What Will Obamacare Mean for the Low-Wage Work Crisis?

Jun 18, 2013Richard Kirsch

New health insurance marketplaces will make affordable care accessible to millions, but low-wage employees of big businesses may be left out.

One of the biggest issues that the Affordable Care Act (ACA) is meant to tackle is the lack of health coverage among low-wage workers. While there is good news for many low-wage workers in the new law, many others will still find themselves locked out of access to affordable coverage. Solving their concerns will be one more part of the huge challenge of confronting the power of mammoth low-wage employers in the new economy.

New health insurance marketplaces will make affordable care accessible to millions, but low-wage employees of big businesses may be left out.

One of the biggest issues that the Affordable Care Act (ACA) is meant to tackle is the lack of health coverage among low-wage workers. While there is good news for many low-wage workers in the new law, many others will still find themselves locked out of access to affordable coverage. Solving their concerns will be one more part of the huge challenge of confronting the power of mammoth low-wage employers in the new economy.

There has been a lot of coverage about the potential for fast food chains and other employers to cut the hours of some of their employees to under 30 a week in order to avoid having to offer them health coverage. To the extent that employers do cut back hours, it will accelerate a long-trend toward part-time low wage work; part-timers increased from 17 percent to 22 percent of the workforce just from 2007 to 2011.

The surge in part-time work is one aspect of the broader increase in low-wage work. Most of the jobs coming out of the recession are low-wage, which has hastened a trend going back 30 years of a growing number of low-wage jobs with no health benefits. The powerful eroding of good jobs is the greatest threat to broadly-shared economic prosperity. It destroys any promise of people living a middle-class life style, creates a two-tiered society, and undercuts the consumer buying power needed to move the economy forward.

The low-wage economy means more than just low wages. Post-World War II jobs, which came with employer-provided health coverage and a pension, are fast disappearing. Now more than four-in-ten workers do not get health coverage on the job. This includes many employees of small businesses, which do not offer any health coverage. It also includes millions of employees of large businesses, who either are not offered health coverage or can't afford the premiums.

Enter Obamacare. The good news in the ACA for low-wage workers who work for small employers (those with fewer than 50 full-time workers) is that many will have access to affordable health coverage for the first time through the new health insurance marketplaces. They will be able to sign up for subsidies that limit how much they pay in premiums to a percentage of their income and get plans with good benefits and moderate out-of-pocket costs. Those with incomes below 133 percent of the federal poverty level (about $15,000 for an individual) will be eligible for Medicaid in states that agree to expand coverage.

But for those who work for bigger employers – and some two-thirds of minimum wage jobs are at employers of 100 or more – it is not clear whether the ACA will deliver on its promise of affordable coverage. Ironically, part-time workers may come out ahead, with a much better chance of affordable coverage, while full-time low-wage workers may find coverage out of their financial reach.

Millions of people who don’t work more than 29 hours a week for any one employer will be eligible for affordable subsidized coverage through the new marketplaces. And even if employers trim back some workers' hours to get below the 30-hour mark, those workers may end up better financially and gain affordable coverage for the first time.

There will also be some employers who increase the hours of part-time workers to above 30 a week, as the Cumberland Farms stores, which employ 4,500 full-time workers and 2,700 part-timers, plan to do. Noting that  full-time workers stay with the business three to four times longer than part-timers, the Cumberland Farms CEO explains, ““Longer-tenured workers deliver a better experience for the customer.” According to the payroll-processing firm ADP, other businesses are also likely to encourage more workers to become eligible for employer coverage.

But it is not at all clear that full-time low wage workers for bigger employers will be able to get affordable coverage. That is because the big business lobby exercised its muscle in shaping the ACA in the Senate Finance Committee. All the law requires is that employers offer individual employee health coverage that does not cost more than 9.5 percent of an employee’s income in order for the business to escape paying a $2,000-to-$3,000 penalty. In addition, the ACA allows employers to offer plans with very high out-of-pocket costs.

Make no mistake about it; 9.5 percent of wages is a lot for anyone to pay for health insurance, and it is a huge amount for low-wage workers. By comparison, an employee who makes $12 an hour and works a 35-hour week would pay about 6 percent of his or her income on health insurance in the new marketplaces, for coverage which is almost certain to have better benefits and lower deductibles and co-payments.

And here’s the kicker: as long as a worker is offered the less-than-9.5-percent-of-income coverage at work, that worker is not eligible for the much better coverage in the marketplace. And if the worker decides that she can’t afford the premiums, she will be have to pay a penalty for not being insured.

The big outstanding question is, what will the bigger low-wage employers do? They could choose to offer affordable coverage to their employees. But the big fast food chains, retail giants, and box stores have a history of offering several levels of coverage to their employees, including bare-bones plans targeted at their lowest paid workers.  

Putting this all together, here is what health coverage for low-wage workers may look like after a couple of years of implementation of Obamacare: good coverage for those who work for smaller businesses and who don’t work more than 29 hours a week for any one employer, but either no coverage or coverage that is costly to buy and to use for many people who work more than 30 hours a week for the biggest low-wage employers in the country.

Seen in this light, Obamacare is one more step toward both improving and exacerbating the low-wage work crisis in the nation. The movement away from employer-provided health coverage is a huge step forward in creating a more just health care coverage system. But justice for low-wage workers at big businesses will mean confronting the power of companies like WalMart, McDonald's, and Bank of America (with its low-wage tellers). This is the same challenge we face in taking the other steps needed to modernize labor standards for the 21st Century: a higher minimum wage indexed to inflation, paid sick days and family leave, and overhauling labor laws so that workers’ rights to form unions is restored. It is fast becoming central to the fight for a new economy that works for all Americans.

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.


Health care reform advocates image via Shutterstock.com

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The Next Big Obamacare Battle: The Low-Wage Workers Who Get Left Out

Apr 1, 2013Richard Kirsch

Reformers should start building a coalition to push for expanding the bill and making it more affordable.

Reformers should start building a coalition to push for expanding the bill and making it more affordable.

The whining from some fast food chains that they won’t be able to afford paying for their employee’s health coverage under Obamacare have gotten a lot of press. But what is more troubling is the recent news that some big chains are concluding that the costs won’t be nearly as high as they had projected. The reason: their employees won’t be able to afford the health insurance and will instead pay a fine and remain uninsured. This fight is just the first battle in the coming war over Obamacare that will center around those who get left out. Big flaws in the bill will mean that many low-wage workers will be forced to choose between paying huge chunks of their income on premiums or on a penalty that leaves them with no coverage at all. Reformers should take note and get ready for the coming struggle.

