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Gender and the First 100 days of Health Policy

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This past March, Republican Representative John Shimkus (R-Ill) took issue with “men having to purchase prenatal care” in a House Committee debate over revisions to the Affordable Care Act.  Just this week, Representative Paul Labrador of Idaho faced angry constituents over his support of the American Health Care Act (AHCA) that narrowly passed in a 217 to 213 House vote on May 4. When someone told him that the House bill sends the signal to people on Medicaid to “accept dying,” Labrador impatiently responded, “That line is so indefensible. Nobody dies because they don’t have access to health care.” These statements get to the heart of two characteristics central to this administration’s and the 115th Congress’ approach to health care policy in its first 100 days: individualization and androcentrism. Both characteristics are bad news for gender equity – and ultimately, families and the economy.

A focus on the individual seems neutral, but in fact ends up favoring male-bodied, white, heterosexual, and wealthy individuals over others.

The individual focus is most clearly observed in the administration’s attempts to reform the Affordable Care Act (ACA), and especially in the version of the AHCA just passed in the House. Through the multiple changes it proposes to the current ACA, the AHCA takes a sledgehammer to the concept of collective responsibility for health, where the healthy and the young help pay for the aged and the sick, knowing that when they are ill or old, they too will be covered. Indeed, while those supporting this latest health bill insist that coverage will remain similar to what it is now under the ACA, the realities of the bill suggest otherwise. They suggest not only that potentially millions will lose access to health care – 24 million according to the Congressional Budget Office’s assessment of an earlier version of the AHCA – but that those likely to be more significantly impacted include women, LGBTQ communities, the elderly, and historically disadvantaged populations.

Central to the AHCA is removing the individual mandate to carry insurance. Aside from the facts that the individual mandate is key to insurance market stability and that the uninsured end up being costly to taxpayers, the individual “choice” to not carry health insurance is highly gender and race inequitable. Only the healthiest and wealthiest in society  –and those without dependents and who cannot get pregnant– can really afford to risk not being insured. Given social and environmental inequities, racial and ethnic minorities tend to suffer poorer health status than whites. These groups, and women overall, are disproportionately represented among those living in poverty. Meanwhile, the AHCA proposes tax incentives for individual health savings accounts; further encouraging health care to become a “go it alone” endeavor.

The AHCA also repeals part of the ACA’s “community rating” system, which prevents variation of premiums based on age, gender, health status and other factors. Under the ACA, insurers cannot charge women more than men and they cannot charge the elderly more than three times what they charge younger individuals. The AHCA would allow insurers to charge the elderly five times the rates for younger people. Since women typically live longer than men, they would be more significantly impacted by this change.

While in the March negotiations, the essential benefits requirement was substantially weakened, the version passed by the House on May 4 would allow states to waive essential health benefits and decide whether or not to require insurers to cover preexisting conditions; a move opposed by hospitals, doctors and insurers, but approved by the conservative House Freedom Caucus.

The waivers further emphasize individualism, and also androcentrism. The androcentrism is particularly acute when it comes to waiving essential health benefits which include denial of reproductive health care.

This clearly impacts women seeking prenatal care and maternity care, but in turn it also affects infant health in a country already showing shameful infant mortality statistics relative to other high-income countries. It would also impact trans men and women seeking care that is appropriate to their health needs and nonjudgmental. Apart from potential loss of maternity and prenatal coverage should states implement essential benefits waivers, the AHCA also disallows the premium tax credit (a credit that makes it more affordable for low to moderate income people to afford individual insurance) if the policy covers abortion services. Similarly, it disallows small businesses from claiming an expense credit if they offer their employees insurance plans that include abortion.

Making insurance financially out of reach for those with preexisting conditions or not covering them at all would be felt across multiple spectrums, including anyone who has chronic or terminal illnesses, mental health diagnoses, or disabilities.

These waivers would also more heavily impact those populations at higher risk of particular diseases. A comprehensive recent study of breast cancer mortality rates by Sinai Urban Health Institute, for example, found not only that black women die at higher rates than white women, but that the disparity over the last decade has grown. In fact nationally, black women were 43% more likely to die of breast cancer than their white counterparts. Though exact causes of the disparity are not clear, late-diagnosis and late treatment – both indicative of inadequate access to health care – are thought to play major roles. HIV/AIDS has fallen from many people’s radar, but not for trans women and gay men. Trans women are three times more likely than the national average to test positive for HIV according the CDC, and just over half of those testing positive are African American. In a 2013 testing of 2,705 trans women, 22% were HIV positive. Gay and bisexual men remain the most at risk of a diagnosis of HIV or AIDS. Again according to the CDC, 54% of those newly diagnosed with AIDS were gay or bisexual men or men having sex with men; and again, a majority were African American.

