The ACA in Threes: The Good, The Bad and the Ways to Make it Better

Mar 31, 2014Richard Kirsch

With the first open enrollment period ending today, consider some successes, outrages, and bug fixes for the Affordable Care Act (ACA). Roosevelt Institute Senior Fellow Richard Kirsch will debate implementation issues and the future of the ACA with the Heritage Foundation's Robert Moffit tonight at New York University. For more information, click here.

The Good: Three Big Successes of ACA:

With the first open enrollment period ending today, consider some successes, outrages, and bug fixes for the Affordable Care Act (ACA). Roosevelt Institute Senior Fellow Richard Kirsch will debate implementation issues and the future of the ACA with the Heritage Foundation's Robert Moffit tonight at New York University. For more information, click here.

The Good: Three Big Successes of ACA:

The Affordable Care Act is saving peoples lives: Already. Like Kathy Bentzoni, a Pennsylvania school bus driver, who dropped her old insurance because it was expensive and rejecting claims because of her pre-existing conditions. After getting ACA coverage at $55 a month, she was able to seek care: “They found my hemoglobin level was 5.7, and the normal is 14. I needed a transfusion. It was due to a rare blood disorder. Where would I be without Obamacare? ER, 3 units of blood, multiple tests in the hospital and a 5-day inpatient stay without insurance? Probably dead.” Kathy was not alone in that fear – studies show that tens of thousands of people each year die because they don’t have health coverage.

Medicaid enrollment is a bigger success than expected: Not only is Medicaid enrolling people who are eligible for the first time – 4.6 million of them – but almost another 2 million more are enrolling who were eligible before, but had not applied. In the big push to get people to sign up for the ACA, many people who have been eligible in the past applied for the first time.

Seniors on Medicare are saving money, getting better care: While most seniors don’t think that the ACA has anything to do with them, it does. Last year, 37 million people on Medicare – seniors and people with disabilities – received free preventive care. Since the law was enacted, 8 million people enrolled in Medicare have saved $10 billion on prescription drugs, as the prescription “donut hole’ closes. And for the first time in 30 years, hospital readmission rates for people on Medicare are coming down, because hospitals are now penalized for pushing people out before they are ready.

The Bad: Three Outrages Against the ACA

States that have refused to expand Medicaid: In an example of partisan politics killing people, Republicans in 24 states have refused to expand Medicaid, leaving 5 million people who would be eligible for coverage without any recourse.

Koch brothers campaign to discourage young people from signing up: In an example of billionaires killing people, the Koch brothers have funded tasteless ads and campus beer parties in an attempt to keep young people from signing up for insurance on the exchanges.

Republican lies about job loss and the ACA: One advantage of the ACA is that it gives people the freedom to leave their jobs or reduce their work hours, and still be able to get affordable coverage. When the Congressional Budget Office estimated that 2.3 million American workers would gain this freedom over the next 8 years, Republicans falsely claimed that it would cost jobs. If anything, it will create jobs for people who fill in for those who take advantage of their new freedom. I thought Republicans liked freedom.

The Ways to Make it Better: Three Big Fixes for the ACA:

Allow Medicare to operate in the exchanges: The best way to bring price competition and access to virtually ever doctor and hospital in the exchanges would be to have Medicare offer a plan (without age requirements) in every exchange. This is the easiest and most effective way to bring back the public option.

Base the employer mandate on a play or payroll tax: As I’ve explained here, the best way to get rid of the convoluted system of employers paying a penalty for employees who work more than 30 yours a week, would be to have employers who don’t provide coverage pay a percentage of payroll for health care, just like employers now do for Social Security.

Lower the premiums and out-of-pocket costs: While the ACA is providing affordable coverage for millions – and will offer lower premiums than 29 million people are paying now – they are still too high for many families. And the out-of-pocket costs in the cheaper plans are way too high. The subsidies should be increased for middle-income people – funded by progressive taxes – and the high-out-of-pocket plans ended. 

Richard Kirsch is a Senior Fellow at the Roosevelt Institute, a Senior Adviser to USAction, and the author of Fighting for Our Health. He was National Campaign Manager of Health Care for America Now during the legislative battle to pass reform.

Photo of President Obama signing the Affordable Care Act copyright George Miller, via Creative Commons license.

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The Contraceptive Mandate Finally Leads America Out of the Victorian Era

Mar 31, 2014Ellen CheslerAndrea Flynn

The Affordable Care Act demonstrates an affirmative, proactive step from government for women's access to reproductive health care, but conservatives are bent on moving backwards.

The Affordable Care Act demonstrates an affirmative, proactive step from government for women's access to reproductive health care, but conservatives are bent on moving backwards.

Contraception should be understood as a fundamental right of American women and a necessary foundation of human security. If that seems controversial, consider this: 99 percent of American women approve of birth control and the vast majority use it over many years of their lives. These women deserve and must continue to demand insurance coverage for the method of their choice, without qualification. That’s why the contraceptive mandate in the Affordable Care Act (ACA) is so important and potentially transformative. For the first time ever, all health insurance plans, whether paid for privately or with public subsidies, are required to cover all FDA approved contraceptives at no additional cost.

Family planning is essential to securing the health and rights of women, but it is also the foundation of sound economic and social policy. Tragically, however, U.S. subsidized family planning programs currently serve just over half of those in need.