Last week, the Wall Street Journal reported that Wendy’s lowered its estimate of the cost of Obamacare for each of its restaurants by 80 percent, from $25,000 a store to $5,000. The hamburger chain figured that many of its full-time employees, who will be offered health insurance through the company, will turn down the coverage because, as the Journal reported, “they can get insurance through Medicaid or a family member, or because they prefer to pay the penalty for not having coverage.” That penalty starts at $95 a year, although it will go up to $695 by 2016.

Wendy’s isn’t alone. Several other fast food chains have come up with similar estimates. One example is Popeyes, which figures that since only 5 percent of its employees have signed up for the high deductible plan now offered at a price of only $2.50 a week, few workers will choose to pay an estimated $25 a week for the improved coverage it will offer under Obamacare. While the new coverage required under the law will be far superior to the plan Popeyes now offers, with a good list of benefits, it will still include a steep deductible, particularly for a low-wage worker.

The debate over fast food chains and their workers is revealing one of the biggest flaws in the Affordable Care Act. Many low-wage workers will be put in a very difficult position: pay a big chunk of their limited wages for health insurance that is costly to use, or pay a fine for the privilege of remaining uninsured. This is an example of how the debate around Obamacare is about to take a huge turn. Instead of partisan opponents fearmongering about the theoretical impact of the law, the new struggle will be around the actual experience of those Americans whom the law was written to protect: people who are uninsured because they can not afford coverage or are locked out of the system because they have a pre-existing health condition.

Come January 2014, millions of people will get affordable health coverage for the first time. These will mostly be working people who do not get insurance on the job now but will become newly eligible for Medicaid or income-based tax-credits to buy insurance in the new health insurance marketplaces (“exchanges”). This will also include those who will no longer be turned down because of a pre-existing condition. The expansion of Medicaid – in states that give that the green light – and the income-based subsidies will create a huge new constituency for Obamacare that will oppose any attempts to roll back the law.

But due to problems written into the Affordable Care Act, the news won’t all be good for many people who can’t get affordable coverage now. There are some for whom the coverage in the marketplaces will still be too costly because the subsidies are too stingy. For example, a single person who earns just $33,500 will be required to pay $258 a month in premiums, which is more than 9 percent of his or her gross income, for coverage. That’s a big chunk out of a moderate income and is more than twice as much as that person would pay under Massachusetts’s current, successful law. In fact, people who earn more than two times the federal poverty level would be required to pay premiums from 6.3 percent to 9.5 percent of their incomes. If those costs are out of their financial reach, the bleak alternative is to pay a fine for remaining uninsured. It’s true that the coverage will include good benefits, free preventive services, and a cap on out-of-pocket costs. But unless it is already paying high medical bills, that won’t help a working family pay a high premium. The millions who face this dilemma will not be happy to have to make the choice between premiums that will put a big squeeze on an already tight budget or paying a fine they can’t afford for no benefits at all.

Which brings us to the second big group of people who will face this dilemma: low-wage workers who work more than 30 hours a week for a business that has 50 or more full-time employees. These employers can require employees to pay up to 9.5 percent of their incomes as premiums. The premiums are likely to be less for individuals; Popeyes estimates $1,200 a year, which would be similar to what has been found workable in Massachusetts. However, unlike in Massachusetts, the minimum coverage will have very high out-of-pocket costs, so workers will face high premiums for coverage that they can’t afford to use (although preventive care will be free). Furthermore, employers could decide to put more of the costs on to their workers, forcing them to choose between the premium and fines.

The news is much worse for family coverage. The IRS ruled earlier this year that the 9.5 percent rule will apply to the cost of individual coverage, even if family coverage costs much more than this. Here is how the New York Times editorial board explained the impact, in an editorial titled, “A Cruel Blow to American Families”:

A Kaiser Family Foundation survey found that in 2012, employees’ annual share of insurance premiums averaged $951 for individual coverage and $4,316 for family coverage. Under the I.R.S. rule, such costs would be considered affordable for an employee with a household income of $35,000 a year — making the employee’s spouse and children ineligible for a public subsidy on a health exchange, even though that family would have to spend 12 percent of its income for the employer’s family plan.

The Times goes on to report that between 2 million and 3.9 million spouses and children could lose access to affordable coverage because of the ruling. Those are millions of people for whom the law will be an empty promise.

The major purpose of the Affordable Care Act was to make decent health coverage affordable to Americans, and the law’s success will depend on how well it does just that. Next year, many millions of now uninsured people will gain access, but there will be millions of others for whom the promise remains out of reach. In the toxic political atmosphere surrounding Obamacare, the people left out will take center stage.

Republicans will seize on this situation to argue that the law is not working and use these people’s frustrations to portray the law as an expensive failure. The task for the champions of the ACA will be to unite those who are benefiting under Obamacare with those who will only benefit if the law is made more affordable. And since making coverage more affordable will take the government and, ideally, employers paying for more of the premiums, enacting the fixes will require a big political lift, particularly in the current Congress. Meeting this challenge will require organizing the winners and the losers to push for strengthening the law together.

All of this will become an issue in the 2014 and 2016 elections. In this way, Obamacare will join Medicare, Social Security, and Medicaid as perennial issues of public debate, with competing visions of the role of government in assuring the security and well-being of our citizens. It’s a fight that never ends. 

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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Paul Ryan’s Budget Would Kill Health Insurance Programs – and Thousands of Americans

Mar 14, 2013Richard Kirsch

Ryan's budget priorities expose a disregard for the fundamental right to a healthy life.

I know you are not supposed to write in hyperbole, but sometimes the truth needs to be told. Paul Ryan’s budget, which kills Obamacare and cripples Medicare and Medicaid, would kill tens of thousands of people. Every year.

Ryan's budget priorities expose a disregard for the fundamental right to a healthy life.

I know you are not supposed to write in hyperbole, but sometimes the truth needs to be told. Paul Ryan’s budget, which kills Obamacare and cripples Medicare and Medicaid, would kill tens of thousands of people. Every year.

I have trouble with putting policy glosses on proposals that would deny health care coverage to millions of people and make care much more expensive to millions more. Because when more people lack health coverage, more people die. And when health costs prevent people from getting the care they need, they get more seriously ill.

How many people are we talking about? Estimates of the number of people who will die because they are uninsured vary, from about 500 to 1,000 for every one million who lack coverage. Repealing Obamacare would block promised coverage for 32 million people, so that would mean somewhere from 16,000 to 32,000 each year who will die prematurely. Of course, since some Republican governors and legislatures are not implementing the expansion of Medicaid coverage in their states, some of those deaths are already on their hands.

