Wednesday, March 17, 2010

I HAVE A BRIDGE TO SELL YOU...

For all you "fix it later" folks: Remember the Civil Rights Act of 1991? Women shortchanged in Title VII remedies "so that we can pass the bill"? In exchange for accepting an albatross, we were promised that the cap on damages in sex discrimination cases would be "fixed immediately." Well, it's nearly 20 years later... and we're still 2nd class citizens under Title VII.

Within the realm of health policy: When Medicare was enacted it was supposed to be the proverbial "foot in the door"... But we couldn't even get kiddicare as an "improvement." US policy history in general does not show that small steps ever lead the way to broad social provision in the structure of programs. We have been able to add previously excluded groups to coverage within existing frameworks -- teachers and domestic workers added to Social Security, eg. But in the current health care proposal, the framework is the problem. It's a framework that unleashes or approves concatenating inequalities in health provision, as well as in personal autonomy. There is no reason to believe that a for-profit, employer-based health care system based on coerced individual enrollment in private coverage can be "fixed," when the only way to provide socially just coverage is through a not-for-profit, not-employer-based, public system of health provision for all.

Fool me three times...?

Thursday, February 4, 2010

HOPELESS in WASHINGTON

Based on its FY2011 budget request for TANF, the Obama Administration continues to link poverty reduction to family structure. The TANF budget request extends TANF funding for one year, including recession-related emergency funds for states that were introduced in last year's American Recovery and Reinvestment Act. The only proposed change in TANF is the allocation of $500 million for a "Fatherhood, Marriage, and Families Innovation Fund." This represents a huge increase in funds for fatherhood and related family structure programs -- from $150 million each year under the Healthy Marriage and Responsible Father Initiative of the Bush Administration, to $500 million in just one year. According to the HHS narrative (http://www.acf.hhs.gov/programs/olab/budget/2011/TANF.pdf) about the proposed family structure initiative, it is hoped that programs supported by these funds will usher in future changes in the TANF program. So, far from a one-shot deal, this is a shot-in-the-arm to proponents of privatizing poverty reduction through patriarchal family norms. Significantly, despite economic hard times, the budget request does not include increases in cash grants to struggling families, a suspension of time limits on eligibility for assistance, an end to sanctions, or a change in rules so that more families in need of assistance can actually get it.

We need to insist on changes to the structure of TANF, not the structure of families. For starters, FY2011 TANF funding should be conditioned on suspending time limits, sanctions, and diversion practices.

Monday, January 11, 2010

BEYOND STUPAK (II): Why The Language in the Nurse Home Visitation Provision in Health Care Legislation Must be Fixed

by
Gwendolyn Mink and Dorothy Roberts
January 11, 2010

As health care legislation enters its final stages, it appears that the federal government is poised to authorize Medicaid spending for an ambitious, mostly privately-run program that enters and touches the most intimate domains of poor women – without any explicitly stipulated protections of their rights.

Six weeks ago, we circulated a commentary about a provision in the House health care bill authorizing funds for nurse home visitation programs aimed at low-income pregnant women and mothers of young children (H.R. 3962, Section 1713). We were concerned that the provision is not aimed at providing health care. Instead, it pledges to advance goals that endanger the reproductive and family freedoms of low income women, conjures stereotypes of low income women of color, and implies that using available public services is a bad thing. The Senate bill contains a similar provision.

Our commentary focused on the statutory language of the House provision. We did not comment on any existing program, but rather drew attention to the legislative wording, which includes as stated goals an increase in birth intervals, a reduction in maternal and child criminal involvement, and a reduction in dependence on public assistance. Unfortunately, our criticism of the statutory language was misread by many program advocates, who concluded that we opposed nurse home visitation services per se (or their own programs in particular).

We received numerous responses to our commentary. Those who disagreed with us generally argued that the good intentions of the people who run current nurse home visitation programs make the statutory language irrelevant. Some defended the statutory language, saying that it was instrumentally necessary to secure support from a majority in Congress. Others pointed to language in the provision promising that programs will be “outcome based,” arguing that such a requirement guarantees that only “good” programs that “work” will be funded.