The stakes are especially high for poor women, who cannot afford the high costs of the most reliable and desirable methods and experience much higher rates of early and unwanted pregnancy as a result. Single women in poverty head a growing percentage of U.S. households. In “Breaking the Cycle of Poverty: Expanding Access to Family Planning,” a new white paper released today by the Roosevelt Institute, we argue that addressing their needs, and opening up opportunities to them and their children, will require multiple policy interventions, but none can work if women are denied the right and the agency to make, and act on, well-informed decisions about their own bodies.

Decades of social science research demonstrate that access to reliable and affordable family planning methods promotes responsible decision-making and reduces unwanted pregnancy and abortion. It allows women to pursue educational and employment opportunities that strengthen their families and their communities. A majority of women who participated in a recent study by the Guttmacher Institute, for example, report that birth control enables them to support themselves financially, complete their education, and get or keep a job. Other recent studies also show that providing family planning services at no cost results in more effective contraceptive use, decreased rates of unintended pregnancy, and dramatic declines in abortion rates.

Many American conservatives, however, reject these claims. They blame single mothers for America’s rising tide of poverty and inequality, not the other way around. They insist that access to sexual and reproductive health information and services exacerbates social problems by promoting promiscuity and unintended pregnancy, when in fact, the exact opposite is true. They promote abstinence-education and marriage promotion programs that have been tried before and been discredited, because they simply do not work.

This conflict was front and center last week as the U.S. Supreme Court heard 90 riveting minutes of argument in Sebelius v Hobby Lobby Stores, Inc. and Conestoga Wood Specialties Corp. v Sebelius, a pair of cases brought by two privately held corporations owned by Christian conservatives. The owners claim that the ACA violates the religious freedom of employers forced to cover the costs of contraception. Much of the testimony turned on technical questions of whether corporations, as opposed to the individuals who own them, legitimately have rights to assert in this instance, and whether they may impose those rights on employees who don’t share their views. There were also important matters of scientific integrity at stake, with the plaintiffs claiming that Intrauterine Devices (IUDs) and morning-after pills constitute methods of abortion, despite overwhelming medical agreement and numerous reputable scientific studies showing that, like everyday birth control pills, they only act to prevent conception.

All but lost in the court’s conversation were larger concerns about the health and well-being of women and families – and of our society as a whole. The Supreme Court hearing comes in the wake of more than three years of persistent attacks by extreme conservative lawmakers who have already decimated publicly subsidized services in states across the country and left many low-income women without access to basic family planning and to other critical reproductive and maternal health care services.

As legal scholar and policy analyst Dorothy Roberts observed, “when access to health care is denied, it’s the most marginalized women in this country and around the world who suffer the most—women of color, poor and low-wage workers, lesbian and trans women, women with disabilities... And this case has far-reaching consequences for their equal rights. Birth control is good health care, period.”

Today, by government estimates, more than 27 million American women already benefit from the ACA’s contraceptive mandate, and 20 million more will enjoy expanded coverage when the law is fully implemented. Yet even by these optimistic assessments, many low-income women will continue to fall through insurance gaps, partly thanks to a 2012 Supreme Court ruling that enables states to opt-out of Medicaid expansion mandated by the ACA. More than 3.5 million – two-thirds of poor black and single mothers, and more than half of low-wage workers – will be left without insurance in those states.

Conservative opposition to contraception is not new. As we observe in our paper, the U.S. controversy over family planning dates back to Victorian-era laws that first defined contraception as obscene and outlawed its use. Those laws carried the name of Anthony Comstock, an evangelical Christian who led a nearly 50-year crusade to root out sin and rid the country of pornography, contraceptives, and other allegedly “vile” materials that he believed promoted immorality. Sound familiar?

It took nearly a century for the U.S. Supreme Court to reverse course and guarantee American women the right to use contraception under the constitutional doctrine of privacy first enunciated in 1965. The ACA promises us even more. It places an affirmative, positive obligation on government to provide women the resources to realize our rights. The question before us is simple: Do we turn back the clock and allow a new Comstockery to prevail, or do we move ahead into the 21st century by defending the full promise of the Affordable Care Act’s contraceptive mandate?

Read Ellen and Andrea's paper, "Breaking the Cycle of Poverty: Expanding Access to Family Planning," here.

Ellen Chesler is a Senior Fellow at the Roosevelt Institute and author of Woman of Valor: Margaret Sanger and the Birth Control Movement in America.

Andrea Flynn is a Fellow at the Roosevelt Institute. She researches and writes about access to reproductive health care in the United States. You can follow her on Twitter @dreaflynn.

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Breaking the Cycle of Poverty: Expanding Access to Family Planning

Mar 31, 2014

Download the paper by Ellen Chesler and Andrea Flynn.

Download the paper by Ellen Chesler and Andrea Flynn.

Poverty shapes the lives of an increasing number of American women and their families and has many consequences, including high rates of unintended pregnancy. Conservatives, eager to further dismantle federal programs and defeat the new Affordable Care Act (ACA), have recently rekindled the idea that marriage promotion will reverse rising rates of poverty, unintended pregnancy, and single parenthood. To the contrary, addressing the root causes of poverty requires multiple interventions and far more generous government programs across a range of issues, particularly the expansion of reproductive health and family planning information, care, and services. This paper reviews the recent literature on women’s poverty and health and argues that accessible and high quality family planning services for poor women remain an essential component of poverty reduction. It also looks back at the history of policy debates over this question in the hope of finding a path toward renewed bi-partisan consensus.
 
