Mama's Got a Plan:

Maternity Care, Health Insurance, and Reproductive Justice


How bad can it be?

How bad can it be?

Very.

Some women1 are pregnant. Some women are fat.2 Some women are fat and pregnant. Almost all of these women need jobs, the same as anyone else. Employment discrimination in hiring is sadly not unknown to many would-be employees, but the fat-and/or-pregnant job-seeker encounters specific additional challenges.

Pregnant?

The Pregnancy Discrimination Act of 1978 forbids employment discrimination on the basis of pregnancy, considering it a form of sex discrimination. The strongest protections apply to the hiring process, but are difficult to access unless an employer documents their decision to discriminate. Employers are not allowed to ask applicants if they have children, plan to have children, or are currently pregnant. Of course, at a certain point a pregnancy becomes visible – unless it is mistaken for fatness.

Fat?

Discrimination faced by fat people is widespread. Fat people are seen not only as failures at controlling their body size, but also as generally untrustworthy, incompetent, and unhealthy. Most U.S. jurisdictions offer no legal protection against weight-based discrimination in employment or any other context. Even if legal protection were available, remedies might remain elusive should traditional code words for overlooking fat applicants be used: “unprofessional appearance” or “incompatible with company image.” Now for the double whammy …

Fat AND pregnant?

Yes, Virginia, fat people get pregnant and have babies! It is in these circumstances that employers fall prey to the particularly injurious prejudices about fat people, who are so often characterized as being “one cheeseburger away from a fatal heart attack.” Imagine if a fat person is also pregnant! It’s practically a death sentence! This rate of fatality would be highly inconvenient to employers – not to mention the fat person herself – if it were true.

There are higher risks of some complications of pregnancy associated with higher body weights, but that is true of other (visible) conditions as well: very low body weight, twin or multiple pregnancy, and pregnancy for African-American women, whose maternal mortality is tragically 3-4 times that of white women. The scientific evidence is finally beginning to concede that higher mortality for the African-American population is not the result of race, but of racism. The role of bias and stigma may also be behind the associations of certain types of risk with bad outcomes for fat pregnant women. Regardless of the science, the popular perception is as stated in Frame 4: hiring a pregnant fat woman will bankrupt your business through high health care costs3 when her pregnancy inevitably goes south.

Why do these beliefs persist?

The cultural understanding of women’s participation in the workplace remains far from settled, at least when women take valued positions previously held exclusively by men. Even women who are not pregnant or incapable of becoming pregnant can suffer from employer suspicion that members of the sex that “naturally” acts as family caretakers are likely to be called to do just that, to the detriment of their jobs. Applicants who are pregnant are felt to be freeloading: if other new employees are not permitted to take leave until they have put in the required amount of time, why can babymakers? They should have kept their legs closed!

As for fat pregnant women, well, should they really be permitted to reproduce? Not only will they almost certainly harm their babies and themselves in the process, draining company and public health dollars at an alarming rate, but they might produce more little fat people. A job would just encourage them! 

While these last paragraphs are increasingly sardonic, they illustrate the result of combining over a century of anti-fat bias, medical eagerness to believe that fat is the cause of all ills, pressure on businesses to reduce health care spending, an economic framework that blames the need of the human race to reproduce on the people doing the reproducing, and a general lack of understanding that we are all in this together. And this moral mess hasn’t even begun to address the additional and intersectional issues encountered by LGBTQ people, people with disabilities, or immigrants.

“I want to do the right thing – what is it?”

You don’t really need us to tell you, do you? Stop discriminating! 

Admittedly, it’s not that simple. However, like charity, abuse begins at home – and that’s a good place to stop abusing your fat friends and family members. Even if you’re doing it because you’re “concerned for their health.” Especially then.

Then take up the standard in your workplace. Make sure that both pregnant and fat people are accepted as full members of the workforce. If you are responsible for hiring, then you are especially positioned to make change. Finally, when the common beliefs about fat and/or pregnant people begin to budge, work with policymakers to forbid this kind of discrimination. 

1We usually use the phrase “pregnant people” or “birthing people.” However, because the topic of this cartoon is extremely gendered, we will refer to “women,” with the understanding that pregnant people who do not identify as women face additional problems beyond the scope of this post.
2The accepted medical term these days seems to be people who “have obesity.” We use “fat” as the term preferred by the fat acceptance movement.
3Obviously, the structure of the U.S. health care payor system is a key culprit in employers’ general fears about health care costs. This post is not trying to solve that problem. One thing at a time, okay?

Bibliography

 

Image credits

All images are shared under a Creative Commons license, unless otherwise noted. Where required by license, changes to the image are noted.


Don’t buy it!

 

Myth! Myth!