Which leads us to the Ryan plan for slashing Medicaid. He replaces a program that now entitles low-income people to health coverage with a block grant to states to spend however they want on health care for the poor. The federal government would save money by decreasing what it pays to state governments and states would get to do the dirty work of cutting people’s health care. That will mean fewer people on the program, higher out-of-pocket costs, or a reduction in coverage of medically necessary care. And more people dying who would have lived if they had kept their previous health coverage.

In cutting Medicaid, Ryan is fulfilling the biggest concern that Republican governors say they have when they consider expanding Medicaid under Obamacare. A typical remark came from Arizona Governor Jan Brewer: “As I weighed this decision, I was troubled by the possibility that a future President and Congress may take steps to reduce federal matching rates, leaving states with a greater and greater share of health costs over time.”

Everyone is familiar by now with Ryan’s proposal to replace Medicare with vouchers to buy private insurance. The Ryan voucher plan is not about controlling health care costs; instead, it is intended to shift costs from the federal government to the seniors and the disabled who are covered by Medicare. When people can’t afford the care they need – and the CBO reported that the first Ryan voucher plan would have doubled the already high cost of health care to seniors – they will get sicker.

The parts of Obamacare that Ryan doesn’t repeal underscore his cynicism. Ryan would keep the $716 billion in Medicare spending reductions over a decade, which he railed against when he was running for vice president. In his debate with Joe Biden, Ryan called the Medicare changes a “piggybank” for Obamacare, which would cause hospitals and nursing homes to close and lead to seniors losing benefits. None of this is true, as Biden pointed out. So now Ryan is using that $716 billion in savings to help him reach his goal of balancing the federal budget instead of what those savings were intended for: increasing Medicare benefits under Obamacare and expanding coverage to millions of Americans.

Remarkably, Ryan also keeps the other tax increases in Obamacare, some $1 trillion raised mostly from upper income taxpayers and various medical providers and insurers. Ryan is using money raised to provide life-saving health coverage to millions of people, taxes he and other Republicans railed against, to meet his fantasy target of balancing the budget in 10 years.

I’ve grown tired of providing a veneer of respectability to people in power – people with good health insurance, coverage that provides them with access to the best medical care, and pays most of their bills – who deny their constituents a basic human right. Governors and state legislatures who won’t expand Medicaid even though the federal government will pay virtually all of the cost. Members of Congress whose health coverage is largely paid for by their constituents who still make political hay by demagoging against Obamacare.

Fortunately for those whose lives are at risk, the Ryan budget is dead on arrival. But the debate about how to make the promise of Obamacare real is only just the beginning. States will continue to debate whether to expand Medicaid. And when Obamacare’s major provisions kick-in next January, there will be a new round of debates about whether families can afford the new coverage and whether employers and government should do more or less to assure that people get covered. What will not end is the real consequences in each of those decisions for people’s lives. 

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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States Saying No to Health Care Marketplaces is Good News

Feb 26, 2013Richard Kirsch

ObamaCare has a better chance at success if it's taken out of the hands of Republican governors who want to see it fail.

The headlines – “Many States Say 'No' to Health Insurance Exchanges,” to take one example – make it seem like bad news. But it’s not. It is good news that half the states are refusing to have anything to do with the new health insurance marketplaces being set up under the Affordable Care Act.

ObamaCare has a better chance at success if it's taken out of the hands of Republican governors who want to see it fail.

The headlines – “Many States Say 'No' to Health Insurance Exchanges,” to take one example – make it seem like bad news. But it’s not. It is good news that half the states are refusing to have anything to do with the new health insurance marketplaces being set up under the Affordable Care Act.

One of the biggest differences between the good version of ObamaCare passed by the House and the mediocre Senate version that became law was the question of whether the federal government or states would run the new health insurance marketplaces (called “exchanges” in the law). But resistance by Republican governors is leading to implementation of the law in a way that is much closer to the vision in the House bill.

The new health marketplaces are the centerpiece of ObamaCare, the mechanisms through which people who don’t get health coverage at work but make too much for Medicaid will be able to purchase subsidized health coverage, even if they have a pre-existing condition. The marketplaces, which are projected to cover 12 million people in 2012 and 29 million by 2021, will also offer more affordable insurance plans to small businesses.

The House legislation would have had the federal government run the marketplaces while allowing states the option of taking over if they could demonstrate the ability to do at least as good a job. Consumer advocates hoped that the result would be a good national marketplace, with some exemplary states demonstrating how to do an even better job at providing quality coverage and good access while controlling costs.

But the Senate legislation, which became law, gave the primary responsibility to each state to set up a marketplace, with the federal government as backup. Advocates were not pleased for two reasons. The first was a concern that states would do a very minimal job of protecting consumers. The second worry was that states would fumble the complicated task of getting the exchanges up and running by October 1, 2013, when they are open for enrollment.

In reality, the reluctance of so many Republican governors to cooperate with ObamaCare has led to the creation of a system that looks more like the House bill. The federal government will run the exchanges in 25 states and will have primary responsibility, in partnership with states, in seven more.

The last thing consumers needed was for governors who want the ACA to fail – like Florida’s Rick Scott and Texas’s Rick Perry – to be in charge of the law’s implementation. We can be sure that governors in these states would do the minimum amount under the law to sign people up or to protect consumers from high-priced, poor-quality health insurance plans.

On the other hand, some of the states that have decided to set up their own marketplaces are doing what the authors of the House law hoped: being models. Massachusetts, which has been running a marketplace since 2007, is the trailblazer. The state did an excellent job promoting health care coverage and making it easy to sign up, either online or in person. There are strict conflict-of-interest protections for the individuals who govern the marketplace. And they have only contracted with health insurance providers, including community providers, that offer quality coverage at a reasonable cost. As a result, premium inflation has been low.

Several states look like they will follow the Massachusetts example, including California, Connecticut, the District of Columbia, Oregon, Rhode Island, and Vermont (which is moving toward a single-payer plan in 2017). If these states prove successful in demonstrating that acting on behalf of individuals and small businesses results in better access at lower costs, the example is likely to be followed by other states and the federal government.

The open question is how good a job the Federal Department of Health and Human Services will do running the marketplaces in 32 states. This year, HHS is setting its sights on the essentials. The top priority – no small challenge – is getting up and running by October 1st, when people and small businesses can start enrolling. Setting up online systems that account for the different plans and the varying Medicaid and Child Health Insurance eligibility rules in each state is daunting. Enrollment will only be available online, and plans will be easy to compare. However, there will be contracts with state-based groups to assist with outreach and enrollment. The feds say they will pay at least some attention to assuring that community health centers are included as providers by some insurers.

