As the nation swings from one polarizing policy debate to another – from health care to taxes to immigration – the connections among these issues can get lost in the rhetoric. The common impacts of those three particular issues are, however, nowhere more visible than in Latina health care access and outcomes. We’re talking about millions of Americans: children, the elderly, low and middle income, citizen and noncitizen alike. Latinas, a sizeable demographic within each of these populations, are especially vulnerable because of the ways in which ethnicity, gender, income, documentation status, and age intersect. Latinas’ lives and livelihoods are on the line.
Regarding health care, the early Trump administration has seen Congress repeatedly fail to repeal the Affordable Care Act (otherwise known as ACA or “Obamacare”), while allowing the Children’s Health Insurance Program (CHIP) to expire and ending the ACA’s individual mandate in the tax bill (before voting to reauthorize CHIP funding in a bipartisan spending bill). Relatedly, President Trump’s decision to end Obamacare enrollments earlier than usual, reduce outreach, and remove government subsidies from insurers indicates further upheaval in the country’s healthcare system.
The tax bill signed into law by President Trump in December 2017 will likely have further detrimental impacts on Latinas.
Proponents of the bill argued that it would improve U.S. economic growth by permanently reducing corporate tax rates to 20 percent and temporarily reducing taxes for middle-class families, yet the nonpartisan Congressional Budget Office (CBO) estimates that the tax bill will add $1.5 trillion to the national deficit over the next ten years and ultimately result in lower income individuals and families – those earning less than $30,000 yearly – paying higher taxes by 2019, and middle income individuals and families earning less than $75,000 yearly paying higher taxes by 2027. Latinas comprise 7.2 percent of the national workforce, with 32 percent of Latinas employed in the service industry. But, they earn an estimated 55 cents to the dollar that white non-Hispanic males earn and constitute 13.68 percent of the working poor. Latinas’ median annual income is typically less than $75,000, meaning that, under the Trump tax changes, many will see a reduction in their already lower than average incomes, especially as they work in low wage jobs.
And although the tax bill is considered separate from health policy, its passage has implications for the health coverage of Latinas, some of whom are among the 13 million Americans now projected to be uninsured by 2027 (an estimated 5 million of those will have, in the past, been able to purchase health insurance through Obamacare marketplaces).
Prior to Obamacare’s implementation, 43 percent of Latinos lacked health insurance. Under Obamacare, the uninsured rate for Latinos dropped to nearly 25 percent by 2016. But because the tax bill quietly rescinded the individual mandate, removing the tax penalty for not having health insurance, it is expected that Latinas’ (along with other ethnoracial groups’) health coverage will return to pre-Obamacare levels, since the tax bill will lower their take-home pay and increase the cost of obtaining coverage.
Relatedly, Congress’ inaction allowed CHIP to lose funding in October 2017, affecting the health coverage of some Latinas’ children. CHIP was established in 1993 to provide health insurance to low- and middle-income children whose families were ineligible for Medicaid and otherwise could not afford insurance for their children. The federal government allocates funding to individual states for program administration, and states have included CHIP funding in their annual budgets to cover low and middle-income kids’ insurance costs. Although the bipartisan spending bill has reauthorized CHIP funding for the next 10 years, it did not reauthorize funding for the community health centers where CHIP recipients go to receive health care. Through CHIP, nearly 8.5 million children were provided health insurance in 2015; among national CHIP beneficiaries, an estimated 37 percent were Latino, 24 percent were black, and 34 percent were white. Funding CHIP without funding health care centers spells grave consequences for low-income kids, so many of whom are Latinx.
Of course, it is difficult to fully understand the social and political implications of diminished healthcare access for Latinas without considering immigration policy.