Other than these more evident categories, specifics on what might constitute pre-existing conditions in the AHCA are sparse, and insurers might have leeway in determining them.

Before the ACA, though, pre-existing conditions included having had a cesarean section, rape, domestic violence, or pregnancy, leading one news analyst to state that just being a woman in essence constitutes a pre-existing condition given the high percentage of women in the US who have experienced at least one of these.

The newest version of the AHCA also cuts back substantially the amount of federal funding for state Medicaid programs, threatening millions of poor Americans with lapse in coverage. When the ACA was passed, minority populations were the ones who achieved the most gains in insurance coverage, narrowing considerably the gap between levels of health insurance among whites versus nonwhites. Women had the most gains, in large part because of their higher poverty rates. Before the major expansion of coverage under the ACA, 40% of low-income women were uninsured. By 2015, however, a study by the National Women’s Law Center found that 90% of women in most states had coverage, and women of color in particular had double-digit gains. The same study now estimates that 8 million women are at risk of losing insurance coverage under the AHCA, two-thirds of these, women of color.

In the AHCA and other legislation, the Trump administration also sought to “defund” Planned Parenthood under the specious idea that this will prevent abortion; even though federal funding for abortion services has long been disallowed.  The current AHCA bill contains language that would deny federal Medicaid funding to Planned Parenthood for one year. On April 13, the President signed a bill into law that would allow states to withhold Federal Title X payments to qualified providers of pregnancy, breast and cervical cancer screenings. This move will undermine Title X, a program developed by the Nixon administration to extend family planning to low income individuals. And we may well see higher rates of unplanned pregnancies, rates that we have seen drop particularly among Latinas with both Title X and the ACA regulation that requires contraceptive coverage.

Considering the overall context — the Planned Parenthood legislation, along with  the Trump administration’s early executive order to reinstate the “global gag” rule that forbids global reproductive health organizations that receive US funding to even mention abortion, and its withdrawal of funding for the United Nations Population Fund based on the erroneous claim that it supports coercive abortions in China —

it appears that individual “choice” of health care options only applies to some individuals and reinforces the idea that non-male bodies are outside the norm and subject to control.

In a study published this month examining inequalities in life expectancy by county across the US, authors found that not only are disparities growing wider among Americans, but that there are counties where life expectancy is actually going down. Lowest life expectancies, which were found in South Dakota Indian reservations and parts of the South, were only in the 60s. Though many factors were examined, socio-economic status and access to adequate and quality health care played vital roles. This is important information to have, but it isn’t new to note that poverty and lack of access to good quality health care both play pivotal roles in keeping Americans healthy, or not.

We know, in other words, that people do die when they don’t have access to health care, and that making health insurance unavailable or too expensive for millions will make health disparities worse instead of better and will have grossly uneven impact across individuals.

Republican health care policy in the first 100 days of the 45th Presidency has relied on the fallacious ideas that individuals can be entirely self-reliant and that care should be tailored to only a narrow group ­– those that fit an able bodied, white, heterosexual, self-ascribed male norm.

But that’s not how the world really works. Nor is it a good long-term strategy for supporting families and the economy.  No one should be sent a signal from our government to accept dying earlier because they’re poor, to adjust to realities of persistent ill health, or to give up on the idea of affordable health insurance because they have had children or experienced sexual assault.

We live in an interconnected world where increasing the health and well-being of everyone benefits all. To give one example: moms with maternity and prenatal care have healthier babies that become the productive workers of tomorrow, and in a collective insurance environment like that under the ACA, these workers support the health needs of the aged and sick, until the cycle begins again. The ACA is not perfect, but reform should focus on reinforcing and improving beneficial cycles like these, rather than promoting devolution to an inefficient, fend-for-yourself model that will only harm millions and the long term prospects for our country’s prosperity.

Susan Craddock, Professor of Gender, Women’s and Sexuality Studies; Global Studies; and Director, Center for Bioethics, University of Minnesota.

Christina Ewig, Professor of Public Affairs and Director of the Center on Women, Gender and Public Policy at the Humphrey School of Public Affairs, University of Minnesota.

–Photo by Quinn Dombrowski