To answer the first point, we would draw your attention to the long and persistent history of government programs for poor women that linked the provision of services to the supervision and regulation of poor women’s fertility and family decisions. Some examples: home visitors who used poverty as an occasion to impose Americanizing domestic practices on immigrant women during the early 20th century; eugenicist birth control clinics of the 1920s and ‘30s; sterilization abuse by government-paid doctors well into the 1970s; ongoing child exclusion or “family cap” rules in welfare policy. Some of these policies are deliberately punitive and rights abusive. But even those programs that began with good intentions – such as providing health services to poor women – often have confused poor people’s access to services with government’s access to poor people, using services as a means to regulate the poor.

The argument that outcome-based criteria assures that only programs that “work” will be funded does not dispel the danger that programs will imperil family and reproductive autonomy and liberty. The goals enumerated in the statutory provision are race-coded social, cultural, and economic goals, which measure program success in aggregate sociological terms rather than in terms of the wellbeing of individuals. A program that “works” is one that is correlated with lower welfare participation, fewer births, and the like. Given these measures, what is to prevent a program from discouraging childbearing by clients who participate in public assistance programs? What is to prevent it from impeding participation in public assistance programs altogether? What checks are in place to prevent a program from encouraging use of risky contraceptives by poor women to increase birth intervals in poor families? Ends-means rationalizations are the start of the slippery slope of rights abuse and disregard for the personhood of poor women.

All of the dangers that we note here are rendered even more acute by the extreme delegation and devolution of authority implied by both the House and Senate provisions for nurse home visitation. The details of how program goals are to be measured are delegated to the Department of Health and Human Services and the selection of funded programs is delegated to the states. States, in turn, are expected to fund private programs. Unless protections for women and families are stipulated explicitly in the statutory provision, there is no guarantee that devolved programs will honor the rights and respect the autonomy of their clients. The good intentions of existing programs may protect low income women in the short term. But who knows what the intentions will be of new programs that arise to take advantage of federal funding? Who knows what the intentions will be of the various states in choosing which programs to encourage? Who knows what the intentions will be of an executive branch controlled by a different party?

It is imperative that a government-sponsored home visitation program for low-income women amply and explicitly protects program clients. Express stipulations to assure that participation is voluntary must be part of the statutory package, along with a guarantee that a decision to participate, or not to, cannot be made a condition of receiving other government assistance. The aim of nurse home visitation programs should be to provide medical and wellness services; neither the statutory language nor administrative regulations should permit or encourage monitoring the family and reproductive decisions of individuals, and neither should denigrate low-income mothers for using public assistance. We should do everything possible to ensure that these programs support the women they are intended to serve rather than using women to advance the interests of government.

To this end, we have developed a set of principles we think should guide revisions of the provision in the final version of health care reform legislation:

1) Define the responsibilities of the federal government and the
states and assure accountability of any nongovernmental grantees
regarding all safeguards and requirements listed below.

2) Explicitly enumerate safeguards for individuals and families,
including:

a) apply HIPAA standards to all interactions with home
visitors;

b) guarantee that program participation or non-participation
cannot be used as a condition or criterion for
participation in other government programs;

c) elaborate mechanisms to ensure that participation is
voluntary.

3) Restrict program goals, purposes, definition of needs, and
benchmarks to:

a) providing medical and wellness services;

b) facilitating linkage to appropriate non-medical/wellness
services if the participating family or a family member
seeks assistance for family or sexual violence;

c) facilitating linkage to appropriate education, income
assistance, or food programs if the participating family
or family member so requests.

4) Require home visiting personnel to demonstrate language and
cultural competence in the languages and cultures of the
communities/families visited.

5) Remove statutory language that could be read to support
monitoring/influencing a woman's fertility and family life.