Key Arguments:
  • Family planning is a fundamental right of women and the foundation of human security.
  • Single women in poverty head a growing percentage of U. S.  households. Addressing their needs requires multiple policy interventions, but none can work if women are denied the agency to make – and act on – well-informed reproductive health decisions.
  • U.S. subsidized family planning programs meet only 54 percent of national need. The ACA will help bridge the gap, although its promise is threatened by legal challenges to the contraceptive mandate. Women deserve insurance coverage for the contraceptive method of their choice, without qualification. 
  • Many low-income women will fall through insurance gaps. Every state should expand Medicaid. The federal government should lift Medicaid’s five-year eligibility requirement for documented immigrants and increase Title X funding to address increased demand for services.
  • We can learn from history. Research since the 1970 adoption of Title X illustrates that access to improved family planning methods promotes responsible decision-making and reduces unwanted pregnancy and abortion. By contrast, abstinence-until marriage and marriage promotion programs advanced by conservatives have failed and been discredited. 

Read "Breaking the Cycle of Poverty: Expanding Access to Family Planning," by Roosevelt Institute Senior Fellow Ellen Chesler and Fellow Andrea Flynn.

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Daily Digest - March 31: Obamacare's Big Step Forward for Women

Mar 31, 2014Rachel Goldfarb

Click here to receive the Daily Digest via email.

The Contraceptive Mandate Finally Leads America Out of the Victorian Era (Next New Deal)

Click here to receive the Daily Digest via email.

The Contraceptive Mandate Finally Leads America Out of the Victorian Era (Next New Deal)

Roosevelt Institute Senior Fellow Ellen Chesler and Fellow Andrea Flynn applaud the Affordable Care Act's proactive steps on women's reproductive health care, which are also key to women's economic security.

  • Roosevelt Take: Read Ellen and Andrea's new white paper, "Breaking the Cycle of Poverty: Expanding Access to Family Planning," here.

Comcast's Power Unveiled, Courtesy of Apple (Bloomberg View)

Rumors of a new content deal between Comcast and Apple demonstrate just how much control the internet service providers could have over what media Americans can access, writes Roosevelt Institute Fellow Susan Crawford.

Private Charity Can't Replace Government Social Programs (LA Times)

Michael Hiltzik looks at "the voluntarism fantasy," as Roosevelt Institute Fellow Mike Konczal describes the idea that charity alone could replace the public safety net. Hiltzik agrees with Konczal: it's just not possible.

  • Roosevelt Take: Mike explains the origins and flaws of this fantasy in Democracy Journal.

The Minimum Wage Symposium: A Lot of Data and a Couple of Fights (The Stranger)

Anna Minard reports on the Income Inequality Symposium held in Seattle on Thursday, March 27. She quotes Roosevelt Institute Fellow Dorian Warren, who emphasized how income inequality leads to political inequality.

  • Roosevelt Take: Roosevelt Institute President and CEO Felicia Wong gave the closing remarks at the symposium.

Blueberry Lies: WSJ Spearheads Disingenuous Effort to Keep Exploiting Farm Workers (Salon)

While the Journal may claim a case of "hot goods," in which the Department of Labor seized goods produced in violation of labor law, is regulation run amok, it's a truly necessary enforcement tool, writes Catherine Ruckelshaus.

Interns Are Now Protected Against Sexual Harassment in NYC (ProPublica)

Blair Hickman reports that in response to the dismissal of an unpaid intern's sexual harassment claim against her boss, the New York City Council passed a law including interns in labor protections, regardless of pay.

Jobs and Skills and Zombies (NYT)

There is no skills gap in the U.S. job market, writes Paul Krugman, but this "zombie idea" keeps hanging around. By blaming unemployment on the workers, this creates a very real policy gap.

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Insurance Pays for Health Care. Who’s Providing It?

Mar 28, 2014Rachel Goldfarb

Public funds for family planning services are essential to ensuring people have somewhere to access health care, not just the insurance to pay for it.

Public funds for family planning services are essential to ensuring people have somewhere to access health care, not just the insurance to pay for it.

As if somehow the case still needs to be made that family planning deserves federal funding (and apparently the case does need to be made), last week a panel of researchers, advocates, and family planning providers spoke at a Congressional briefing on the topic “The Publicly Funded Family Planning Network: An Essential Partner in the New Health Care Environment.” Among the panelists was Roosevelt Institute Fellow Andrea Flynn. She and the others explained how Title X, the only federally funded family planning program, fits into the health care landscape now so dramatically changed by the Affordable Care Act. On the heels of Flynn’s white paper on this topic, last Thursday’s panel marked the next step in Roosevelt’s approach to research and policy discussions – namely, to get ideas up and out to those, like the Congressional staffers who attended the briefing, that can convert them into action.

Some background: when Title X was signed into law in 1970, it was intended to ensure that more Americans had access to family planning services, including birth control, because of rising concerns about population growth and poverty. Title X funds patient services, staff salaries, infrastructure, and supplies at clinics across the country. The law had strong bipartisan support – Democrats worked alongside Congressman George H. W. Bush and President Richard Nixon to pass it. And it is pretty effective: according to Flynn, the program today provides care to 4.7 million individuals annually. From 1980 to 2000, Title X-funded clinics provided women with 54.4 million breast exams and 57.3 million Pap tests and prevented an estimated 20 million unintended pregnancies. It’s also cost effective: Flynn notes that in 2008 alone, services provided at Title X-supported clinics accounted for $3.4 billion in savings.

