The stately Lady Justice sits beneath the Supreme Court inscription: “EQUAL JUSTICE UNDER LAW.”
Advocates at the national family planning conference visited our elected officials this week. As I passed Lady Justice, I thought about the pending case on contraceptive insurance coverage under the Affordable Care Act (ACA). Much of the public is weary of this seeming tedious and endless debate on women’s health and women’s rights. But if the court’s motto is not to become an epitaph for equality for women, individual constitutional rights in these most intimate and personal decisions must be upheld.
Several private for-profit corporations argue that bosses opposed to birth control methods for personal religious reasons, should be permitted to deny all contraceptive coverage to their employees.
“Equal justice under law” promises that each person before the court will have impartial and evidence-based judgment. The scales of justice declare that evidence will be weighed.
First the court must decide whether a for-profit corporation is even able to exercise religious liberty. An employee can claim religious rights, but it seems overreach to say that corporations with no religious purpose are able to deny equality of health care access to their employees to impose the religious beliefs of their owners.
Even if the court determines that for-profit corporations are able to exercise religious liberty rights, then it must say whether the requirement of the ACA is asubstantial burden. Actuarial studies have shown that the cost of providing contraceptive coverage is less than $2.00 per employee per month. With many exceptions and alternatives available for providing contraceptive coverage, the cost of the benefit is not substantial.
The burden, even if substantial, can nonetheless be justified. In this situation, the compelling argument is that preventing unintended pregnancies and their outcomes, including impacts on women’s health, children in poverty and even abortions, represent a national public health goal. These very corporations benefit from women participating fully in the work force including by reducing the substitution, replacement and productivity costs of family medical leave.
Contraceptive care is primarily used by women and has been shown to advance equality of opportunity – a national goal. Enabling a few employers to deny health care that others are guaranteed is contrary to foundational American separation of church and state.
Contraceptives prevent pregnancy. Some corporate owners may believe that contraception is equivalent to abortion, but under accepted medical, legal, and scientific standards it is not. Almost everyone understands that a woman cannot have an abortion prior to pregnancy. An employee whose employer offers health insurance cannot simply go to the ACA marketplace and get coverage. If the employer denies contraceptive coverage, the employee may not be able to afford themost effective or medically necessary method.
Regardless of what the court decides, family planning clinics in Wisconsin and throughout the country will continue to provide all approved methods of birth control confidentially to men and women. Insured or uninsured, rich or poor, in the face of persistent political and legal attacks, family planning programs will support equal justice and equal access under law.
Women’s Equality Day is no time for a nostalgic look at past achievements. When Elizabeth Cady Stanton and Lucretia Mott linked arms in the streets of London at the 1840 World Anti-Slavery Convention, they bound themselves to an ongoing struggle: the march for recognition that women, as well as slaves, deserved full human rights with equality of social and economic participation.
American women at the Anti-Slavery Convention, separated from full participation in the conference by a strategically placed curtain, forged an alliance and planned a movement to win human rights for women. At the first women’s rights convention in American history in 1848 in Seneca Falls, New York, the gathering adopted Stanton’s “Declaration of Sensibilities,” establishing goals for the movement that won women the right to vote – including former slave women — 72 years later. In 1971, fifty one years after the right to vote victory, Congresswoman Bella Abzug (D-NY) led the way to passage of a law commemorating the civil rights struggle of women and declaring August 26th “Women’s Equality Day.”
Stanton, Mott, and Abzug never did and never would rest on battles already won. Although it is a day for reflection and recognition of heroines who led the way, it is most importantly a day for recommitment and continuing resolve to achieve full equality and participation.
On this day, let us think about our victories: the right to vote, equal property protections, the right to privacy in reproductive health, equality of employment opportunity, federal protections against sexual harassment in the workplace, federally protected access to safe abortion services, equality of opportunity in education, strong legal and service programs against domestic violence and sexual assault, and insurance coverage for women’s preventive care.
Let us also commit to the struggles confronting us. It might seem lately that on the long march to equality, we have been pushed back. On this Women’s Equality Day, it is especially important to remember that the road is long, the march goes on, and our American journey toward full participation continues.
