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Policy Conference Bypasses Reproductive Issues

When White House Deputy Director of Health Reform Jeanne Lambrew ascended the podium to open the AcademyHealth National Health Policy meeting, I was filled with expectation. As a women's health provider, I was eager to hear what our nation's health policy leaders had to say about the ways in which women's health policy has become such a contentious issue in the larger effort to expand access to insurance coverage.
I sat up a little straighter in my chair when Dr. Lambrew congratulated the architects of the Affordable Care Act for dismantling
Pooja Mehta
Photo: Megan Pellegrino
Pooja Mehta, MD, is a Robert Wood Johnson Clinical Scholar at the University of Pennsylvania's Perelman School of Medicine, and a Fellow at the Leonard Davis Institute of Health Economics (LDI).
discriminatory policies that had led to higher insurance premiums for women in the past. But she did not, as I had hoped, go on to discuss the ACA's failure to safeguard the health of women in other vital ways -- for instance, through the protection of basic provision of family planning services as part of every health plan, whether through Medicaid, federal, or state-sponsored insurance exchanges.

A political casualty
Lambrew's was just the first of two days of conference presentations marked by silence on women's health. It was a silence that confirmed the national health policy community's perception of a health reform agenda that explicitly embraces reproductive health as an inevitable political casualty of our current partisan environment.

Meanwhile, there is anything but silence on how women's health fits or does not fit into health reform in the national media. Debates over whether plans could be required to cover abortion as an essential health benefit dominated final discussions leading up to the passage of the ACA. To date, eighty corporations have filed lawsuits challenging the ACA tenet for contraceptive coverage with no-cost sharing -- a legislative element that has significant economic as well as public health implications. Arguments and media coverage have been short on data but heavy on emotion, ideology, and citation of legal precedent.

One in five women
Despite this charged context, policymakers and providers cannot simply give up on specifically incorporating reproductive health into mainstream discussions of our programmatic priorities, delivery innovations, and research agendas. Family planning is a key aspect of broader women's health that protects gender equality and autonomy, prevents maternal mortality, reduces costs attributable to unintended pregnancy, and is an important component of a healthy workforce. One in five women are currently uninsured and two thirds of women on Medicaid are
Pooja Mehta
Photo: Hoag Levins
White House Deputy Director of Health Reform Jeanne Lambrew said little about women's issues.
currently in their reproductive years, making women of reproductive age key targets for efforts to expand insurance coverage and leaving reproductive health an important component of their care.

With federal restrictions on abortion funding firmly in place, and ACA exclusions restricting private insurers' coverage of abortion, providers and payers alike will have to solve the ever-present demand for family planning services creatively -- by addressing the problem at its root and investing in interventions that broaden access to contraception and address social determinants, with the bipartisan goal of reducing rates of unintended pregnancy.

With this in mind, what can women's health providers and policymakers learn from the National Policy Conference?

Legislative obstacles
Presentations that described innovation at the state and local levels offered models that use local assets and non-traditional partnerships to build on the incomplete framework provided by the ACA, approaches that could be of particular importance as we try to surmount legislative obstacles and maintain affordable access to women's health services.

For instance, presentations at the State Health Research and Policy Interest Group Breakfast focused on how states like Maryland are using the convergence of Medicaid and private insurer markets to mediate "churn" between private and public insurance coverage; private-public partnerships are being leveraged to stabilize coverage for at-risk individuals. This is an issue of key importance for low-income women who may lose Medicaid eligibility at the end of a pregnancy or when a child is no longer eligible for CHIP.

During his presentation "What Will It Really Take to Improve the Nation's Health?" Mark McClellan of the Brookings
Pooja Mehta
Photo: Hoag Levins
Mark McClellan touched on the social determinants of health in his remarks.
Institution and RWJF's Commission to Build a Healthier America reminded conference participants of the importance of social determinants of health, such as housing and education, to creating a broader culture of health.

Not brought up
It was also an important reminder to women's health providers that interventions that improve access to education and address poverty are just as important as expanding access to insurance coverage and health services in reducing persistent disparities in reproductive health outcomes -- along lines of race and income (openly discussed at NHPC), as well as gender and sexual orientation (not brought up at all).

This theme was expanded upon at a rousing closing session on "Community Health & Disparity: Moving Beyond Description" -- where speakers Jeff Brenner and Brian Smedley, from Camden and Detroit respectively, described local interventions that moved beyond simply documenting disparities to attempting to truly empower at-risk individuals -- by leveraging community-based knowledge and resources to connect individuals to healthier neighborhoods, social support, and care coordination.

It is precisely this type of "disruptive innovation" that is sorely needed as we try to shift local and national conversations on gender equality and reproductive health and build for ourselves as advocates, policymakers, and providers the community-engaged, innovative delivery systems that passage of the ACA alone simply will not generate.

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