’s health across income levels, but basic access to physicians is the key. “When you visit a doctor because your knee hurts, the truth is that she probably won’t do very much for your knee. But you’ll get your blood pressure taken. She’ll ask you about your diet. And she’ll recommend you for other screenings and lifestyle adjustments,” he said. Oregon recently found that poor people with health insurance were healthier than poor people without it.

Pollack’s keynote address was not uniformly cheerful, however. “The bill is vulnerable, and reform is a risk,” he said. The politics around health care reform have become poisonous, he said, and some of the best public policies in the bill are the most under attack.

Pollack lamented that the great benefits of health care reform won’t be enacted for a few years, during which time public opinion on health care reform could sour more dramatically. “Backloading was the sin of this bill,” Pollack said. It takes time for reforms to embed in society, he said and the legal challenges to the bill may stop the process before it can begin.

To keep the Affordable Care Act on track and make the reforms sustainable, Pollack suggested that the people who support the bill should put a human face on it. “Americans are deeply ambivalent about sexuality and reproductive health,” he said. “But even people who disagree with abortion are uncomfortable with making a poor woman carry a baby to term after a rape or if the pregnancy will seriously damage her health.”  The more human and less theoretical the reforms can become, the more likely they are to survive the next few years of budget cutting.

One way to predict how health reform will impact women and girls nationally is to look at Massachusetts. As governor of the state, Republican presidential candidate Mitt Romney passed comprehensive health reform in 2006, requiring nearly every person in the state to have some form of insurance.

Amanda Dennis, from the reproductive rights group Ibis Reproductive Health, has observed the outcomes for women’s health since the law passed. At the conference, she said they have been mixed. Almost everyone in Massachusetts is insured now, and therefore has more access to preventative medicine and emergency services. But there are women in Massachusetts who now have worse access to doctors: immigrants, young women, and women living in rural areas.

“Some women, especially immigrants, are now afraid to come to medical centers without insurance because they’re afraid of getting caught,” Dennis explained.  Massachusetts fines people for being uninsured, like fines for driving without car insurance.

Dennis also believes that health reform in Massachusetts neglected the contraceptive needs of young women in their early 20s, whom she called “churners.” Young women switch between their school insurance, their parent’s insurance, their employer’s insurance, and no insurance in their early 20s, and they have a hard time getting contraceptives and reproductive health needs covered. Oral contraceptives were often left uncovered by insurance companies for women in this age group, because they didn’t have prescription drug benefits.

Dennis theorized that health insurance companies are aware that these young women change insurance providers often, and that each provider is unlikely to be stuck with the bill for a pregnancy. Therefore, the eventual cost savings to the company of paying for a woman’s contraception were externalized.

This problem, however,  isn’t unique to Massachusetts. “Young women often decline the prescription drug benefit or aren’t offered it, and then discover that paying for birth control out of pocket is prohibitively expensive.”

Overall, Dennis and the other panelists who have studied Massachusetts health care reform refrained from giving it a “pass” or “fail,” but noted that health care delivery had changed, for the better and the worse. Only time will tell whether the Affordable Care Act will replace “incomplete” with an A or an F in the arena of reproductive health.

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