Retrogression appears most consequential where it is most controversial–in reproductive rights and reproductive justice. Many states, including Wisconsin, have passed laws depriving women of access to preventive care and even mandating unjustified medical procedures to block access to safe and legal abortions. To achieve equality, every woman must be free from reproductive coercion, must have access to high quality health care and information, and must have the fundamental freedoms of self-determination as a human right.
Celebrate Women’s Equality Day, remembering the common roots of human rights begun 173 years ago with two women linking arms against slavery, fully aware that the march to equality for women, including the right to freedom from reproductive coercion, goes on. Today we can sing with activists like Sandra Fluke and Wendy Davis the civil rights refrain: “Ain’t gonna let nobody turn me around.”
Redux – The personal is political
Teaching children to understand and cope with bullies is essential, but bullying isn’t limited to elementary school. Bullying may not be physical or direct. It is persistent, intimidating, and it flourishes when victims and witnesses are afraid to speak up or speak out. It is time to identify reproductive coercion for what it is and call the bullies what they are.
“Reproductive coercion” includes sabotage of birth control by abusive partners and occurs in all social and economic groups and most frequently to unmarried sexually active women. Male partners seek control over their partner’s reproductive options, even whether and when to have sex, to assert and maintain power.
Just as the pattern of intimidation, harassment, aggression and control is not limited to schools, reproductive coercion is not limited to interpersonal relations. It is ubiquitous at public forums, health care settings, legislative discourse, and campaign politics. This bullying is intended to intimidate, to silence people who disagree, to deny people access to health care they want or need, to pass legislation that denies reproductive justice, and to maintain power by opposing reproductive rights and justice.
Last week, one of Family Planning Health Services’ (FPHS) employees was participating in a health fair sponsored by our local United Way and county health department. It happened to be hosted at a Catholic hospital. One of the medical directors required the employee to remove information on emergency contraception. The doctor then used post-it notes to obscure “prescription contraception” and “non-prescription contraception” on the FPHS display.
The hospital has been recognized for its work with sexual assault victims and the hospital president is on the state attorney general’s sexual assault task force. We can assume the hospital is in compliance with state law to provide emergency contraception in the emergency room and we know that many of the physicians provide prescription and non-prescription contraception to their patients. But, like the classic elementary school bully, the physician used position and status to censor and deny information to participants.
Victims and bystanders might excuse the bully; “I should have known this would provoke him,” or “I should have known better than to be in this neighborhood,” but motivation does not excuse intimidation, bullying and harassment. On a public level we may understand religious objections, but using status, position, power, volume or force to control someone else’s reproductive health and behavior must be challenged and condemned if the culture of sexual coercion is to change.
Several days ago, Wisconsin’s State Senator Mike Ellis used the power of the majority and the gavel to silence debate and fast-track a bill that requires women to undergo a medically unnecessary ultrasound procedure and morality message before they can have an abortion. In our state assembly, our state representative shared her experience as a child rape victim and spoke very personally to how she felt as a victim and as the mother of three daughters, to a law requiring victims to undergo a re-invasion of privacy and self-control. On-line bullies vilified and harassed her for speaking out as a victim against the “pro-life” legislation.
There are self-styled “prayer warriors” standing outside our family planning clinics for a few months each year. They know that many of our patients and WIC participants/children are intimidated by their presence, but they justify the bullying on the basis of their religious beliefs about abortion, which we do not provide.
Victims and witnesses to reproductive coercion, intimidation and bullying must try to speak up, seek help, or intervene as the situation requires. When it comes to public and political behavior, calling reproductive coercion what it is the first step to ending it.
President Obama recently reassured women’s rights advocates: “As long as . . . we’ve got to fight to protect a woman’s right to make her own choices about her own health, I want you to know that you’ve got a president who’s going to be right there with you.” Right now, he seems to be in both corners of the ring.
In this corner
Under federal court order the Food and Drug Administration (FDA) was to make Plan B™ available over the counter without age or prescription restriction by May 10th. (Plan B™ is a pill taken as soon as possible and up to 120 hours after unprotected sex to prevent a pregnancy.)