First, President Trump announced that he was ending the Obama-era Deferred Action of Childhood Arrivals (DACA) program in September 2017, which provided deportation relief and work permits to an estimated 800,000 undocumented young adults—mostly of Latin American ancestry—who were brought to the U.S. as children. With the September end date, the federal government had until March 5, 2018 to receive DACA applications for renewal. Despite some inaccurate media and anecdotal reports, DACA does not provide a path to citizenship and DACA recipients cannot legalize their undocumented parents. Although the deadline for the program’s renewal was on March 5th, federal court challenges to ending DACA resulted in the program remaining open to receive applications. Recently, the Supreme Court declined to hear a case on DACA, allowing the federal court decisions and DACA to stay in place. Nevertheless, Congress has remained unable to find a permanent resolution, leaving DACA recipients, a sizeable percentage of whom are Latinas, in limbo.
President Trump’s administration has also begun the process of ending Temporary Protected Status (TPS) for Salvadorans, Nicaraguans, Haitians, and Sudanese refugees. TPS is a status granted to victims of natural disasters, political conflict, and war, temporarily protecting from deportation and making them eligible to receive certain federal benefits like health insurance (i.e., Medicaid, Medicare). Latinas and their children who have TPS will see their ability to access health care erode even further, especially those who obtained coverage through the ACA Medicaid Expansion.
Cumulatively, these macro-level policies will affect the life of nearly every individual in the U.S. in some way, shape, or form. But, these policies will have a disproportionately negative impact on Latinas, who are, by dint of structural racism, increasing anti-immigrant sentiment in public policy, and working in low-wage “bad jobs,” particularly vulnerable to exclusion from health care, social mobility, and full membership in the body politic.
Even those policies that are, on the surface, racially, ethnically, and socioeconomically neutral carry consequences that will fall heavily on women and those who are racially, ethnically, and socioeconomically disadvantaged.
At every level of policy making and enforcement, we must ask: Whose life or livelihood is on the line when government funds for community health centers expire, when individual health coverage is no longer mandated, or when immigrants lose protected status? Increasingly in this country, the answer is Latinas’. As a society, where the federal government does harm, we must find ways, whether through subnational governments with inclusive immigration and health policies or non-governmental organizations, to mitigate that damage.
The #MeToo movement has been crucial in raising the profile of sexual harassment and violence through the voices of women from Hollywood to Congress, yet we have heard less about the experiences of women from other socioeconomic sectors – poor women, women of color, immigrant women. The U.S. does have limited policies in place to protect some immigrant victims of sexual violence, but those systems need to be more accessible and to be made consistent across jurisdictions.
Some immigrants in the U.S.—predominantly women—who have been victims of sexual and other forms of violence are eligible for a humanitarian visa. The U Nonimmigrant Visa is designed to protect those who have suffered mental or physical abuse and encourage them to cooperate in criminal investigations and prosecutions. It allows victims to remain in the country and apply for a green card. The goal is to protect both individuals and communities by helping law enforcement agencies better serve crime victims.
The bad news is that getting a U Visa depends more on a victim’s zip code than on the merits of her application.
Congress created the U Nonimmigrant Visa to help foreign-born victims of crime as part of the Victims of Trafficking and Violence Protection Act of 2000. Each year, up to 10,000 victims of violence receive this protection from deportation, employment authorization, and opportunity to become lawful permanent residents—and ultimately, U.S. citizens.
Still, demand for U Visas far outpaces the supply. In addition, there is wide variation in the extent to which law enforcement agencies facilitate or impede the certifications that are a required part of the application process.
According to attorneys at Her Justice, an organization that assists thousands of women applying for U Visas, the most serious obstacle to the protection of foreign-born victims of violence is that 10,000-per-year cap. There is a huge, and growing, backlog of applications. In fiscal year 2017, for example, the USCIS received 36,531 U visa petitions and approved 10,031. Adding the balance to backlogs, that meant 110,511 petitions were awaiting decisions. For victims, this means waiting years to have their cases heard and to get even conditional authorization to work in the U.S.
Without permission to work, already vulnerable women who may have separated from abusers, are in a uniquely difficult bind if they need to support children, or simply want to support themselves.
Other, less-well-known barriers to these protections stem from law enforcement officials’ poor understanding of victims’ circumstances. To be eligible for a U Visa, an individual must demonstrate that she has cooperated in the investigation or prosecution of the crime, as certified by police and/or a district attorney (if the abuser was arrested). Obviously, there’s a great deal riding on how any given official defines “cooperation.” This varies greatly across the U.S. and even within the same county.