6) Remove statutory language that denigrates low income mothers who
seek or use public assistance.


Gwendolyn Mink, Ph.D., an independent scholar, is co-editor of the two-volume Poverty in the United States: An Encyclopedia of History, Politics and Policy and author of Welfare's End and The Wages of Motherhood: Inequality in the Welfare State. She is on the board of the Institute for Public Accuracy and is coordinator and trustee of the Patsy Takemoto Mink Education Foundation for Low Income Women and Children. She can be contacted at wendymink@gmail.com

Dorothy Roberts, J.D., the Kirkland & Ellis Professor, Northwestern University Law School, is the author of Killing the Black Body: Race, Reproduction, and the Meaning of Liberty and of Shattered Bonds: The Color of Child Welfare. She serves on the boards of directors of Black Women's Health Imperative, National Coalition for Child Protection Reform, and Generations Ahead. She can be contacted at d-roberts@law.northwestern.edu.

Wednesday, December 16, 2009

KILL THE BILL

At this point in the development of legislation, legislators usually are too invested in the process itself to see the grand arc of a given policy's trajectory. If Senators Wyden, Brown, et al would step back a bit and think in terms that history teaches us, they would see that the current health care legislative proposal is not reform. It is a windfall for for-profit health insurance companies. The wellspring of this windfall is the mandate for individuals to feed insurance companies buy buying medical coverage from them.

History teaches us that there is no "improving" bad legislation. Social Security and Medicare have been successful and expandable because the legislation creating these programs advanced bold visions and put sturdy new frameworks in place. Groups were left out initially, social justice deferred -- but the framework that the legislation put into place was conceptually friendly to including excluded groups. Slowly,coverage broadened to include mostly all persons in the labor market. The current health care "reform" bills, especially the Senate bill, is conceptually friendly only to tightening the grasp of for-profit private insurance on our discriminatory, punitive, and arbitrary medical delivery system. Don't let Democrats desperate for a win in the roll-call column tell you that "we can make it better later." It won't happen. To make anything better, we would have to overturn the paradigm the Congress currently is poised to put in place. We never have overturned a social provision paradigm in the short term, and we have never overhauled such a paradigm to make it more progressive. In fact, only one social provision paradigm has been overturned: the New Deal income assistance program for poor single mothers. That change hardly advanced social justice.

If enacted in its current form, health care legislation will come back to bite all of us -- with uncontrolled, soaring premiums; new methods of excluding and punishing patients; unequal access; unequal services. Worse, all Americans will be compelled to prop up the unjust system through mandatory buy-ins to the private insurance system.

If the Democrats need to salvage something, they should split the bill into its component parts. One big part could pass right away -- Health Insurance Reform, prohibiting pre-existing condition exclusions; gender and other demographic rating; annual and lifetime caps on coverage; churning of expensive patients from insurance rolls. Pass that now.

The other big part of the bill should be scrapped, and we should start from scratch. That's the part that is farcically referred to as "universal coverage." End the farce and let's get to work on a truly universal system that covers everybody in the same way.

Progressives should join Howard Dean in standing up for what's right instead searching for a silver lining that tarnished long ago.

Kill the Bill.

Monday, November 23, 2009

BEYOND STUPAK

the shocking fertility and family control provisions in health care reform legislation

Gwendolyn Mink, Ph.D. and Dorothy Roberts, J.D.

While the latest clash over health care reform has focused on abortion funding, no attention has been paid to a shocking fertility and family control provision slipped into the House health care bill. Many reform opponents are up in arms over imaginary state intervention in medical care. But the House bill actually would authorize state intervention in a plan to monitor the childbearing decisions and family lives of low-income women.

The House health care bill (H.R. 3962), contains a provision affecting Medicaid recipients who are pregnant for the first time or who have a child under two years of age. Section 1713 allows States to use Medicaid funds for non-medical home visits by nurses to advance certain goals affecting reproductive decisions and family life. The goals include: "increasing birth intervals between pregnancies," "reducing maternal and child involvement in the criminal justice system," "increasing economic self-sufficiency," and "reducing dependence on public assistance."