Opponents of federal family planning clinics argue that with full implementation of the Affordable Care Act, the need for funding will drop off. No, said Clare Coleman, President and CEO of the National Family Planning and Reproductive Health Association. Insurance, she pointed out, isn’t the same as access to care. Patients still need providers. Amanda Dennis of Ibis Reproductive Health, based in Cambridge, highlighted an Ibis study conducted after health care reform went into effect in Massachusetts, that found many women took their new insurance straight to Title X-funded clinics for family planning services. Patient numbers actually increased at these clinics and so did the number of insured patients. Women like the care they get at Title X clinics; having insurance doesn’t mean they want to switch providers.

The panel confirmed Flynn’s major conclusions on Title X: the Affordable Care Act doesn’t guarantee every American will be insured at all times, so there remains a need for publicly funded care providers. More federal funding for the Title X family planning network will be essential to ensure women can access reproductive health care. And Coleman drove home another invaluable point as we work on health care access: the Affordable Care Act creates a massive shift in the way many Americans actually go about getting their health care. As a child growing up with insurance, I had an annual physical that was scheduled months in advance, and my mom picked up our prescriptions at the pharmacy. Americans who grow up uninsured have a different experience. They go to public clinics, where they can expect long waits, and when they leave, they go with prescribed medication in hand, obtained at the on-site dispensary.

In other words, signing up for health insurance on healthcare.gov won’t on its own teach anyone how to use insurance. That will take a generational shift. Besides which, you don’t get health care from your insurance – you get health care from your doctor, and cover the costs with insurance. That’s why Title X clinics must remain an option. Public funding for family planning does increase access to providers. Advocates: keep driving this point home to legislators!

Rachel Goldfarb is the Communications Associate at the Roosevelt Institute.

 

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Daily Digest - March 25: Organizing Towards Shared Prosperity

Mar 25, 2014Rachel Goldfarb

Click here to receive the Daily Digest via email.

The New Deal Launched Unions as Key to Building Middle Class (Next New Deal)

Click here to receive the Daily Digest via email.

The New Deal Launched Unions as Key to Building Middle Class (Next New Deal)

In the first of a series of posts summarizing his new report, which explores possibilities for labor-organizing reform, Roosevelt Institute Senior Fellow Richard Kirsch looks at the history of union organizing as a source of shared prosperity.

The Next Health-Care Debate (WaPo)

The Affordable Care Act's success will prove that government is indispensable in fighting widespread inequality, writes E.J. Dionne, who sources Roosevelt Institute Fellow Mike Konczal's work on why charity can't tackle the problem.

The U.S. Cities Where the Poor Are Most Segregated From Everyone Else (The Atlantic Cities)

Noting that "moral cynicism" is among the corrosive "neighborhood effects" of grinding poverty, Richard Florida looks at the data concerning the segregation and concentration poor people, which is greater in large, dense metro areas and where wages are higher.  

Freelancers Piece Together a Living in the Temp Economy (NYT)

Planning for the future in an age of job insecurity is nearly impossible, writes Adriene Hill. She reports on a Las Vegas woman who knows her current assortment of appearance-based gigs can't last forever.

Forces of Divergence (The New Yorker)

John Cassidy reviews Thomas Pikkety's Capital in the Twenty-first Century, which considers the swing back towards capital accumulation over wages in today's economy. Cassidy deems it a must-read for anyone interested in inequality.

The NLRB Must Restore Democracy in Chattanooga (Truthout)

John Logan calls on the National Labor Relations Board to overturn the recent United Auto Workers vote in Tennessee, because otherwise the NLRB will set a precedent that accepts outside interference.

The Law That Could Sink Birth Control Coverage (MSNBC)

In the context of today's Supreme Court hearing on the contraception mandate in the Affordable Care Act, Adam Serwer and Irin Carmon explain the history of the 1993 Religious Freedom Restoration Act.

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Memo to Congress: Family Planning Needs More Funding

Mar 21, 2014Andrea Flynn

On Thursday, March 20, Roosevelt Institute Fellow Andrea Flynn joined the National Family Planning and Reproductive Health Association for a briefing on "The Publicly Funded Family Planning Network: An Essential Partner in the New Health Care Environment." Her prepared remarks are below.

On Thursday, March 20, Roosevelt Institute Fellow Andrea Flynn joined the National Family Planning and Reproductive Health Association for a briefing on "The Publicly Funded Family Planning Network: An Essential Partner in the New Health Care Environment." Her prepared remarks are below.

The Affordable Care Act represents an historic investment in the health of American women and girls. It has already improved the lives of millions of Americans and will make health care accessible for many more as rollout continues. Fulfilling the promise of the ACA, however, depends on the continued support of existing programs, such as Title X, which must remain as pillars of the country’s public health infrastructure.

For more than 40 years, Title X has provided critical medical care to low-income women, immigrant women, and young women across the country.  Some have suggested that the ACA’s expanded coverage of women’s health care will obviate the need for Title X. In fact, the opposite is true. Title X will play a number of important functions in the coming years.