The FDA had determined Plan B ™ to be safe over the counter (OTC) for all girls and women at risk of unwanted pregnancy. In what appears to be an attempt to evade the court order, the Whitehouse engineered an FDA compromise requiring women to show identification and proof of age (15) before they can purchase Plan B™.
Judge Edward Korman sharply denied the Department of Justice (DOJ) request for a stay of his order. He said that the DOJ’s arguments on EC contradict the FDA’s own recommendations and he pointed out the administration’s inconsistency in its positions that requirements for photo IDs are unconstitutional barriers to voting rights, but photo IDs are acceptable for women who need to exercise their reproductive rights.
And in this corner
Meanwhile, half the country away in Denver, the DOJ is defending policy that health insurance should include preventive coverage, including hormonal contraceptives and emergency contraception, without copays or deductibles. Consistent with President Obama’s 2009 directive that political officials should not influence scientific findings and conclusions, he commissioned the National Institute of Medicine (IOM) to make recommendations on prevention for women’s health. In stark contrast to the Plan B ™ FDA case, the President implemented the IOM recommendations and is vigorously defending policies to give women access to EC and other contraceptives against secular corporations such as Hobby Lobby which are claiming a religious exemption so they can deny employees reproductive health coverage guaranteed to others.
When the DOJ asserted “public interest” to Judge Korman, he invited them to explain what public interest is served by unplanned pregnancies and abortions. That is the standard by which this dispute should be decided. No public interest is served by unplanned pregnancies. Which policy best prevents them?
- Unwanted pregnancies – like unplanned and involuntary sex — are more likely to occur to teens, to present higher medical risks, and are more likely to be terminated.
- Judge Korman’s comparison between reproductive rights and voting rights is important because pregnant teens and low-income minorities have the fewest resources to overcome obstacles placed in their way. Those same women and girls also have the greatest difficulty overcoming the health and social consequences of an unplanned pregnancy.
- For almost ten years, FPHS has dispensed 10,000 cycles of EC to our patients — quickly, confidentially, and at low or no cost. We have seen our unplanned pregnancy rate drop. We have identified the greatest obstacles to effective emergency contraceptive use are cost and a lack of accurate knowledge about how it works and when to take it. OTC status is an inadequate and imperfect solution, but adding unnecessary photo ID requirements only amplifies its imperfections.
The Obama administration’s now repeated politicization of the EC issue, in contrast to the Obama administration’s defense of contraceptive coverage in primary care, adds to the stigma and enables the opponents of contraception in their efforts to misinform.
It is unclear in its fight against itself, what the Whitehouse will win, but in the fight to prevent unplanned pregnancies and abortions, it is too clear what women and girls might lose.
Cardinal Timothy Dolan, who has problems of his own in Milwaukee, is leading a procession of lawsuits opposing a national requirement of health insurance companies to cover contraceptives. The cardinal called it a “totalitarian incursion against religious liberty.” His principle argument, is that religious institutions should not “… be forced by the government to provide coverage for contraception or sterilization,” because it “… violates their religious beliefs.”
On that principle, legislators across the country are working to deny state and federal funding to organizations that provide contraceptive services. These lawmakers and their political allies echo the United State Conference of Catholic Bishops’ (USCCB) reasoning that it is unjust to force taxpayers, employers, or members of the Church to support institutions or their affiliates which are committing acts they decry as “intrinsically evil.”
The morality of contraception has been debated for generations, but what if we apply Cardinal Dolan’s reasoning where the question of morality and legality is indisputable?
Recent polling shows that 80 percent of American Catholics find contraception morally acceptable andalmost all Catholic women who have had sex have used a method forbidden by the Church.
On the other hand, protecting sexual predators is neither moral nor legal. At the same time the anti-contraception lawsuits were filed, a Wisconsin court ruled that the Green Bay Archdiocese illegally concealed sexual assaults of children and put other children at risk. If it is the bishops’ principle to stop federal and state funding for institutions and affiliates that have acted immorally, we can begin where there is no question of legality or morality. Let us deny funding to institutions, like the Green Bay Archdiocese, that have been convicted of conspiring to protect child sexual predators.