These goals of the home visitation program have nothing to do with providing health care. Instead, they are based on the false premise that poor mothers’ childbearing is to blame for social problems. The proposed visitation program is eugenicist, deceptive, discriminatory against low-income women, and utterly inappropriate to the medical work of nurses.

Under the program envisioned in the House bill, government-sponsored medical professionals are charged with exhorting fertility control among poor women, based on the mistaken premise that reproduction among the poor leads to crime, neglect, low educational attainment, and dependency. According to the government's own statistics, –families receiving welfare have, on average, only 1.8 children; half the families receiving welfare have only one child, and only one in ten have more than three children.
http://www.acf.hhs.gov/programs/ofa/data-reports/annualreport8/chapter10/chap10.htm#4

Although the data show that poverty is not correlated with family size -- and that childbearing does not cause poverty -- the U.S. House of Representatives seeks to tell low-income women who receive medical assistance how many children to have and when to have them.

The House health care bill codifies some of the worst stereotypes of low-income mothers, suggesting that bad reproductive choices and misguided family practices make their families poor. Similarly, the provision blames low-income mothers for raising criminals and accuses them of maintaining unstable and neglectful home lives for their children.

Black mothers in particular have been subjects of deeply-embedded stereotypes about sexual and reproductive irresponsibility that have supported a long legacy of repressive state policies, including sterilization and coerced birth control. The mythical “welfare queen,” portrayed as a black woman who deliberately becomes pregnant to increase the amount of her monthly check, was propaganda used to support welfare reform. Several state legislators even proposed bills requiring women to use birth control or undergo sterilization as a condition of receiving welfare benefits. Immigrant women and other women of color have suffered similar injustices that devalue their reproductive decision making, as well as their parental rights and family practices.

These statutory devices and impositions should sound familiar to anyone aware of the 1996 welfare reform law. It too pivoted on the idea that regulating poor women's reproduction would end their need for welfare. Congress transformed welfare from a system of aid to a system of behavior modification that attempts to control the sexual, marital, and childbearing decisions of poor unmarried mothers by placing conditions on the receipt of state assistance. Section 1713 interprets literally the language of "pathology" from the welfare debate in its plan to "cure" the putative effects of poverty by curing poor mothers' fertility and motherhood.

We applaud the lawmakers who have banded together to take a stand against inclusion of the Stupak amendment in the final bill. But we urge them look beyond Stupak - to support a vision of reproductive justice that extends beyond abortion and respects the childbearing decisions and mothering of all women. Health care reform must not only ensure the right to abortion but also must protect the full spectrum of women's reproductive and family rights. Congress can start to promote the well-being of all women by rejecting eugenicist provisions such as the home visitation program. Any visiting nurse program in health care legislation should stick to providing medical care regardless of economic or social status. Economically vulnerable women should not be treated as sitting ducks for social engineers.

____________________

Gwendolyn Mink, Ph.D., an independent scholar, is co-editor of the two-volume Poverty in the United States: An Encyclopedia of History, Politics and Policy and author of Welfare's End. She can be contacted at wendymink@gmail.com

Dorothy Roberts, J.D., the Kirkland & Ellis Professor, Northwestern University Law School, and Professor, Departments of African-American Studies and Sociology, is the author of Killing the Black Body: Race, Reproduction, and the Meaning of Liberty and of Shattered Bonds: The Color of Child Welfare. She can be contacted at d-roberts@law.northwestern.edu

Wednesday, November 11, 2009

Fertility Control of the Poor

The House Bill includes a section calling for home visits to poor pregnant families and poor families with children to provide cultural/relational and reproductive counseling. This provision is NOT about the delivery of medical services. It is about making the poor "self-sufficient" and less "dependent" on public assistance. In addition to providing for social/cultural interventions, the provision calls for INCREASING BIRTH INTERVALS among the poor -- READ: fertility control.