Some officials understand the U Visa requirements and have reasonable, streamlined procedures for evaluating applications for the cooperation certification. Others may be reluctant to provide certifications because they believe that people apply for U Visas fraudulently—not because they need protection from violence, but because they are seeking an “easy” path to legal status. Authors of a UNC Law School study of differences in U-visa certifications across the U.S. cite the case of a Spring Lake, Minnesota Chief of Police, who said that he would not feel “comfortable” certifying U visa applications for anyone whom he did not know personally.
In some jurisdictions, if a woman drops the charges against her abuser she is considered to be “non-cooperative.”
Such policies ignore the myriad factors that can lead a woman to drop charges—for example, fear of retribution, or the fact that a victim and her children are often dependent upon the abuser for financial support. In other circumstances a woman may want to separate, but not necessarily to see her partner or the father of her children jailed or deported.
Sealed criminal records are also an impediment: if an abuser is undocumented, his attorney may try to get the charges sealed so that they don’t lead to his deportation. Then, when district attorneys are asked to certify that a victim has cooperated, they may say (incorrectly) that they are unable to certify because the court records are sealed, and punt the request back to police.
Such arbitrary differences in local policies and procedures can result in immigrant victims with identical histories of abuse and law enforcement cooperation seeing different certification outcomes (and recall, the certification is only one step in the process of getting a U Visa). Many jurisdictions have no standard policies or designated certifiers. Some states are taking action, implementing uniform definitions of what constitutes cooperation with law enforcement. California, for example, has enacted the 2016 Immigrant Victims of Crime Equity Act.
The stresses experienced by abused women are greatly compounded for immigrants who do not have permanent legal status in the US. Without work authorization, many face an impossible choice between fleeing an abuser and being able to pay rent and living expenses for themselves and their children. It is thus unsurprising that some victims who call the police during a crisis later decide to drop charges against their abusers. Sadly, in some localities this decision can have serious consequences, making them ineligible for the kind of protection offered by the U Visa.
The current Administration’s anti-immigrant rhetoric and actions have exacerbated the plight of foreign-born victims of violence.
Delays in obtaining U Visas today have a particularly devastating impact in this climate because a victim may be picked up by ICE during the waiting period before her application is reviewed or approved.
Furthermore, inflammatory statements and actual immigration raids make many victims fearful of coming forward to report crimes. When law enforcement and immigration enforcement are tied, victims understandably avoid contact with both groups; this is precisely what the authors of the original Victims of Trafficking and Violence Protection Act hoped to avoid.
One, as-yet-unexplored outgrowth of the #MeToo movement should be attention to the plight of foreign-born victims of violence, particularly through designing better, more standard U Visa policies and working to educate the public and law enforcement officials about this uniquely vulnerable set of victims.
President Trump has taken many by surprise with his recent threats to impose global tariffs on steel and aluminum imports. Presumably seeking to deliver policy goods to his political base, the remarks appear aimed to support the principally white male workers in the steel and aluminum industries.
But if these tariffs are imposed, negative consequences will hit a whole host of other workers, and women workers in particular. Trade, too, is a gendered policy area.
Trade issues formed a central pillar of Trump’s campaign promises, which emphasized re-negotiating multilateral and bilateral trade agreements and increasing tariffs on imported goods from specific countries (China, Mexico) as well as across the board. These promises appealed to voters who saw globalization generally and free trade deals in particular as detrimental to American jobs and workers.
Now Trump appears to be making good on this promise, even if we have few details. His statements followed the Department of Commerce’s release of reports under Section 232 of the Trade Expansion Act of 1962. This section authorizes the Department of Commerce to investigate the impact of imports–in this case of steel and aluminum–on U.S. national security. In these reports, Secretary of Commerce Wilbur Ross recommended that the President consider a number of remedies to address the national security problem posed by steel and aluminum imports, including global tariffs on both. The administration has not yet officially adopted any specific remedy or released any specific proposal. Still, President Trump’s statements floating the idea of a global tariff of 25% on steel imports and 10% on aluminum imports alarmed many at home and abroad.