First, Title X will support a network of qualified family planning and reproductive health care providers who will deliver care and services to the growing ranks of insured. Clinics funded by Title X will become an even more critical building block of our nation's health system. Even when individuals obtain coverage, many will continue to choose publicly funded clinics as their main source of care. As one of my colleagues here will further explain, during the four years following the implementation of Massachusetts’ health care reform patients continued to rely on Title X centers even after they gained insurance coverage. 

Women who are already fully insured will also continue to rely on Title X clinics because they can access care with complete confidence. Issues such as intimate partner violence and religious beliefs of employers, family members, and partners, cause many women to circumvent their insurance plans when accessing family planning services. Sadly, these concerns will persist regardless of the coverage status of American women.

Second, Title X will guarantee family planning access to those still uninsured. The ACA was intended to provide a path to health insurance for most Americans. However, because of the Supreme Court’s decision to allow states to opt-out of Medicaid expansion, fewer uninsured Americans will gain coverage than originally planned.  As Clare mentioned,  today, 22 states are still refusing to expand Medicaid, leaving more than 3.5 million low-income women without coverage. As a result, two-thirds of poor black and single mothers, and more than half of uninsured, low-wage workers, remain without coverage. Title X clinics will continue to be a trusted place of care for these women.

Moreover, even in states that participate in Medicaid expansion, many low-income individuals may still remain uninsured. Estimates suggest that between 25-35 percent of those eligible for Medicaid still do not know it, and are failing to enroll.  Many immigrants will also remain uninsured, given the federal 5-year eligibility requirement for Medicaid. And millions of others will churn among coverage plans. One study estimates that up to 29 million people under age 65 will be forced to change coverage systems from one year to the next. Individuals who fall into these categories will rely on the Title X network for quality, affordable, and confidential care.

Third, and equally important, Title X will continue to set a comprehensive standard of care for family planning and reproductive health services.

Finally, Title X clinics are a primary and trusted point of entry into the health system. Six in ten women who receive services at a publicly funded family-planning center consider it their primary source of medical care. As such, the Title X network will continue to play an important role in ACA outreach and enrollment efforts to ensure that health coverage is realized by as many Americans as possible.

Title X is particularly important given the health challenges facing many women in the United States. However, current funding for U.S. public family planning programs extends care and services to just over half of the women in need. Per capita, the United States spends two and a half times more on health care than other developed countries, yet Americans overall have less access to services and experience worse health outcomes. The United States reports among the highest rates of teen birth, unintended pregnancy, and maternal and infant mortality of any industrialized country. Almost half of all U.S. pregnancies – approximately 3.2 million annually – are unintended. Poor women, women of color, and immigrant women bear a disproportionate burden in this regard. They are also more likely to experience chronic disease, maternal mortality and have a lower life expectancy than women with higher incomes.

Unintended pregnancy and teen pregnancy remain persistent issues in the United States, ones that Title X has been tackling for decades. Unintended pregnancies have a number of larger health implications. Women who have unintended pregnancies are more likely to develop complications and face worse outcomes themselves and for their infants. They often receive inadequate prenatal care, and the care they do receive begins later in pregnancy. Research has shown that pregnancies that occur in rapid succession pose additional risks for both mother and child.

The U.S. teen pregnancy rate has declined dramatically over the last decade, thanks to services offered by programs like Title X. However, it is still considerably higher than in any other developed country, where rates are generally 5 to 10 births per 1,000, compared to the current U.S. rate of 29.4 per 1,000. Racial disparities are especially pronounced in relation to teen pregnancy, with teen birth rates for white women hovering around 21.8 per 1,000, while the rates for Hispanic, Black, and American Indian teens are at least twice that. Research has shown that increased access to comprehensive reproductive health information, care, and services, including a broad range of contraceptive methods, reduces rates of unplanned pregnancy among teens.

Title X has prevented these various health disparities from becoming even more troubling. With an increased investment the program could replicate its incredible results many times over, leading to significant health improvements for American women.

In times of economic uncertainty the demand for publicly funded family planning services increases. Since the 2008 financial crisis and the ensuing recession, the need for Title X has grown dramatically, while funding levels have declined or remained flat. Over the past few years the Title X budget has been cut by $40 million. To make matters worse, the anti-family planning and overall austerity sentiments that have since prevailed reduced and restricted family planning budgets in many states. There have been fewer state and federal funds for women’s health during the very time that women have also lost jobs and insurance coverage.

When Title X centers lose funding, they are forced to make cuts in three places: services and supplies, hours, and staff. As a result of funding challenges, six in ten Title X clinics have been unable to stock the most costly contraceptives, particularly long-acting reversible contraceptives (LARCs) such as the IUD and implants, methods considered highly effective and most desirable among women wanting to avoid pregnancy.

Family planning is first and foremost a matter of women’s health and rights. But it is also central to women’s economic security. The continued fragility of the U.S. economy and the recession’s devastating impact on low-income families requires an increased investment in family planning. American families, many of them now headed by single women, face enormous challenges. Access to affordable contraception enables women to pursue educational and professional opportunities that strengthen their families and their communities. The majority of women who participated in a recent Guttmacher Institute study report that birth control enables them to support themselves financially, complete their education, and get or keep a job. 

Given the tenuous state of the U.S. economy, the vulnerability of women’s health programs in the face of unrelenting political attacks, and the fraying social safety net more broadly, public funding for family planning is more critical than ever. Continued – indeed, increased – funding of Title X will maximize the impact and reach of the ACA and ensure continued quality care for those who remain uninsured.