For now, HHS is not implementing key measures to assure that quality health insurance is provided at the best possible cost. It has decided to wait four years until all health insurance plans must be fully accredited by quality assurance bodies. More significantly, it will not initially use its biggest tool, restricting access to the marketplaces to health insurance plans that meet quality standards at a reasonable cost. Most people in the health exchanges will have their costs capped at a percentage of their income, with the government picking up the difference. So limiting insurance plans to those that provide good value will be essential to keeping the system affordable to the government and resisting pressure to increase the cost to consumers.

This October, three and a half years after the ACA was passed, consumers will start enrolling in the new marketplaces. At that point, the debate about ObamaCare will shift from theory to practice. It is vitally important that people learn about the new marketplaces and can readily comparison shop and qualify for income-based subsidies for coverage. There will be huge headaches in the process. But there will be a lot fewer problems than if every state in the union was doing this on its own. It’s good to have one instance where opposition to ObamaCare from the right is all for the best. 

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.


Rick Perry image via Christopher Halloran / Shutterstock.com.

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Emergency Contraception Use Spreads, but Many Women Are Still Left Out

Feb 26, 2013Ellen CheslerAndrea Flynn

New evidence shows more young women are using emergency contraception but we still have work to do to reduce all barriers.

New evidence shows more young women are using emergency contraception but we still have work to do to reduce all barriers.

A federal study released recently shows that use of emergency contraception (EC) in the United States, known colloquially as the “morning after” pill, has more than doubled in the past decade. This is good news. It demonstrates the critical and expanding role the method may now be playing in enabling women, particularly young women, to prevent unplanned pregnancies. But there are still serious hurdles women face in accessing this method of birth control. While access has expanded, there is still work to be done.

The study, conducted by the Centers for Disease Control and the National Center for Health Statistics, strengthens the case for promoting EC widely and making it more readily available. Based on interviews with more than 12,000 women from 2006-2010, the research finds that EC use among all sexually experienced women between the ages of 15-44 has increased to 11 percent (up from a baseline of 4.2 percent). That number is even higher among women 20-24, one of the highest risk groups for unplanned pregnancy. Nearly a quarter of this cohort now reports having used EC.

This is no coincidence. In 2006, nearly a decade after EC first entered the market under the trade name Plan B and after years of stalling and political maneuvering by the Food and Drug Administration (FDA), the agency finally ruled that the product can be provided without prescription to women over the age of 18. A year later, a federal judge ordered the FDA to make it available to women over the age of 17. An important provision of the Obama administration’s Affordable Care Act (ACA) also now promises to cover the cost of all methods of contraception, including this one.

The government study confirms what we already know: accidents happen. Half the participants report having used EC out of fear that their initial birth control method had failed; the other half used it because they had unprotected sex. This reminds us that even women who have a “plan A” need a “Plan B,” or, as the product is now also marketed, a “Next Choice.” Nearly one-third of all U.S. women using contraception rely on the pill, and approximately 16 percent use condoms – both effective methods when employed perfectly, but also ones prone to human error. Condoms break, and sometimes women forget to take a daily low-dose pill. And then there are still the many women who, because of lack of access, cost, forgetfulness, or spontaneity, still don’t consistently use birth control and need protection after the fact.

One of the most common arguments against EC is that it is really just an early abortion method masked as contraception. This simply has no basis in science, as most recently explained by the International Federation of Gynecology and Obstetrics. Unlike medication abortion, which terminates a pregnancy in its earliest stages, EC actually prevents a pregnancy from occurring.

The next most popular and equally erroneous claim is that increased access to EC – and, for that matter, any program or product that provides access to abortion, contraception, or sexuality education – will promote risky sexual behavior. Studies from diverse countries over many years tell us this is not the case. But new research coming out of New York City now confirms that access to EC right here at home does not encourage young people to become more sexually active. In fact, it does just the opposite. The NYC Department of Health recently reported a 12-point drop over 10 years, from 51 to 39 percent, in the proportion of public high school students who are sexually active. Over the past few years, the proportion of sexually active students using contraception, including Plan B, increased from 17 to nearly 27 percent. Both trends coincided with an expansion of school-based health centers that provide free contraception (including EC), counseling, and sexuality education.

So now we have homegrown data to show that when young people have access to sexual health information, no or low-cost products and services, they make better and safer decisions about their reproductive and sexual lives.

But while the federal data illustrates an overall increase in EC use, it also reveals an educational and economic divide among women who use it, suggesting the need for better information and access for low-income women. The CDC study finds that EC use is highest among college-educated women (12 percent), compared to women who have only completed high school or received a GED (7 percent). A 2011 study conducted by researchers at the Boston University School of Public Health also found that while a majority of pharmacies in low-income neighborhoods do have EC available, they often provide incorrect information about eligibility.

Add this to a number of other potential barriers, and it is clear why EC use isn’t higher.

The drug is not actually sold over the counter, where it would be most accessible, but rather behind the counter, where a pharmacist must retrieve it. (Still, this makes it more widely available in the 72-hour window after unprotected intercourse when it works most effectively.) Nine states around the country have a “conscience clause” on the books that permits pharmacists to deny filling a prescription on religious or moral grounds. Only 17 states and the District of Columbia explicitly require hospital emergency rooms to provide EC and related services to sexual assault victims.

The cost of EC is prohibitive for many potential clients. Plan B and Next Choice, the two most popular products on the market, range in price from $35 to $60 at a pharmacy and from $10 to $70 at Planned Parenthood and other public health clinics, which offer an income-based sliding fee scale and often include counseling and other services.

Even at these high prices, the limited market for the product may not provide private drug companies any incentive to advertise it beyond women’s magazines or other niche marketing sites. This means that young women just becoming sexually active, and all women who do not regularly visit a clinic or a private physician, may never learn about it. Age restrictions requiring a photo ID and concerns about confidentiality may also be intimidating and restrict use.

There are also a number of potential hurdles to EC provision under the Affordable Care Act. Will women be able to use their private insurance or Medicaid benefits to purchase it at a drug store? Or will they need to visit a Planned Parenthood or community clinic? What about the many states that are not planning to participate in the Medicaid expansion? How will low-income women in those states receive information about and access to EC and, for that matter, regular methods of contraception?

In recent years, Planned Parenthood has put forward an effective reproductive health information campaign using online and cell phone platforms. Millions of women, and especially young people, are now texting or visiting its website each month to learn about and gain access to EC, along with other important sexual health information.

The Obama health care plan needs to imitate and vastly expand this marketing approach if it is to be effective. At long last, the Affordable Care Act promises to provide a national policy that prioritizes women’s health and primary, preventive care. But we must seek greater clarity about its implementation. Our next challenge will be to buttress the ACA with an inventive, far-reaching public information campaign so a broad and diverse population can understand and access its many benefits. How about calling this campaign “Morning After in America"? For those Americans old enough to remember Ronald Reagan, this surely has a familiar ring!