While Trump appears to be catering to one group of workers and their bosses, other groups will likely directly suffer.
Research demonstrates that tariffs tend to place a heavier burden on certain categories of consumers–namely single parents–and many goods that women overwhelmingly purchase (such as women’s clothing) have historically faced higher tariffs than goods typically consumed by men. Tariffs on steel and aluminium will hit broad US manufacturing sectors that depend on these inputs — from beer breweries to the aerospace industry. It will also affect household consumers as they absorb the increased costs of a soup can, the pot the soup might be cooked in, and aluminium foil.
Perhaps more detrimental, there is the risk that the imposition of such high global tariffs could lead to trade retaliation (which the EU –among others– has already threatened against American bourbon and bluejeans) or a full-blown trade war.
In evaluating the impact of such a scenario on the U.S. economy, one study found that while sectors that produce capital goods are likely to be the most intensely affected, the largest absolute number of job losses would occur in non-trade service sectors.
These sectors include wholesale and retail distribution and sales, restaurants, healthcare, and temporary employment agencies, sectors that tend to disproportionately employ women, and are also among the primary employers for women of color. According to the most recent American Community Survey (2016), while 16% of white men worked in service or sales, 24% of white women, 31% of African American women and 27% of Latinas (16 and over) worked in these occupations.
Tariffs and trade wars may be good for a handful of principally white male workers and CEOs. But the ripple effects will be negative for the rest of us, and harshest for women of color and those with lower economic means.
On January 5th, 2018, Secretary Ben Carson and the Department of Housing and Urban Development (HUD) announced a delay of an Obama-era fair housing rule, the Affirmatively Furthering Fair Housing (AFFH) measure, until 2020. Instituted in 2015, the rule was meant to extend pieces of the Fair Housing Act (FHA) of 1968 that were never actualized—measures that call for communities to review and account for racially discriminatory housing policies or face sanctions such as the loss of community block grants and fair housing aid. Secretary Carson has called the AFFH “failed socialism” and “social engineering,” while U.S. Representative Maxine Waters (D-CA) characterized its delay as an attack on “minorities, women, families with children, and persons with disabilities.”
Histories of black migration indicate that, in fact, the delay of the AFFH will chiefly impact communities of color, women, and children, and it will especially impact black women and black woman-headed households in the deindustrialized urban north—that is, a group disproportionately affected by housing insecurity and discriminatory housing policies in a region with some of the country’s highest rates of residential segregation.
To situate these measures, it helps to consider two phases of black migration out of the rural, agricultural south to the urban, industrialized areas of the U.S. north and Midwest: The Great Migration (1910-1940) and the Second Great Migration (1940-1970).
In the Second Great Migration, some five million African Americans (47% of the total black population) migrated North. Black women and girls largely migrated to work as domestic laborers or clerical worker and outnumbered black men in the migration 88:100 from 1955-1960 and 91:100 from 1965-1971 (historian James N. Gregory attributes the gender tilt to the women’s particularly low job prospects in the south).
These women and girls immediately faced racialized residential segregation, crowded into inner city ghettos. Milwaukee provides a representative case in which the confluence of migration, gender, and federal policy led to housing discrimination amongst black women (similar processes took place in industrialized cities across the urban north).
In this brewing and manufacturing city on Lake Michigan, the government was largely socialist, yet black women migrants were forced into an area known as the “inner core.” A complex matrix of racially exclusive policies enacted by white residents who feared black residency in the city’s inner ring suburbs—communities such as Whitefish Bay, Shorewood, and Greendale—put them there. Eventually, these suburbs would even gain a reputation as “sundown towns,” where black people effectively weren’t allowed after dusk (a dubious distinction also earned by Cicero, a suburb of Chicago).