Thank you. 

Andrea Flynn is a Fellow at the Roosevelt Institute. She researches and writes about access to reproductive health care in the United States. You can follow her on Twitter @dreaflynn.

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Florida Election Shows Danger and Promise in Obamacare Debate

Mar 17, 2014Richard Kirsch

Democrats may have lost the special election for Florida's 13th congressional district, but the polling shows a path to success in 2014 with the Affordable Care Act.

Democrats may have lost the special election for Florida's 13th congressional district, but the polling shows a path to success in 2014 with the Affordable Care Act.

As pundits debate the impact of Obamacare on the special Congressional election held in Florida on March 11, a headline from a new Bloomberg national poll actually does as good as any describing what happened in the Sunshine State: “Americans Stick with Obamacare as Opposition Burns Bright.” That national finding also describes what happened in Florida, where swing voters supported the ACA, but more opponents turned out to vote.

The Bloomberg survey found the “highest level of acceptance for the law yet” in Bloomberg’s polling, with almost two out of three (64 percent) of those surveyed saying they supported either retaining the Affordable Care Act (ACA) with “small modifications” (51 percent) or as it is (13 percent).

The troubling result in the survey for the political prospects of the ACA is that the one-third (34 percent) who want to repeal the law are much more likely to vote. No news here. We’ve known that the ACA is a highly motivating issue for Republican voters, who turn out at a much higher rate in off-year elections than Democrats and independents.

The real news is in the first set of findings, the growing popularity of Obamacare outside the Republican base. These findings were confirmed in the Florida election, when Alex Sink, the Democratic candidate, pushed back against attacks on the ACA from David Jolly, the Republican candidate, and independent groups supporting him.

Jolly’s position was clear:  “I’m fighting to repeal Obamacare, right away.” So was Sink’s: “We can’t go back to insurance companies doing whatever they want. Instead of repealing the health care law, we need to keep what’s right and fix what’s wrong.”

The key part of Sink’s message was to remind voters why people wanted health care reform in the first place. As one of Sink’s TV ads said, “Jolly would go back to letting insurance companies deny coverage.” That’s an effective reminder of the huge problems Americans have had for decades, when insurance companies could deny care because of a pre-existing condition, charge people higher rates because they were sick, even charge women higher rates than men. The ACA ended all that.

As would be expected in Florida – and even more so in a special election – the candidates worked especially hard for the votes of seniors. In their ads for Jolly, the Republican Congressional Campaign Committee repeated their misleading charge from 2010, trying to scare seniors into opposing the ACA by saying that it cut $716 billion from Medicare. But unlike 2010, when Democrats did not respond to attacks on the ACA, Sink pushed back. She reminded seniors that the ACA actually provides important new Medicare benefits, including closing the infamous prescription drug “donut hole.” Sink’s ads accurately said, “His [Jolly’s] plan would even force seniors to pay thousands more for prescription drugs.”

By Election Day, voters had a clear contrast between the positions of the candidates on the ACA. It was a close election, with Jolly winning by a small margin (48.4% to 46.5%) in a district with an 11-point Republican advantage, one that has been represented by the GOP for nearly 60 years. But polling found that independent voters in the district supported the “keep and fix” position over the “repeal” position by a margin of 57% to 31%. Sink actually gained ground over Jolly during the election on the question of which candidate had a better position on the ACA.

The narrow margin is encouraging in a district with this large a Republican voter advantage, but still falls short of the turnout in 2012, when President Obama narrowly carried the district. Democrats will need to do better in November, if they are going to hold on to contested Senate races and have a chance of picking up House seats.

Fortunately, unlike in 2010, the Democratic Senate and Congressional campaign committees at least understand that they can’t run away from Obamacare. Doing so will cede independent voters to Republicans, just when those voters are becoming very supportive of the “keep and fix” message. While Democrats would prefer to keep the focus on the economic pressures being faced by American families – highlighting issues like the minimum wage – they’ll only be heard if they also engage aggressively in the fight over the ACA.

In fact, the ACA is an economic issue; just ask anyone who has lost her job and her health coverage. Or the millions of low-wage workers who can’t afford to go to the doctor, or are trying to pay back medical bills from the visit they could not put off. As millions more Americans get coverage – 11 million as of the end of February between the new exchanges, the expansion of Medicaid and young people under 26 – Democrats should incorporate the ACA into their overall economic message.

Supporters of the ACA have consistently believed that once the ACA began to be implemented, it would become more popular. We’re starting to see that shift. The challenge now will be turning that popularity into votes in November. 

Richard Kirsch is a Senior Fellow at the Roosevelt Institute, a Senior Adviser to USAction, and the author of Fighting for Our Health. He was National Campaign Manager of Health Care for America Now during the legislative battle to pass reform.

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The Story of Atalissa Highlights America's Long-Term Care Problem

Mar 11, 2014Sarah Galli

America's health care system neglects people who require long-term care and denies them the opportunity to lead full, rewarding lives.

Since the moment my brother was rendered a quadriplegic in a diving accident when we were teenagers, I have maintained a constant, silent stress in my body. I am worried about health complications inherent in a paralysis injury, terrified for what happens when my parents are no longer able to serve as Jeff’s primary caregivers.

America's health care system neglects people who require long-term care and denies them the opportunity to lead full, rewarding lives.