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. 


Contraception image via Shutterstock.com.

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The Real State of the Union Requires a Stronger Government

Feb 15, 2013David B. Woolner

Instead of downplaying the role of government, we should recommit to a "spirit of charity."

We of the Republic sensed the truth that democratic government has innate capacity to protect its people against disasters once considered inevitable, to solve problems once considered unsolvable…

In this we Americans were discovering no wholly new truth; we were writing a new chapter in our book of self-government . –Franklin D. Roosevelt, 1937

Instead of downplaying the role of government, we should recommit to a "spirit of charity."

We of the Republic sensed the truth that democratic government has innate capacity to protect its people against disasters once considered inevitable, to solve problems once considered unsolvable…

In this we Americans were discovering no wholly new truth; we were writing a new chapter in our book of self-government . –Franklin D. Roosevelt, 1937

In his State of the Union address, President Obama challenged the Congress and the American people to join him in a common effort to make the United States a better nation; to recognize that while we “may do different jobs, and wear different uniforms” we are all “citizens” imbued with the rights and responsibility “to be the authors of the next great chapter in our American story.”

Certainly, the president’s call for “investments” in setting up universal preschool, increasing access to higher education, promoting research and development, fixing our broken infrastructure, and establishing a higher minimum wage so that in “the wealthiest nation on earth, no one who works full-time should have to live in poverty,” is a welcome development. So too is the president’s acknowledgment that there are still communities in this country where, thanks to inescapable pockets of rural and urban poverty, young adults find it virtually impossible to find their first job. “America,” he insisted, shouldnot [be] a place where chance of birth or circumstance should decide our destiny.”

And yet, if we examine the state of our union honestly, it not only becomes apparent that we are indeed a society where “chance of birth or circumstance” decides our destiny, but also a society that has fallen far behind the rest of the world in education, health care, infrastructure, and a host of other indicators that determine the overall quality of life.

In study after study, for example, Americans are found to be far less economically mobile than their counterparts in Canada and Europe. In education, the U.S. now ranks 17th in the developed world overall, while we are ranked 25th in math, 17th in science, and 14th in reading, well behind our Asian and European counterparts. For decades the U.S, was ranked number 1 in college graduation, but we now stand at number 12, and even more shocking, we are now ranked 79th in primary school enrollment. This is no way to sustain or build a competitive edge in a global economy.

Other statistics tell a similar tale. How many Americans, for example, are aware that out of the 35 most economically advanced countries in the world, the U.S. now holds the dubious distinction of ranking 34th in terms of child poverty, second only to Romania? In infant mortality, the U.S. ranks 48th. As for overall health and life expectancy, a recent report by the Institute of Medicine and the National Research Council found that among the 17 advanced nations it surveyed, the U.S.—which in the 1950s was ranked at the top for life expectancy and disease—has declined steadily since the 1980s. Today, “U.S. men rank last in life expectancy among the 17 countries in the study and US women rank second to last.” In infrastructure, the World Economic Forum recently ranked the U.S. 25th in the world, behind virtually all other advanced industrialized nations and even some in the developing world.

Still, there are some categories where the United States ranks number one: we have the highest incarceration rate in the world—far higher than countries like Russia, China, or Iran. We have the highest obesity rate in the world and we use more energy per capita than any other nation. And while the U.S. does not possess the highest homicide rate in the world—that distinction goes to Honduras—the rate of death from firearms in the U.S. is nearly 20 times higher than it is among our economic counterparts. And on a city-by-city basis, we would find that if New Orleans were a country, for example, its homicide rate would rank number 2 in the world.

Eighty years ago, when the United States found itself in an even more precarious state than it does today, Franklin Roosevelt used the occasion of his first inaugural address to say to the American people that “this is preeminently the time to speak the truth, the whole truth, frankly and boldly,” to avoid the temptation “to shrink from honestly facing conditions in our country today.” The president then went on to implore the American people to reject the fear and apprehension that had paralyzed the nation by reminding them that “in every dark hour of our national life, a leadership of frankness and of vigor has met with that understanding and support of the people” which is essential to overcoming the challenges we face.

Four years later, in the first State of the Union address of his second term, President Roosevelt observed that “the deeper purpose of democratic government is to assist as many of its citizens as possible, especially those who need it most, to improve their conditions of life…” But, he went on, even with the “present recovery,” the United States was “far from the goal of that deeper purpose, for there were still “far-reaching problems… for which democracy must find solutions if it is to consider itself successful.”

President Obama certainly echoed these sentiments when he spoke about the meaning of citizenship and “the enduring idea that this country only works when we accept certain obligations to one another and to future generations; that our rights are wrapped up in the rights of others.” But the president said little about the role of government in ensuring that these obligations are met, and he qualified his remarks by opening his speech with his oft-repeated maxim that the American people do not expect government “to solve every problem.”

FDR took a different tack. For him government was the instrument of the common people, and as such its primary responsibility was not to serve as an arbiter between the demands of the rich and the needs of the poor, but rather as the vehicle through which the hopes and aspirations of all Americans could be met. In this he argued that:

The defeats and victories of these years have given to us as a people a new understanding of our government and of ourselves…It has been brought home to us that the only effective guide for the safety of this most worldly of worlds, the greatest guide of all, is moral principle.

We do not see faith, hope, and charity as unattainable ideals, but we use them as stout supports of a nation fighting the fight for freedom in a modern civilization…

We seek not merely to make government a mechanical implement, but to give it the vibrant personal character that is the very embodiment of human charity.

We are poor indeed if this nation cannot afford to lift from every recess of American life the dread fear of the unemployed that they are not needed in the world. We cannot afford to accumulate a deficit in the books of human fortitude.

In the place of the palace of privilege we seek to build a temple out of faith and hope and charity.

To bring about a government guided by the “spirit of charity,” FDR initiated the most far-reaching social and economic reforms in our nation’s history; reforms designed to provide the average American with a measure of economic security; reforms that reduced the vast, unjust, and unsustainable economic inequality that had brought the country to ruin just a few short years before.

If we are going to “honestly” face “conditions in our country today,” then we need to recognize that the steady abandonment of the principles of governance put in place by Franklin Roosevelt in the past three decades have done enormous harm to the state of the union. In light of this, rather than repeat the conservative mantra that government cannot solve every problem, perhaps President Obama should follow the example of President Roosevelt by reminding the Congress and the American people that even though

Governments can err, [and] presidents do make mistakes… the immortal Dante tells us that Divine justice weighs the sins of the cold-blooded and the sins of the warm-hearted on different scales.

Better the occasional faults of a government that lives in a spirit of charity than the consistent omissions of a government frozen in the ice of its own indifference.