When the 1965 “Moynihan Report” (formally, the Department of Labor commissioned “The Negro Family: The Case for National Action”), authored by sociologist and Assistant Secretary for Labor, Patrick D. Moynihan, was released, it maintained that the preponderance of black female headed households in the urban north rendered the black family a “tangle of pathology.” This federal document essentially argued that black men had been emasculated by black matriarchy and concluded that black families could be reintroduced to the normative ideals of the state (i.e., middle class prosperity and two-parent households) through the destruction of said black matriarchy. Black feminist scholar Hortense Spillers argues that the report’s language gave rise to damning archetypes of black womanhood: the “misnaming” and depiction of black women as “sapphires” and “Black Ladies”, as pathological “welfare queens” scamming the system and bringing down housing values. In turn, these stereotypes impacted housing policy and its effect on black women, fueling racial resentment and white flight.
A succession of marches and rebellions in Detroit, Chicago, and Milwaukee pushed back against segregation and housing discrimination.
In Milwaukee, fair housing activists crossing the Menomonee River suffered hurled bricks and racial slurs as angry whites enacted their fears of black integration into white neighborhoods. Yet the protestors’ actions were successful in pushing forward the 1968 FHA, which mandated that it was unlawful to refuse to rent or sell to an individual because of their inclusion in a protected group.
Of course, one key directive was never enacted: the FHA’s order that local municipalities become active agents in racial desegregation. Today, black women migrants and their descendants still face housing insecurity and discrimination in Milwaukee. Historian James Loewen writes that, in the year 2000, Milwaukee was unique in that 96% of the city’s black residents still “lived within Milwaukee itself”; in other words, the suburbs were still out of reach for most black residents. Additionally, the city has an integration/segregation index of -13.6%, making it the third most segregated city in the country after Chicago (-18.6%) and Atlanta (-14.5%). Furthermore, sociologist Matthew J. Desmond depicts the ways in which African American women in Milwaukee (and other Midwestern cities) are disparately affected by eviction and unfair housing policies—maintaining that black women in predominantly black neighborhoods are twice as likely as men to be evicted (black women represent 9.69% of the city’s population but 30% of its evictions).
Compounding the devastating effect of housing discrimination on black women is the fact that some 1.5 million black men across the country have essentially disappeared from social life, whether through early death or incarceration.
When black women, on average, only possess $5 in median wealth in comparison to the rest of the country’s citizens, eviction and conviction are twin evils, working together to perpetuate economic disadvantage and housing insecurity.
While it remains to be seen whether the implementation of the AFFH might help curb segregation and housing insecurity, one thing is certain: without rigorously funded and enforced federal policy initiatives, black women will never get a chance to find out. In the wake of the delay, a possible way to rectify this disparity might be for HUD to expand funding as well as eligibility requirements for federally subsidized housing, an unlikely fix given proposed cuts to HUD’s budget.
In the absence of significant new commitments to affordable housing, arguably the most effective way to reduce racial disparities in housing, the federal government could take other less costly steps such as expanding targeted assistance for renters who experience a drastic but temporary loss of income. According to Desmond, when Milwaukee tenants facing eviction were given access to emergency housing aid from the American Recovery and Reinvestment Act of 2009, the city’s formal eviction rate fell by 15 percent. In addition to direct financial assistance, increasing publically funded legal services for low-income families in housing court could reduce discrimination in eviction and other decisions.
Federal infrastructure spending is generally popular across the political spectrum – but with research-informed policy-making, that infrastructure spending could be more effective in achieving multiple policy objectives, including greater gender equity. A large part of President Trump’s $1.5 trillion infrastructure plan is slated for improvements to our transportation system. With significant public and private partnerships envisioned, policy choices at all levels of government and within private sector organizations are important for achieving a more gender equitable public transportation system.
Public transportation—including bike share, city buses, and rail transit—expands mobility options and improves access to education, employment, and everything else a person may need to survive and thrive.
Transportation research has long documented that women, in particular, have lower access to private transport (with lower driver’s license attainment and rates of vehicle ownership than men).