Since the moment my brother was rendered a quadriplegic in a diving accident when we were teenagers, I have maintained a constant, silent stress in my body. I am worried about health complications inherent in a paralysis injury, terrified for what happens when my parents are no longer able to serve as Jeff’s primary caregivers.

My brother is, aside from requiring constant care for his injury, in good health. My parents have done an exceptional job of keeping his life, unlike his cervical vertebrae, stable.

We are, in many ways, lucky.

The same cannot be said for a group of men my father’s age in Atalissa, Iowa.

In a groundbreaking feature released last weekendThe New York Times profiled a group of Iowan men with intellectual disabilities who were forced to perform backbreaking hard labor for more than 30 years, housed in filth by "caregivers" who did nothing of the kind. These men, who worked in a slaughterhouse for hours on end, with no treatment or support for their disabilities, lived in a schoolhouse so squalid they had to cover their dinner plates to protect them from cockroaches. Many still have chronic health issues resulting from such neglect.

Wrote Times reporter Dan Barry, “Every morning before dawn, they were sent to eviscerate turkeys at a processing plant, in return for food, lodging, the occasional diversion and $65 a month. For more than 30 years. Their supervisors never received specialized training; never tapped into Iowa’s social service system; never gave the men the choices in life granted by decades of advancement in disability civil rights. Increasingly neglected and abused, the men remained in heartland servitude for most of their adult lives.”

Since they were discovered in 2009, advocates and social workers have worked to give these men a sense of freedom seemingly granted to everyone but individuals with disabilities. These men each lost over 30 years of their lives because Iowa failed to protect them from their designated protectors. Families were told Henry’s Turkey Service was the best option for their sons and brothers. Instead, these men were as much prisoners as the turkeys they were told to tear apart.

Reports of barbaric conditions surfaced every few years; no action was taken.

A few men tried to escape; one, Alford Busby Jr., ran away during a 1987 snowstorm: “Local officials searched the wintry landscape without success. Three months later, during the spring thaw, a farmer found a body along a field’s fence row, a quarter-mile from the main road. Mr. Busby was 37, or maybe 43. 'Mentally retarded man wandered away from home in subzero temperature,' his death certificate says, citing hypothermia.”

The men were rescued five years ago. They now receive Social Security and Medicaid, they have homes to live in and care for them, and they are paid wages for jobs worked. They have the freedom to meet new people, date, and live a life they’ve chosen.

The Times piece exposed my greatest fear: what will happen when my parents are no longer able to provide for Jeff, when my brother will have to join the ranks of thousands of Americans who require 24/7 care and lodging somewhere separate from their chosen home.

My father spent the summer as an embedded journalist in Baghdad a few years ago, and because my mother couldn’t work her full time job and also fill the holes in nursing care normally covered by my dad, my brother was forced to stay temporarily in a nursing home. I would travel from Manhattan to see him in Rhode Island, and attempt to hide my tears until after I’d left. A nurse came over at the end of one such visit, and in what she intended to be a moment of trust between us, gave Jeff a kiss on the cheek. I wanted to tackle her to the ground, furious that this stranger was playing at false intimacy with a young man she knew nothing about.

Instead, I choked back tears and left my twentysomething brother in his room, a bright young man relegated to living in a home with elderly residents in a system that treats them all as if they're just waiting to die.

President Obama proposed the Community Living Assistance Services and Supports (CLASS) program as part of the Affordable Care Act, which offered voluntary long-term care insurance. But that support (granted to eligible workers after five years, not taking into account exceptions for those whose disabilities preclude employment) capped out at a lifetime cash benefit of $75 a day/$27,000 per year. According to the National Spinal Cord Injury Statistical Center, the average yearly expenses for someone with a high-level spinal cord injury run an average of $181,328, not including indirect costs.

The CLASS Act has since been repealed and replaced with a long-term care commission; there is no word on what recommendations will come, nor when.

The Christopher & Dana Reeve Paralysis Act, passed in 2009, aimed to further scientific research and improve “quality of life” and rehabilitation options for individuals living with paralysis. But there has not yet been comprehensive legislation to protect Americans with chronic spinal cord injuries as their caregiving options change over time. There is no mechanism to support independent living for someone with a high-level injury, and no understanding that an otherwise healthy, capable person should not be relegated to the same care granted to the elderly. 

Curt Decker of the National Disability Rights Network said the Iowa story “is what happens when we don’t pay attention.” I read about the men of Atalissa and I mourn for the years lost, taken away from these sons and brothers.

And I wonder who will care for mine.

Sarah Galli is the Political Action co-chair of Women’s Information Network (WIN.NYC). She is also the Founder & Executive Producer of Born for Broadway, whose mission is to raise funds for paralysis research through special events, education, and advocacy. For more information, please visit www.sarahgalli.com.

Image via Thinkstock

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The Simple Solution to Obamacare's Employer Mandate Problems

Mar 3, 2014Richard Kirsch

Requiring employers to offer insurance to all employees or pay an additional payroll tax would eliminate the problems with the employer mandate, and start a shift toward broad tax-based coverage.

Requiring employers to offer insurance to all employees or pay an additional payroll tax would eliminate the problems with the employer mandate, and start a shift toward broad tax-based coverage.