David Woolner is a Senior Fellow and Hyde Park Resident Historian for the Roosevelt Institute. He is currently writing a book entitled Cordell Hull, Anthony Eden and the Search for Anglo-American Cooperation, 1933-1938.

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What Did the State of the Union Say to Women?

Feb 14, 2013Ellen CheslerAndrea Flynn

The president didn't just lay out specific policies that will benefit women. He also shifted the theory of how government can help them.

The State of the Union address is inherently a political exercise, intended to chart a course for governing but also to let important constituencies know that they are heard and valued. On Tuesday night, President Obama seemed intent on sounding down-to-earth, sensible, unthreatening, and easy to understand. He presented a long list of concrete proposals as if there couldn’t be any disagreement over their merits.

The president didn't just lay out specific policies that will benefit women. He also shifted the theory of how government can help them.

The State of the Union address is inherently a political exercise, intended to chart a course for governing but also to let important constituencies know that they are heard and valued. On Tuesday night, President Obama seemed intent on sounding down-to-earth, sensible, unthreatening, and easy to understand. He presented a long list of concrete proposals as if there couldn’t be any disagreement over their merits.

For women, a critical voting bloc who helped deliver his second term, the president checked off many important boxes. He spoke about ending violence against women, guaranteeing them equal pay, preventing teen pregnancy, providing working families with more daycare and early child education, and promoting military women in combat roles. He also acknowledged that women around the world are drivers of prosperity and must be empowered if we hope to reduce global poverty and secure emerging democracies.

Hearing this litany of familiar issues was reassuring, but the overall theme of the speech provided an even more important takeaway. Without much fanfare, the president put forward a reshaped agenda for government programs that are, as he put it, not “bigger” but “smarter.” This is vital for women because it would have the government target policies and marshal resources for women and families, which, in turn, prevent larger and costlier social and economic problems. It’s a welcome departure from forgetting about women and children and waiting around to address the unfortunate consequences after the fact.

No grand principles were enunciated. But the president craftily put forward a theory of change that emphasizes strategic and comprehensive investments and interventions to establish a floor of well being for at-risk women and families.

  • He called on the House of Representatives to follow the Senate’s lead and reauthorize the Violence Against Women Act, not just as a moral imperative but because studies since its passage demonstrate the effectiveness of the social services and criminal justice reforms this pioneering legislation funds. Over two decades, rates of intimate partner violence and homicides have decreased dramatically, as the White House recently reported.
  • He called for expanding mandatory and free early childhood education – currently available to only three in ten American children – not just because it’s the right thing to do for hard-pressed parents, but because the data shows that it also boosts graduation rates, decreases teen pregnancy, and even correlates with palpable reductions in violent crime in communities across the country.
  • He promised to fight to increase the minimum wage and pass the Paycheck Fairness Act. This would close a real gender earnings gap. It would also benefit the nearly two-thirds of all minimum wage workers who are female, many of them single heads of households who can’t possibly lift their families out of poverty without this critical and long overdue intervention. Small businesses have long opposed a raise, despite studies that demonstrate a return to employers through increased productivity.
  • He mentioned the Affordable Care Act only in passing, but it too provides many additional preventive policies, which, as he noted, are already improving services while driving down health care costs overall. For example, the ACA has already brought comprehensive, affordable family planning and reproductive health care to more than 1 million women. By 2016, it could extend those services to as many as 13 million additional uninsured women if the many state challenges to contraceptive coverage and the Medicaid expansion do not undermine its potential reach and impact. And here again, as we have written previously, data demonstrates incontrovertibly that these services will dramatically reduce rates of unintended pregnancy and abortion.
  • While the focus of the president’s speech was primarily domestic, he also mentioned America’s responsibilities in the world and obliquely referenced the signature efforts of his administration to mainstream gender considerations into our diplomatic, defense, and development policies. Under the president and Secretary of State Hillary Clinton, the United States has joined 30 other countries in adopting a National Action Plan on Women, Peace, and Security, facilitated by the United Nations, which applies gender considerations and disaggregates spending across all agencies to require focused investment to improve the status of women. The government recognizes that this is not just the right thing to do, but also the smarter course if our aim is to meet the security and development challenges of our foreign policy. This shift in thinking lies behind the decision to promote military women to combat rank, for example, because in conflicts that involve civilian populations, as in Afghanistan and Iraq, women officers on the frontlines have played critical roles in connecting with local populations. And local women empowered by the U.S. presence have in turn become important agents in post-conflict resolution and peace processes and in relief and reconstruction efforts.

The president’s State of the Union provided a blueprint for a strong, positive government obligation to secure the wellbeing of women and families at home and abroad. Not a lot of detail was offered, nor was there any fancy philosophical framework for what would represent a palpable shift in U.S. priorities and our traditional ways of governing. He spoke as if this was all pretty much just common sense – the better part of wisdom.

But certainly if Senator Marco Rubio’s response is any indication, the president’s intentions, however masked in straightforward, anodyne rhetoric, face innumerable obstacles to their realization. That should not, however, stop us from applauding and getting behind the potential for meaningful policy change.

Ellen Chesler and Andrea Flynn are Fellows at the Roosevelt Institute.

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The Progressive Economic Narrative in Obama's State of the Union

Feb 13, 2013Richard Kirsch

President Obama has begun telling the right story about the economy. Now we need to make sure that story spreads.

President Obama has begun telling the right story about the economy. Now we need to make sure that story spreads.

Two years ago, frustrated by a conservative resurgence in the 2010 election, a group of progressive activists, economists, communicators, and pollsters came together to write a compelling story about our view of the economy (as Mike Lux relates). Our goal was to write a story that people could easily understand, based on our beliefs about how to create an economy that delivered broadly shared prosperity -- a story that could stand up against the right’s familiar recipe of free markets, limited government, and rugged individualism. The core of the story we developed in our progressive economic narrative (PEN) was: “The middle class is the engine of our economy. We build a large, prosperous middle class by decisions we make together.”

So it was a milestone in our work to hear President Obama tell our story and use our language in his State of the Union address. The key line, delivered at the top of the speech and quoted in almost every news story, was “It is our generation’s task, then, to reignite the true engine of America’s economic growth: a rising, thriving middle class.”

Taking another lesson from PEN, the president prefaced that quote with an explanation of what the economic problem is, focusing on how working families and the middle class have been crushed. In PEN we say, “American families are working harder and getting paid less, falling behind our parents' generation. Too many Americans can’t find good jobs and too many jobs don’t pay enough to support a family. Big corporations have cut our wages and benefits and shipped our jobs overseas.” Here’s the president’s version:

But – we gather here knowing that there are millions of Americans whose hard work and dedication have not been rewarded. Our economy is adding jobs, but too many people still can’t find full-time employment. Corporate profits have skyrocketed to all-time highs, but for more than a decade, wages and incomes have barely budged. It is our generation’s task, then, to reignite the true engine of Americas economic growth: a rising, thriving middle class.