We also know that communities of color make up a majority of public transportation riders (60%). So it makes sense to consider whether and how public transit options are reaching and moving their female customers, particularly women of color. Do public mobility resources make up for gendered transit deficiencies? Do women have equitable access and safe experiences using public transit? Increasingly, world-class cities are taking notice.
Motivated by the proliferation of bike sharing systems in China, I recently worked on a study there examining demographic differences in the use of public bicycles. Recent European studies have shown consistent evidence that women make fewer public bicycle trips than men.
Sure enough, with my coauthors, I found that female commuters in China are less likely to use public bicycles to access rail transit than there are male counterparts.
This gender gap may be due to the inconvenience of cycling for women accomplishing household tasks such as grocery shopping and chauffeuring children: public bicycles in Chinese cities are inexpensive, one-speed bicycles without any rear seating or carrying capacity. Further, women may have additional safety concerns when it comes to walking to and using bicycle docking stations.
When it came to commuter transit, such as city buses and trains, we surveyed 800 transit riders about their waiting and transfer experiences in the Twin Cities region of the United States. Our data showed that gender interactively affects individuals’ perceptions of the time they wait and the safety of their transit environment. That is, when the environment is perceived as “unsafe,” female transit users report that a 15-minute wait feels like 24 minutes—dramatically longer than male users’ wait time perceptions in the same environments. Still, even in unsafe waiting areas, shorter waits reveal smaller gaps in the perception of wait time by gender.
As we contemplate and debate new, significant transportation investments at multiple levels, policy efforts informed by such research and a desire to broaden the scope, safety, and utility of public transit options may begin to close these gender gaps.
With respect to public bicycle sharing, companies and cities might consider adding carrying capacity to shared bicycles and improving safety around docking stations, where women’s attention may be divided (as they interact with the computer interface to unlock or return a bicycle) or where additional lighting might be installed. And for those efforts aimed at bus and train transit, though the conventional wisdom has been to improve waiting experiences overall by adding amenities to high-use stations, the longer wait times observed in less-frequently used stations indicate attention to security improvements would best be applied there. That is, at stations served with less frequent services and where women riders have long waits, safety improvements will pay bigger dividends in rider satisfaction, likely increasing women’s use of public transit.
In the world’s richest country, maternal mortality rates are rising steadily. A 2016 study revealed a drastic increase in U.S. deaths during childbirth from 2000 to 2014, while worldwide rates were dropping. Advanced industrialized countries overall have an average maternal mortality rate of 12 deaths per 100,000 live births, while the U.S. has a rate of 19.9. Measuring up to 42 days after birth, the current rate for the U.K. is 8.9 deaths per 100,000 live births.
There are a number of factors that play into maternal death rates, but given that the vast majority of pregnancy-related deaths are preventable, it is reasonable to conclude that greater availability of medical care could reduce this elevated death rate (and, conversely, a contraction of such care may well lead to higher mortality). This conclusion is borne out in a comparison of two states, Texas and California. Beyond their differences in the expansion of insurance to low-income residents, these states also differed in their attention to maternal medical care.
Texas’s mortality rate has trended up since 2000, increasing from 17.7 at the turn of century to 18.6 in 2010. Between 2010 and 2012, things got far worse: Texas’s maternal mortality rate doubled (Figure 1). In the same period, Texas imposed restrictions on women’s health clinics and cut funding for family planning by $73.6 million in 2012. Those women’s health clinics that stayed open treated only half as many patients as they had prior to budget cuts.
These cuts were compounded by Texas’s refusal to expand Medicaid coverage to its low-income residents. As part of the Affordable Care Act (ACA) legislation, states had this option; eighteen states – including Texas – rejected the offer.
Much of the debate over the Affordable Care Act’s (ACA) merits and demerits has been silent on the real impact of health insurance for saving lives, including those lost in or directly after childbirth. The ACA has reduced uninsured rates by a considerable margin: 44 million people lacked coverage in 2013; at the end of 2016, that figure was less than 28 million. However, Texas claims the highest uninsured rate in the country and a maternal mortality rate of 31.5 deaths per 100,000 live births. Some of this increase may be due to misclassification and over-reporting, but there remains a real and deadly problem of medical care inaccessibility in Texas. In fact, its medical climate is actually dangerous for women.