The bishops have tried and failed to make a credible cost or health argument against contraception even among their parishioners. Family planning saves taxpayer dollars and insurance premium increases for contraceptive coverage would be nominal. Failing at persuasion, they turn to federal courts. They demand a series of exemptions for employers and institutions in the name of religious freedom:
The bishops invoke the legacy of Martin Luther King Jr. in their insistence on being awarded federal grant funds without anti-discrimination protections for women, sexual assault victims, and homosexuals. The demands reveal that Dolan’s defense of civil rights begins and ends with imposition of his narrow institutional authoritarianism even on employees or students or women who disagree. This profoundly contradicts the individual liberty protections guaranteed by our Bill of Rights.
The bishops’ central argument is that we must enforce a standard of de-funding institutions engaged in actions they disapprove. Let us call upon Cardinal Dolan, the USCCB, and their political allies to practice what they preach. Eliminating public funds and taxpayer support for organizations criminally convicted of protecting child predators will prove they are standing on principle.
Cardinal Timothy Dolan, in his March 18 op-ed, correctly characterizes the contraceptive insurance coverage debate (“It is a matter of religious liberty,” Crossroads). He says: “This is first and foremost a matter of religious liberty for all.” But well-hidden under his rhetorical robes is that when it comes to religious freedom, he’s against it.
The cardinal, in an ecclesiastical lift worthy of Samson, invokes the Declaration of Independence to prove that freedom of religion is “God-given.” With that jawbone, the cardinal smites the Philistines of insurance coverage for contraceptives, which he misleadingly refers to as “abortion-inducing” drugs.
He hopes the readers will accept his point of view that drugs that prevent pregnancy cause abortions. Most people, faithful or not, do not accept the theology that a woman can have an abortion before she is pregnant.
He hopes his faithful Catholic readers will forget the First Commandment (which forbids “religious freedom” outside Jehovah) in his defense of the First Amendment. And he hopes that readers will accept his explanation of the Bill of Rights.
When he says “Catholics and other people of faith and good will are not second-class citizens,” he invokes a constitutional interpretation under which a woman employed by self-insured employers (most people) or a business owned by someone who objects to contraception or a religiously affiliated insurance company can be denied the guaranteed preventive care coverage that other citizens have been granted.
Dolan asks readers to accept a First Amendment under which people of faith are not second-class citizens – unless, of course, they are women.
The US Conference of Catholic bishops (USCCB) are incensed at the decision by the Obama administration to guarantee that the preventive health care benefit package in the Affordable Care Act (ACA) includes contraceptive care. In a USCCB video, Cardinal-designate Timothy Dolan, the former Archbishop of Milwaukee, wags an index finger as he invokes religious freedom protected by the “very first amendment.” The archbishop calls upon his flock to contact their elected officials and let them know that “religious liberty must be restored.”
Under a cloak of reverence for religious freedom, the bishops say reproductive health care must be denied. As do the rights to millions of American women, millions of people of other religious faiths, and even to millions of American Catholics – most of who disagree with the archbishop.
Before we ask President Obama to reverse his administration’s decision, there are some troubling questions we should ask the bishops and ourselves lest we destroy religious freedom in the name of preserving it:
- A patient who takes birth control pills, under the USCCB’s code of conscience, with the intention of preventing pregnancy commits a sin. If that same patient takes the same prescription for another health purpose, it is permissible. Is there any way that respects a patient’s right to privacy that also enables insurance companies and employers to deny birth control pills to prevent pregnancy while it permits them for regulation of menstrual cycles?
- In Wisconsin, we have a Medicaid family planning program to prevent unintended pregnancy. It has been very successful. It saves taxpayer dollars by reducing unwanted pregnancies and abortions among participants. Medicaid payment records show that many Catholic hospitals, clinics, physicians, and pharmacists are participating in the program. These institutions provide birth control services and receive public insurance (tax) dollars in payment. There is no reason for the bishops to wait to exercise their conscience “rights.” They could stop accepting payment for family planning services now. Why wait?
- Many people of sincere faith disapprove of childhood immunizations even though they are, like family planning, on the top ten list of major public health benefits. Under the religious exemption based on an employer’s conscience that the USCCB is asking for, an employer with a conscientious objection to immunization might deny its employees’ children insurance coverage for measles, mumps, polio, Pertussis, and rubella vaccines. What would be the public health impact on children when so many are not immunized?