When it came to describing how we build this middle-class engine, the president again used the same ideas frame laid out in PEN: “We build a large and prosperous middle class through the decisions we make together; investing in our people, expanding opportunity and security, paving the way for business to innovate, and to do business in ways that create prosperity and economic security for Americans.” The president’s agenda was based on these same concepts:

  • Invest in people through education (starting at Pre-K), skills we need for today’s jobs, affordable health care, and a secure retirement.
  • Pave the way for businesses through research, infrastructure, and green energy.
  • Do business in ways that create prosperity, with a higher minimum wage and pay equity for women.

The president’s story contrasted sharply with Marco Rubio’s. Rubio also paid homage to the middle class, but he told the conservative tale:

This opportunity – to make it to the middle class or beyond no matter where you start out in life – it isn’t bestowed on us from Washington. It comes from a vibrant free economy where people can risk their own money to open a business. And when they succeed, they hire more people, who in turn invest or spend the money they make, helping others start a business and create jobs. Presidents in both parties – from John F. Kennedy to Ronald Reagan – have known that our free enterprise economy is the source of our middle class prosperity.

So the fight is joined. For too long, progressives have not taken on the conservative story with our own narrative. As a result, even when people agree with us on specific issues, they still hold fast to the right’s definition of how to move the economy forward. We have, with the simple tale told by the president and in the progressive economic narrative, a very different story, an economy driven by working families and the middle class, which we create by decisions we make together, with our government as the catalyst.

Our next task is to tell this same story over and over again in all of our communications. Repetition is key. People need to hear the story whenever we communicate on an economic issue. We give examples of how do to that on job quality, job creation, the federal fiscal mess, and health care at progressivenarrative.org.

President Obama left out one part of the progressive economic narrative in his speech. As we say in PEN, “Our political system has been captured by the rich and powerful and corrupted by big money in politics. The issue is not the size of the government, it’s who the government works for – powerful corporations and the richest few, or all of us. We have to take our democracy back to ensure that our economy will work for all of us. ”

That’s a story that politicians are reluctant to tell. As always, we need to lead and the leaders will follow. It is up to us to build an America and economy that works for all us. Clearly describing our vision of how to do that is a crucial element of building power that progressives overlooked for too long. We’re much closer when the president tells that story to the nation. It’s up to us to keep telling it every day.

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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Memo to Lawmakers: Young Americans Demand More Health Care, Not Less

Feb 13, 2013Rahul Rekhi

President Obama's SOTU mentioned Medicare, but he still fails to realize that young people are ready for even greater investment in health care.

President Obama's SOTU mentioned Medicare, but he still fails to realize that young people are ready for even greater investment in health care.

Last night, President Obama delivered a State of the Union address that outlined an ambitious second term agenda while touting a steadily recovering economy and asserting the need to strike a budget deal that preserves the generational promise of Medicare. What he did not mention, however, is an underlying but oft-neglected truth: that our national health care debate still neglects the needs, perspectives, and interests of young adults. The State of the Union may be stronger, but for young Americans around the country, its health requires a new prescription. This is perhaps most critical in two key but distinct areas: innovation and mental illness.

Consider, firstly, that the health reform debate—subsumed into the longstanding clashes on the federal debt and deficit—has lately centered on cost cutting. Thus far, such discourse has largely been framed as benefiting young Americans, those who, the argument goes, will bear the brunt of the nation's debt burden in the absence of immediate cuts to the federal healthcare budget. However, from a young person’s perspective, there exists compelling evidence for a converse narrative: public health care as an incubator for innovation. The safety net that health care provides actually emboldens young people to take risks, to try creating the next Facebook or Google, rather than play it safe for fear of being denied care in later years. 

Evidence of the critical role that public health care can play in entrepreneurship and innovation is plentiful in the research literature. For instance, a recent RAND Corporation study observed the prevalence of so-called "entrepreneurship lock": a phenomenon in which prohibitively high costs of obtaining health insurance as individuals preclude workers from leaving large firms that can offer subsidized premiums to strike out on their own. But we can also look across the Atlantic to see the catalytic properties of such social insurance—and the costs of not providing it—in action. For example, Sweden, a nation that possesses a social safety net among the world’s most robust, ranked 2nd globally on the INSEAD’s Global Innovation Index. The US, with comparatively meager public insurance, came in at a distant 10th. Such nations as Norway, Finland, Denmark, and Switzerland–hardly bastions of Randian self-sufficiency—also handily outstripped our own ranking on this measure.

This is not to say that public health care is the only factor that will determine the fates of Googles to come. But this data should prompt us to reformulate our rhetoric around programs like Medicare and Medicaid: not as hammocks, but springboards. We should not be focused on heavy-handed cost-shifting measures that merely limit the scope of coverage, but instead how to thoughtfully modernize the fundamental societal value that these programs provide. It is precisely this values-based approach to national health care financing that young Americans value most greatly, as attested to by thousands of students in the Roosevelt Institute | Campus Network’s recently published Government By and For Millennial America.

Arguably the most significant example of this false dichotomy between cost and value is mental health care. Much has been made of our healthcare system’s dismal performance on health indicators, but in no field does this ring truer than in psychiatric care. Yet what’s often overlooked is that mental healthcare is, above all, a youth problem, afflicting no demographic more than my fellow young Americans—my classmates, colleagues, and friends. Millennials, as a demographic, report rates of depression well above the baseline: almost 9 percent of 20-somethings in America are thought to have developed major depression, panic disorder, or anxiety. The shocking nature of this statistic is only amplified by considering that a full 75 percent of diagnosable, life-long mental health illnesses develop by age 24. Yet an estimated 75-80 percent percent of youth in need of mental health services do not receive any care.

But potential solutions abound, even for such a complex problem. If states are the laboratories of our democracy, mental health has proven no exception. Even while the U.S. lags nationally on mental health—rated a ‘D’ by the National Alliance on Mental Illness—states like Connecticut, Massachusetts, and Maryland lead the pack in developing thoughtful, innovative proposals to improve the quality and coverage of care. Moreover, a recent study out of UCLA in California demonstrates that sound mental healthcare can actually be a cost-saving measure.

Ultimately, progress on both of these fronts depends on whether our political leaders choose to prioritize young Americans across the nation. The health of an entire generation hangs in the balance.

Rahul Rekhi is a student at Rice University and the Senior Fellow in Health Care Policy for the Roosevelt Institute | Campus Network.