Figure 1. Texas’s Maternal Mortality Rate. MacDorman, 2016
As of 2017, 16.6 percent of Texas’s population (45 million people) lacked insurance coverage—a full 10 percentage points higher than in those states that expanded Medicaid under ACA. If Texas were to accept the Medicaid expansion, they would reduce the national insurance coverage gap by 27 percent.
Further, of the 638,000 Texans who might benefit from Medicaid expansion, 74 percent are people of color for whom many conditions commonly linked to pregnancy-related deaths exist at greater rates. According to the CDC, cardiovascular diseases and non-cardiovascular (endocrine, hematologic, immunologic, and renal conditions) diseases accounted for 30 percent of pregnancy-related deaths in 2011-2013. Because African-Americans are 1.7 times more likely to develop diabetes than non-Hispanic whites and 1.6 times more likely to have high blood pressure than white women, these conditions impact their pregnancies at disproportionate rates. In an uninsured population largely composed of people of color, the intersection between chronic conditions and maternal mortality is life threatening.
California is a different story. It entered the 2000s with daunting rates of maternal mortality (Figure 2) and a high population of uninsured individuals. With Medicaid expansion and deliberate efforts to reform maternal medical care, those rates have dropped consistently. In 2013, prior to the ACA’s implementation, California’s uninsured rate hit 17.2 percent. After the state opted-in to the Medicaid expansion, the uninsured rate dropped to 7.4 percent in 2016. In the same year, the state reached a maternal mortality rate of 5.9.
One of California’s targeted efforts to improve mothers’ health outcomes came with the 2006 launch of the California Maternal Quality Care Collaborative. In most cases of pregnancy-related deaths, the organization found that better monitoring could have prevented death. Thus the CMQCC created “toolkits” to provide medical professionals with emergency guidance. For instance, to stem obstetric bleeding, which can quickly become fatal, the CMQCC recommends “hemorrhage carts” of necessary medications and supplies be on hand during birth and for nurses to train in measuring postpartum blood—a step that could be widely implemented and has the potential to save lives. The results are telling: since the CMQCC’s inception, California has seen a 55 percent decrease in its MMR. Acknowledging that a variety of factors could be at play, the organization notes that nonparticipating hospitals saw a 1.2 percent reduction in severe maternal morbidity from 2014-2016, compared to a 20.8 percent reduction among participating hospitals. It would be worth considering the demographic makeup of the communities benefitting from these medical reforms to better understand other confounders; however, the impact of attentive maternal care implemented state-wide seems to be real.
Figure 2. California’s Maternal Mortality Rate 1999-2013.
Medicaid expansion is a clear answer for states struggling with high maternal mortality rates, and some Republican legislatures are beginning to reconsider the prospect of implementing it. In a departure from longstanding Obama Administration practice, the U.S. Department of Health and Human Services has permitted Kentucky to add a work requirement for Medicaid beneficiaries. This waiver is likely the first of many for states that had previously rejected ACA funding. By excluding those unable to work, states will increase the total number of people covered while artificially limiting the eligible population.
Medicaid expansions would also make it feasible for states to fund programs like early intervention for heart disease and diabetes, which can eliminate many adverse pregnancy outcomes, and prolonging the post-birth Medicaid coverage period could have a tremendous impact on maternal health outside the delivery room. For women who are covered by Medicaid during their pregnancy in Texas, coverage lasts up to two months after the birth. Given that Medicaid finances 54 percent of births in that state and that most of the deaths occurred more than 42 days after the end of the pregnancy, an additional month of coverage has the potential to improve outcomes for a large portion of the state’s population.
That female bodies have been giving birth for millennia does not obviate childbirth’s risks. When birth occurs in combination with serious underlying conditions and uneven access to health insurance and medical care, tragic outcomes are not an insignificant risk. By taking the common-sense step of expanding Medicaid coverage, states can and should save lives.