- Many Catholic employers throughout the country have family planning and birth control coverage in their insurance policies right now. Is there a reason to wait for ACA permission to exclude contraceptive care from the insurance coverage of their employees? If the bishops implement the limits on insurance coverage they are asking for in their own clinics and hospitals and pharmacies — which even though they haven’t, they say they must — will these employees continue to provide birth control and family planning services to patients and receive insurance reimbursement while they no longer have insurance coverage for that care themselves? Will employees be forced to seek out non-sectarian health care and pay for it out-of-pocket?
- In Cardinal-designate Dolan’s former diocese, there is a nettlesome question of who is an employee of the archdiocese and who is not. Today, diocesan attorneys will argue that sexual assault claims against priests working in diocesan religious orders should be thrown out because the priests were not employees. The bishops need to clarify how they are accountable and responsible for the sexual health and morality of the employees of these separately-incorporated religious affiliates – until they engage in criminal sexual behavior.
Those of us who revere the constitution and the individual right to exercise freedom of religion enabled by the separation of church and state must stop the mass media procession that is now engaged in a responsive reading from the archbishop’s hymnal. These sounds you hear are not the chimes of freedom.
Who is my neighbor?
“What are they doing out there?” is the question I am most often asked about the picketers standing in front of our family planning clinic.
What they are doing by holding signs that say “The Pill Kills” and “Stop Chemical Abortion,” is misinforming and misleading the public. They give the misimpression that we provide abortion services; or drugs that terminate a pregnancy; or that using hormonal birth control is a deadlier health risk than unplanned pregnancy.
Sometimes, what they are doing is intimidating our clients – especially the young women and children coming for WIC services. The most dangerous picketers have physically blocked entrances and exits and pushed literature at people walking past or driving through.
But “What are they doing out there?” isn’t really a question about effects, it’s about motivations — and I’m giving up mind-reading and name-calling for Lent, so I won’t interpret or judge them. Still, I have questions about whether the picketers are reasonable. Many of our neighbors have lost their jobs and their health insurance. Many have seen their income reduced or lost their bargaining rights as workers. Some are in danger of losing their Medicaid and Medicare benefits and we are all losing environmental protections and the constitutional right to see the Wisconsin legislature when it is in session. Around the world, people are struggling to win the right to elect their leaders and they are too often killed, imprisoned, and beaten. Our world neighbors and friends have been lost to earthquakes, tsunamis, to floods and storms; and in nearby Haiti, cruel and corrupt dictators return triumphantly to the crime scene in the midst of catastrophic events and an election.
That’s why I am troubled and unsettled by what the self-styled ‘prayer warriors’ are doing. There are so many struggles for freedom, social justice, and disaster relief right now, that I do not think it is justifiable to be blocking access to health care for our uninsured neighbors who want to delay childbearing so they can finish school or take a new job or even wait to have children until they can afford them.
Publicly-funded family planning saves millions of taxpayer dollars while improving public health, yet the picketers demand to know why their tax dollars should pay for STD testing, birth control, and cancer screening. They oppose hormonal contraception to prevent a high risk pregnancy or even (maybe especially) a teen pregnancy. The picketers disagree with these services and even sexual health education, so they demand that others be denied them (if only this argument would work for oil company subsidies or middle-east military interventions.)
Recently, former State Senator Walter John Chilsen, in a statewide radio program said; “The use of contraceptives does not prevent unwanted pregnancies. I think you could even make the argument that it increases them.” The program’s host quickly changed the subject – leaving the claim unchallenged.
The scientific truth and the medical fact is that contraceptives prevent unwanted pregnancy. The primary cause of abortions is unwanted pregnancy and both the abortion rate and the unintended pregnancy rate have been falling for a generation. FPHS changed our banners on the building from “Condoms Save Lives” to “Birth Control Prevents Abortion” because the persistent campaign of misinformation puts our services and our community’s health at risk. It’s time to be more direct.
It is within the rights of the picketers to argue that birth control and reproductive health care should not be available, but I believe it is unethical and wrong to do it.