In the last month, two more misleading headlines – one on lost jobs and the other on premiums for small businesses – have further roiled the overheated debate about the impact of the Affordable Care Act (ACA) on business and jobs. The question of how to deal with our employer-based health system continues to provide fodder for attacks on Obamacare. And it has proven to be  – and promises to continue to be – the basis for the most potent attacks against Republican proposals to replace the ACA. But in terms of policy, there is a simple solution, which would rationalize the contradictions in the Affordable Care Act and ease the way for the long-term goal shared on the left and right of separating health coverage from employment.

The general approach taken in the Affordable Care Act was to require most employers to provide coverage. The specific proposal in the final legislation, shaped by compromises with and pressure from both small and big business lobbying groups, required employers with more than the equivalent of 50 full-time workers to pay a portion of health coverage for employees who work 30 hours a week, or pay a fine. This is the employer mandate, which was delayed a year by the Obama administration and will be phased in starting in 2015.

The employer mandate does accomplish much of the prime goal of reform. Most employers have incentives to continue to provide coverage, or expand coverage. New coverage options are available for most people who do not get coverage at work, which was virtually all of the 50 million people who were uninsured when the ACA became law in 2010. People are not locked into jobs just because of health coverage, which was the real finding of the Congressional Budget Office report projecting 2.3 million people would retire or reduce their hours of work. Ending job lock opens up those hours to people who want to work and is a huge boon to entrepreneurship.

But the problems with the structure of the employer mandate are obvious. The law creates incentives for employers to keep workers’ hours under 30. It also establishes the potential for a business with a growing number of employees, when it exceeds the 50-employee threshold, to suddenly have to pay for health coverage.

The existence of incentives to cut hours or limit employees does not at all mean that employers will adjust for them. The accusations that the ACA is creating a part-time economy are belied by the facts: part-time employment is going down as the economy accelerates. In addition, employers that are adding workers rapidly as their businesses grow are not going to stop expanding  – or establish dozens of very small corporations – to avoid paying for health coverage. Still, we are seeing examples of some employers, including public employers and universities, limiting workers’ hours to less than 30. Others, like Trader Joe’s, are establishing different employment tracks for part and full time employees, with health care as a key factor. As this is all new – with the mandate not yet in effect – it is impossible to measure the future impact, but the incentives are certain to shape some business decisions.

There is a simple solution, one that was included in the version of the ACA enacted by the House in 2009. Employers that decide not to provide health coverage for their employees would be required to pay a percentage of payroll as a tax to cover health care, just like employers do now for FICA (Social Security and Medicare). Instantly, the cliff impact is gone, both in terms of hours and number of employees. Employers could either provide coverage to all employees, or pay for health coverage in the same manner as FICA, a regular cost of adding an employee, with a marginal increase in cost for each hour someone works. There is no advantage to hiring someone for less than 30 hours or keeping under 50 employees.

Paying a percentage of payroll also has another huge advantage over both the ACA and the current system of employer-provided coverage. Right now, the cost of health insurance premiums does not vary with an employee’s income. This creates a much bigger disincentive to hiring lower-wage workers. For example, a $6,000-a-year policy is 20% of the wages of a $30,000 a year employee but only 5% of the pay of a $120,000 a year employee. Paying a percentage of payroll instead would make it much more affordable to hire low-and-middle income wage earners than it is now. And while it would make it more expensive to employ higher-wage workers, most employers with high-wage workforces already provide health coverage and would be likely to continue to do so, rather than pay the payroll tax. If they did choose to pay, the cost is more easily absorbed for high-wage employees. Besides, that is not where we have an employment problem in the U.S.

This solution mimics the structure of union-employer benefit funds, which are typically found in industries where workers have fluctuating hours. Under these “Taft-Hartley” funds, employers and workers pay into the fund based on the number of hours an employee works. The loudest opponents from the left of the employer mandate in the ACA have been unions whose members get health coverage through such funds now. The unions have said that the ACA encourages employers to stop paying into the funds, now that government will provide subsidies for many workers. But if the current employer mandate were replaced by a payroll tax, the status quo that has worked well for these funds would be maintained.

Historically, the biggest opponent of a payroll tax for coverage has been the small business lobby, which is why the ACA does not require small employers to provide coverage. That is why the House version of the ACA phased in the payroll contribution based on payroll size, with no contributions required for payrolls under $500,000, increasing gradually to an 8% contribution for payrolls over $750,000.  This eases the burden on small employers.

Slowly, the employer-based health coverage system in the United States is dissolving. Over the past 30 years, the share of workers with ESI has shrunk from 70% to 57%. Recently we have seen employers who traditionally have wanted to take responsibility for structuring employee coverage begin to use private exchanges, in which their workers get a fixed amount of money to choose from a choice of health plans. These trends hasten the broadly shared goal of separating employment from health coverage.

As the debate over the ACA turns from repeal to fixing the law, progressives should make the payroll contribution proposal a central focus, our response to problems with the employer mandate. If enacted, as more employers choose to pay into the fund rather than provide their own coverage, we would move closer to ideal of a broad-based tax for coverage, not tied to an individual employer. And while a payroll tax is not progressive – it is proportional – it is much more progressive than the very regressive system we have now of fixed premiums regardless of income. The result would be evolution toward a relatively broadly based tax for health coverage, a key to making health coverage a right. 

Richard Kirsch is a Senior Fellow at the Roosevelt Institute, a Senior Adviser to USAction, and the author of Fighting for Our Health. He was National Campaign Manager of Health Care for America Now during the legislative battle to pass reform.

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