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The Battle Over Women's Health is a Fight for Human Rights

Dec 5, 2012Andrea Flynn

The election is over, but the work of expanding and improving women's access to quality health care is just beginning.

The election is over, but the work of expanding and improving women's access to quality health care is just beginning.

Last month, the United Nations declared access to family planning to be a universal human right that all member countries should respect, protect, and fulfill—a decidedly non-controversial concept for most of the developed world, and indeed not a novel concept for the UN or its members. That is, of course, with the exception of the United States, where human rights are mostly regarded as instruments for other countries to adopt and implement while considered quite unnecessary for our own advancement and wellbeing. So far are we from adopting a human rights framework at home that it’s hard to imagine what would happen if U.S. policymakers approached access to health care – and women’s health in particular – as a right akin to free speech, bearing arms, or practicing our religion. However, given our domestic women’s health crises, we could certainly benefit from adopting some outside perspectives on the right to health care.

Women’s health issues were front and center in the 2012 presidential campaign, garnering far more mainstream attention than in previous elections. From serious discussion in the primary and general election debates to thoroughly considered policy positions to uncensored public remarks, hot-button women’s health issues—rape, abortion, contraception—created a gender gap in the electorate to which many attribute President Obama’s victory. As we look toward the commencement of Obama’s second term, it's clear that the president has numerous monumental challenges before him. But we must not let the protection of women’s health and rights be compromised by other priorities such as the fiscal cliff, the federal budget, or foreign policy crises.

Obama’s victory was a win for women in the short term because it averted the immediate decimation of women’s health funding and infrastructure promised by Romney and his Republican counterparts across the country. But the country needs a long-term win: one that will improve the lives of American women and girls for generations to come. Such a win will require the president’s unwavering determination to improve women’s access to health services and their health outcomes throughout the course of his second term. And it is the job of women and the people who love them to provide a constant reminder that he must deliver on his promises.

Our government should ensure that all women have access to affordable, quality health care not only because it is morally the right thing to do, but because it is the smart and necessary thing to do to strengthen the entire country. Critical indicators such as maternal mortality, teen pregnancy, and unintended pregnancy illustrate the high cost of treating women’s health care as a privilege instead of a right. The United States trails 49 other nations in a ranking of maternal deaths worldwide and has a teen pregnancy rate higher than almost all other industrialized countries. Moreover, nearly half of all pregnancies in the United States are unintended. The data below illustrate how the health circumstances of women of color and low-income women have truly reached crisis proportions and demand immediate action.

(Sources: 1. National Campaign to Prevent Teen and Unplanned Pregnancy, 2. Centers for Disease Control and Prevention, 3. Guttmacher Institute, 4. Ibid, 5. Amnesty International, 6. Ibid, 7. New York City Maternal Mortality Review Project Team)

These inequities in women’s health in the United States are shameful, are a violation of human rights, and are, of course, directly related to the quality and availability of family planning and reproductive health care. Obamacare is certainly a historic step in the right direction. It has already extended contraceptive coverage (including highly effective methods such as the IUD, hormonal implants, and injections) to more than 1 million young women, and by 2016 it will cover nearly 13 million more. It also mandates the inclusion of other critical services: one annual “well woman” visit to a primary care physician, access to emergency contraception (also known as the morning-after pill), HPV testing, screenings for STDs, screenings for gestational diabetes, and coverage for maternal health care, including breast-feeding support.

Despite the immediate improvements to women’s health and the long-term cost savings associated with expanded coverage, Obamacare faces a steep uphill battle. Twenty-seven states have filed suit against the president’s plan, challenging its constitutionality. Additionally, over the last year a number of states have attempted to defund Planned Parenthood and other facilities that provide information about, referrals for, or counseling on abortion (even though none of these providers actually perform abortions), threatening to dismantle an irreplaceable infrastructure that has provided millions of women across the country with critical health services.

So far none of these states have succeeded in their lawsuits, but new challenges pop up every day. In Texas alone, more than 50 women’s health providers have closed over the past year as a result of Governor Rick Perry’s decision to slash the state family planning budget by two-thirds and his promise to eliminate Planned Parenthood and other clinics from the state’s Women’s Health Program. Numerous court battles are underway, but regardless of their outcome, the governor has successfully chipped away at a system of care upon which thousands of women – particularly young women, poor women, immigrant women, and women of color – have relied for decades. This system cannot be easily rebuilt.  As anti-choice and anti-family planning lawmakers across the country continue to face resistance from the courts, they will likely look to Texas for strategies of how to successfully defund our nation’s most effective, far-reaching women’s health care providers. Even if Obamacare succeeds in continuing the expansion of Medicaid and private insurance coverage, its impact will be diluted if women have fewer places to receive comprehensive, quality care.

The United States cannot afford these inequities. The National Campaign to Prevent Teen and Unplanned Pregnancy reports that nearly three in ten girls become pregnant in their teenage years and that teen childbearing now costs U.S. taxpayers more than $10 billion annually. Thirty-eight percent of African American girls and 36 percent of Latino girls who dropped out of high school in 2006 reported doing so because of pregnancy or parenthood. And only 40 percent of teens with children complete high school, with less than 2 percent finishing college by the time they are 30. Teen pregnancies levy an additional toll on young women and the U.S. public by contributing to these higher drop-out rates and reducing the potential lifetime income for teen moms.

Unintended pregnancy among women of all ages is a major drain on U.S. coffers. According to the Guttmacher Institute, public insurance programs paid for more than 60 percent of all births resulting from unintended pregnancies, with total public expenditures for these births totaling more than $11 billion in 2006. A number of studies have shown that by expanding contraceptive coverage to underserved communities, Obamacare would drastically reduce these expenditures.

Providing all women better care before and during their pregnancies is clearly the smart thing to do financially. It is also, plain and simple, the right thing to do. The UN says that access to family planning is a right that should be enjoyed by all women because it “permits the enjoyment of other rights, including the rights to health, education, and the achievement of a life with dignity.” Women fully understand that having the ability to control their bodies, preserve their reproductive and sexual health, and make fully informed decisions about when they will have children impacts their ability to thrive socially and economically.

The election may be behind us, but the battle for women’s health is far from over. States will continue to push back against the mandates of Obamacare and conservative legislators will continue to peel away at women’s health rights and their ability to access the care they need. Women in the United States must remain diligent as Obama begins his second term, reminding him, along with local, state, and national leaders that they demand and expect better health care and better health outcomes in the four years to come. They should do so because having affordable and accessible health care and the ability to make fully informed decisions about their bodies is a universal human right. And that is an idea that anyone invested in America’s long-term stability, strength, and security should embrace.

Andrea Flynn is a Fellow at the Roosevelt Institute.

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