Let’s carve a stake to drive into the heart of health promotion and prevention strategies that exclude sexual health as a vital and normal part of human health and health care. As a first step, you can speak up in the U.S. Health and Human Services’ process of developing a national prevention plan.
President Obama formed the National Prevention, Health Promotion, and Public Health Council in June 2010. The council posted a draft plan for moving “from a focus on sickness and disease to one based on wellness and prevention.” The goals include healthy communities, preventive clinical efforts, and empowered individuals. The four Cross-cutting Strategic Directions include:
- Healthy Physical, Social, and Economic Environments
- Eliminate Health Disparities
- Prevention and Public Health Capacity
- Quality Clinical Preventive Services
Complementing those Strategic Directions are six Targeted Strategic Directions:
- Tobacco-Free Living
- Reduce Alcohol and Drug Abuse
- Healthy Eating
- Active Living
- Injury-Free Living
- Mental and Emotional Wellbeing
You know what is missing. The National Healthy People goals for 2020 include specific objectives for family planning, sexually transmitted infections, maternal and child health, and adolescent health. In Wisconsin, our Healthiest Wisconsin 2020 goals include normalizing sexual health as well as objectives to reduce maternal and child health disparities related to sexual health risks and access to care.
But in the National Prevention, Health Promotion, and Public Health Council draft, we have a “Waist-up Wellness” model that seems timid about even mentioning sex. There are a few references to HIV/Aids and STD testing and treatment, but they are imbedded in the subsections. If, as the plan asserts, we are going to “expand and connect prevention-focused health care and community prevention efforts,” and if we are going to “empower and educate individuals to make healthy choices,” then reproductive health and family planning clinics and providers must be a component of the transition.
By “Component” I don’t mean a sub-goal vaguely referenced. How about a specific and explicit Targeted Strategic Direction titled “Sexual Health and Wellbeing”? Paraphrasing a few recommendations from the existing targeted strategic directions, the recommendation for Sexual Health and Wellbeing might include:
- Use media and social support (e.g., social networks, shared space) to empower individuals to make responsible and well-informed choices about sexual health.
- Expand opportunities for health within communities and populations at greatest sexual health risk.
- Conduct research on promising strategies including research on reducing unintended pregnancy rates and measureable results for community-based and other types of reproductive health services.
- Establish and maintain clinical practice standards for preventive reproductive health services to encourage continuous improvement and collaboration across health care provider entities and types.
- Expand interoperable health information technology, including telemedicine and patient health records that are affordable to community-based primary prevention clinics and accessible to patients in rural areas.
- Strengthen capacity to control and prevent sexually transmitted infections and to effectively respond to outbreaks in communities.
- Protect the right of patients to choose a willing and qualified provider for the sexual health and family planning care they want and need.
- Link community-based reproductive health prevention services with clinical care, acknowledging that technological innovation will increasingly integrate patient health records and telemedicine so that for a patient, a “Medical Home” is not a place, but a care coordination concept. In sexual health, the patient is probably the best coordinator.
These are the four main points of consideration that I am inviting you to emphasize to our decision-makers and within our community of advocates and health care providers:
1) The right to confidential reproductive health doesn’t mean very much without access to confidential, affordable, comprehensive, competent, and willing health care providers.
2) When it comes to providing sexual health care, the realities are: sectarian provider institutions — gaps in insurance coverage — practitioners exercising a ‘right of conscience’ over their patient’s need for comprehensive care — and established institutions looking for ways to limit access to a full range of reproductive health care.
3) While the Patient Protection and Affordable Care Act will help, the right to choose a willing and capable sexual health care provider is still best left in the hands of the patient and not the private HMO, government regulation, or a hospital’s health information network. On a broader scale, the realities of a primary preventive health care delivery system with an existing and predictably continuing shortage of practitioners with extensive reproductive health care training and experience demands that we protect the existing infrastructure of family planning clinics and use technology to link it with other primary care providers.
4) Sexual health has been uniquely constitutionally-protected because reproductive self-determination is a core human right and because sexual behavior and decision-making is an extremely personal matter. Forty years ago, when legislators permitted Medicaid to establish managed care organizations, the regulations protected the right of patients to choose an out of plan reproductive health care provider. Sexual health lends itself to care models (such as individual Patient Health Records) which enable and empower patients to make their own choices. Advocates, community health providers, and public health policy-makers, must recognize that upholding the right of a patient to choose her own community provider or her own method or her own nurse practitioner is not only good policy — it leads to the best health results.