Tuesday, November 10, 2009

Say No to Health Care Legislation that Creates More Inequality

Kill so-called health care reform legislation UNLESS:

1) the public option is available to ALL;

2) the status quo ante is restored for private insurance coverage of reproductive decisions, including abortion;

3) public option coverage for individuals honors the complete reproductive rights of individuals;

4) the provision for government intervention into low income families with children through home visits is removed;

5) price controls on premiums are added; and

6) the scope of the basic benefits package is specified in the statute rather than delegated to an invisible administrative committee that will easily be captured by monied interests.

There are other reasons to defeat the current bills, no doubt.

The good parts of the bills -- eg, no exclusions for pre-existing conditions -- can be legislated separately. It makes no sense to authorize massive government income transfers to for-profit insurance companies. The structure of the current legislation, from abortion through the public option, will deepen inequalities in health coverage and provision, notwithstanding the extension of coverage to many who currently are uninsured.

Enough pussyfooting in the White House and horse-trading in Congress. Back to the drawing boards -- this time Medicare for All.

Wednesday, July 15, 2009

Sotomayor Hearings, Day 1

The Sotomayor confirmation hearings are a sorry reminder of the continuing hegemony of white male privilege. Racisms and sexisms of all stripes -- liberal, as well as reactionary -- so tightly cramp our discourse about inequality that if we don't all pray to the sameness/symmetry/colorblind god, we must be racists/sexists/UnAmerican.

Since the late 1980s, the Supreme Court itself has led the political suffocation of common sense and social justice, with its increasingly harsh insistence that race-sensitive policies of all kinds are evil, whether the policies are geared toward rectifying the marginalization of people of color or toward shoring up the power of white people. Where the Court in Brown v. Board saw marginalization and subordination of people of color as the evil, current jurisprudence holds that power and powerlessness are irrelevant aspects of inequality. Race-neutrality, color-blindness, "treating everybody the same" are the power-blind standards of the controlling discourse.

Gender jurisprudence for the most part has supported this cramped, power-preserving view of equality, with its preeminent concern for winning for women the same treatment/privileges men enjoy -- in sports, military academies, employment and the like. Winning sameness is an important goal where sameness promotes equality, but our singular focus on Constitutional equivalence between men and women has choked off claims and articulations for gender-sensitive remediations and provisions that also are necessary for equality.

In any event, we are stuck in the mid-1970s, circa Bakke, when vast numbers of women of all races and men and men of color could not say out loud what we all recognized as true: that the desegregation of American life entails more than peppering schools, workforces, and politics with a few colored or female faces just for the sake of visual variety; and that desegregation isn't merely about allowing isolated individuals to maximize opportunities and fulfill dreams. Desegregation, whether through bars on race or sex exclusions or through affirmative action, is also important because marginalized groups have something significant and distinctive to offer public discourse and the life of the polity -- because of their social, economic, and cultural experiences.

But if we say that out loud in mainstream political processes, we are called racists (or sexists) by white men who believe they own "neutrality." Jeff Sessions!!! and Lindsay Graham. And the white-dominated media doesn't interrogate their assumptions. Instead, they say things like "strong cross-examination by Senator Graham," or "Sotomayor didn't put the racism charge to rest."

The idea that ignoring race is good (even if to do so exacerbates racial disparities) so grips official consciousness that the obvious response to Lindsay Graham's assertion ("If I said that a wise white man would reach better conclusions than a wise Latino woman, I would lose my job." [sic]) -- cannot even be uttered. Equality is not just about exchanging modifiers in sentences; it's not just about flipping phrases. The reason inequality is still a problem and the reason we struggle over the path to equality is because the standpoint and power of a white man who claims superior wisdom is in no way comparable to the standpoint and relative powerlessness/outsiderness of the woman of color who claims a different wisdom that would improve an outcome.

More later.