I hope you will take a few minutes before January 13th and go to http://www.hhs.gov/news/reports/nphps.html. Read the National Prevention and Health Promotion Strategy draft. Pick up that Boehner-sized mallet and help me drive that stake home
Wisconsin family planning advocates, providers, and citizens of reproductive age have another gift to be thankful for this holiday season. Wisconsin is the first state in the nation to win approval of a Medicaid (MA) State Plan Amendment (SPA) — making our very successful MA Family Planning Waiver a permanent part of our MA plan. Helping women and men protect their sexual health and future fertility; helping them take charge of timing their childbearing; helping them get testing and treatment for STDs; helping them complete their education and/or get the job training they need; these are perfect gifts in these tough economic times.
At the beginning of the year, Speaker-to-be John Boehner denounced inclusion of the plan in the American Recovery and Reinvestment Act to make it easier for states to expand their MA family planning programs saying it would not stimulate the economy. Speaker Nancy Pelosi seemed unprepared to make the economic argument for family planning services and President Obama pulled the language with a promise to bring it back later.
President Obama kept his promise. The Patient Protection and Affordable Care Act included language empowering states and the District of Columbia to have much easier access to federally-funded family planning services. In April, the Wisconsin Family Planning and Reproductive Health Association began working diligently with the Wisconsin Department of Health Services and the state MA program to enable and encourage an early application for an effective program. Using blogs, letters-to-the-editor, web video interviews, and even a professional lobbyist, we tried to inform legislators and advocates from Wisconsin as well as from other states and the District of Columbia about the opportunity. We hoped to establish a context where legislative leaders and state employees would feel they had a solid basis to proceed with an MA State Plan Amendment in Family Planning.
Faced with an end-of-year expiration of our existing Family Planning Waiver and armed with convincing evidence of cost-efficiency, our pro-family planning administration in Wisconsin submitted a request to make our family planning program larger and permanent. Wisconsin submitted a request before the Centers for Medicaid and Medicare Services even established the criteria. In an April 2010 RHRealitycheck.org blog, advocates set out our “recipe” for success:
- Presumptive eligibility for immediate contraceptives and STD services.
- Full eligibility must be processed quickly.
- Income eligibility must be broad.
- Covered comprehensive services must include most contraceptive methods and Emergency Contraception.
- Eligibility for students and minors must be based on their own income.
On December 22nd Wisconsin’s application was approved. Although there were a few points of negotiation and compromise on structural points, all of the ingredients in our “recipe” were included. California and South Carolina have also applied for SPAs and are in the queue for approval.
The celebration is justified and the victory is truly monumental. However, there is no time to be self-satisfied. In Wisconsin, a new anti-choice administration and an anti-choice legislature is almost certain to test the federal maintenance of effort requirements for the family planning program. Although the program has established its cost-efficiency, ideologues are likely to try to use the budget pressures of a tough state economy as cover for efforts to dismantle the program. Because they have repeated it so often, the opposition believes that access to family planning and sexual health care undermines parental authority and encourages promiscuity.
Although the political battles are formidable, I don’t think the ideologues at the gates are the greatest challenge ahead to family planning and reproductive health access. I think our greatest challenge is our own vision for change in the new environment of primary preventive health care. How will we make the transition to electronic health records? How will we collaborate with other primary care providers? Will we see ourselves or be seen as competitors and be marginalized by our unwillingness or inability to be a part of the emerging systems? Even though Medicaid patients have a choice of provider for reproductive health care, how will we be their provider of choice? Are we ready to negotiate contracts with Health Maintenance Organizations (including state Medicaid plans) and to participate in the new Health Exchanges?
These challenges cannot be trusted to fortune. While the opponents of sexual health care must be vigorously resisted, we must simultaneously articulate and achieve a new complementary role for family planning programs and clinics in the reformed health care world. If we fail, the fault will not be our opponents or in our stars, it will be our own.