One myth that refuses to die is that patients who refuse a test or procedure Against Medical Advice (AMA) will be billed for all care up to that point, which their insurance company will not cover as a result of the refusal. Since shouting NOT TRUE! NOT TRUE! NOT TRUE! isn’t – or shouldn’t be – as persuasive as evidence, we incorporate a reference to published research in the cartoon itself, and provide this complete citation to the free full-text article:

G.R. Schaefer, et al., Financial Responsibility of Hospitalized Patients Who Left Against Medical Advice: Medical Urban Legend? J Gen Intern Med. 2012 Jul; 27(7): 825–830. https://doi.org/10.1007/s11606-012-1984-x

Should I sign the form?

Hospitals and health systems usually require patients to sign a form acknowledging that they are taking an action AMA, such as discharging themselves from care. This documentation protects the provider from liability in the event that some harm befalls the patient as a result of the refusal. However, a patient’s right to refuse treatment is not conditioned on their signature. In other words, there is no requirement under state or federal law that patients sign such a form.

Why the big deal?

Misconceptions are one thing. But willfully using falsehoods in order to override patient informed consent is quite another. If a health care provider has to resort to effectively threatening a patient with bankruptcy in order for the patient to consent to a course of treatment, then that provider is clearly not thinking of the patient’s best interests or rights. It is not very different from ensuring “compliance” by raising the specter of Child Protective Services intervention or playing the Dead Baby Card.

Takeaways

  1. It’s a myth! Patient refusal of a treatment or procedure will not cause a health insurance carrier to refuse coverage or payment.
  2. Providers who use this myth to attempt to coerce their patients are acting unethically and in violation of the laws of informed consent.

Image Credits

Frame 2.
  • Photo of pregnant person and physician is by Bokskapet.
Frame 3.


Catching up cartoons

The following cartoons were published on Facebook before they were posted here. Without further ado …

Subject-consent-object (SCO order!)

 

The usage “consent the patient” is one that horrified us when it first came to our attention. If any verb should be an active one, “consent” is the one.

Image credits

“Doctor Visit” is by mohamed mohamed mahmoud hassan, shared under a Creative Commons license. We added the facial features, which were chosen from assortments provided here and here. The framed picture is courtesy a collection of fantasy landscape cartoons.

 

Medicaid work requirement

The Michigan Legislature has decided to prioritize removing health care from expanded Medicaid recipients who are not working sufficient hours. They were able to do so because the federal government urged states to apply for waivers in order to allow exactly this kind of proposal.

Medicaid was not established in order to force people in need to abandon their families and work sub-subsistence-level service jobs; rather, its purpose is to provide health care for those who cannot afford to purchase it, even with the subsidies that the Affordable Care Act provides (so far!). When one of the Senators behind this bill claimed that “work improves health,” we were moved to create this cartoon.

For those who require a translation for the ironwork behind the Senator: Arbeit macht Gesundheit.

Michigan Governor Snyder has not yet signed the bill, which was enacted on June 7, 2018. We encourage him to veto this measure and instead throw his support behind federal proposals to institute Medicare for All.

Image credits

The Senator and his podium are from an image entitled “Presentation,” by Mani Amini.  The audience is from a FEMA photo, in the public domain.

 

Non-Apology

So many non-apologies arrive in the passive tense, don’t they? Another cartoon in the Bureau of Apologies series.

This image only suggests the offensive words issued by the doctor representing the American Birth Doctors Association (ABDO). The real-life context in which a major professional organization suggested that women control rising maternal mortality rates by using condoms (!) is described here.

Image credits

The doctor and his podium are both from PlusPNG.com.


Obamacare, Again

 

Image Credits


Oh, Obamacare

As we were creating a cartoon about the complexity of the current health care payment system, we noticed media reports on common misunderstandings of the Affordable Care Act (ACA). The most recent was in the Michigan news weekly Bridge, which noted, “In Michigan, some counties with the highest Medicaid expansion and ACA usage gave Trump some of his largest victory margins …”
People have been known to vote against their own interests for the sake of broader principles, a tendency that politicians are happy to exploit. However, on the chance that voters were misled on simple facts, we bring you the following educational cartoon, put together lickety-split to be of service before the ACA can be repealed!

obamacare-101-p1

obamacare-101-p2

A few slightly more detailed facts:

  • Obamacare is the Affordable Care Act (ACA). Strictly speaking, it’s the Patient Protection and Affordable Care Act.
  • The ACA was the result of a series of compromises, but its goal was to provide health insurance coverage, either public or private, for anyone who did not have coverage through an employer-provided plan. In the past, options for the planless who were not eligible for public insurance (Medicaid, Medicare, TRICARE, etc.) included buying “individual” insurance on the private market at great cost, paying for COBRA through a recent employer at great cost, paying for care in cash at great cost, or going without.
    The ACA succeeded in insuring 20 million Americans. Of the 27.2 million (non-elderly) Americans who remain uninsured, 11.7 are eligible for financial help. For information about health insurance for the elderly, see the final bullet point below on “Medicare.”
  • The ACA bans insurers from refusing coverage to people with pre-existing conditions. In the past, people were refused insurance for reasons ranging from the tragic (had suffered from cancer) to the ridiculous (tested negative for a medical problem).
  • Because young and/or healthy people would naturally wait until they needed care to buy insurance, the ACA mandates that everyone have coverage. This ensures that the risk pool is not made up solely of very sick people who need expensive care.
  • In the past, only the poorest of the poor were eligible for Medicaid, except for certain special (and temporary) categories, like children or pregnant women. The ACA required states to expand Medicaid to people whose income was at 133% of the federally-determined poverty line or below. Following a challenge, the U.S. Supreme Court conceded that states did not need to expand Medicaid. Many states (green on our map) nevertheless did so because generous federal subsidies are offered for the purpose. But states that did not expand Medicaid caused many of their residents to remain trapped in the “donut hole” that existed pre-ACA: their income was too high for Medicaid, but too low to afford private insurance. It is worth noting that the decision to expand now rests solely with the states; those who blame the feds for the donut hole are blaming the wrong government.
  • The ACA reduces premium costs up front, by providing tax credits for households whose income is 400% of the federal poverty level. If an applicant’s income is considered too low for tax credits, that person is funneled toward their state’s Medicaid program.
  • Many people insured by public plans were unaware they were benefiting from Medicaid expansion, because their plans bore state-specific names that did not include the word “Medicaid.” Some examples: Husky Health Connecticut, MassHealth, Healthy Michigan Plan, Washington Apple Health, and many more. These state plans are Medicaid.
  • The ACA allows children to remain on their parents’ plans until the children reach the age of 26. William Shatner’s 1978 Saturday Night Live skit is referenced here purely for the nostalgic amusement of your cartoonist.
  • The ACA requires that free preventive care be included in all insurance plans.
  • We can identify and acknowledge many drawbacks to the ACA, many of which are continuations of problems that existed pre-ACA or resulted from compromises made in response to opposition challenges. But even political opponents who have been fighting like cats and dogs can agree on what’s wrong and how to fix it. Insurance premiums do keep increasing, just as they did in the past; however, the absence of an ACA cap on premium increases exacerbates the problem. Correspondingly, tax credits arguably should be adjusted to accommodate unaffordable higher premiums. This is purely a political problem and should be addressed accordingly. High-deductible plans are a reasonable choice for people who do not expect to use much care, but can be financially devastating for those who find themselves in need of medical attention. The answer, again, is to adjust the tax credit and premium caps to make better plans affordable to more people. Insurance does not guarantee health care, it is true. While the ACA contains provisions to increase access from the provider side, those preparations will require years to bear fruit. More immediate creative solutions are clearly needed. Finally: big government. This is a philosophical objection that begs for its own cartoon. Stay tuned!
  • Where is this all leading? Medicare for all. Medicare is the federal health insurance program for people who are 65 or older. “Medicare for all” suggests extending this insurance program to all Americans in a national single-payer health insurance plan – the kind favored by a majority of Americans. This proposal does not necessarily involve a centralized authority that employs providers and directs all medical care. Rather, it proposes combining the entire population into one insurance risk pool in order to take the greatest advantage of potential savings, particularly from administrative spending, which currently accounts for one of every three health care dollars spent in the U.S. Much more information on single-payer systems is widely available. We suggest starting with Physicians for a National Health Program.

We hope that The Affordable Care Act/Obamacare 101 has been useful to you. Please respond on our Facebook page if you have ideas for future cartoons on this subject – or any other!

Image credits


Graphic and Fact Sheet: U.S. Midwives – Now You See ‘Em, Now You Don’t – AwakenMichigan

We continue to share cartoons created for other organizations. This one, on the history of midwives in the U.S., was created for AwakenMichigan: Reproductive and Sexual Justice Project

Rather than composing a new fact sheet to accompany this graphic, we instead include a paper (see below) written in 2012 for the edification of the students in our Reproductive Justice class offered at the University of Michigan for several years through the Women’s Studies Department. First, however, a few explanatory notes on the graphic:

Page 1

Page 2

Page 3

Page 4

  • Frame 1. The Practicing Midwife is a journal found in the University of Michigan Libraries’ collection. Many of those images were used in the 2013 conference exhibit, Birthing Reproductive Justice: 150 Years of Images and Ideas. You can still view the online portion of the exhibit. In the middle photo, Geradine Simkins is shown holding her recent book, Into These Hands: Wisdom From Midwives (2011). Simkins is included here because she is a key figure in the revival of Michigan midwifery. Finally, no discussion of a women’s health issue would be complete without a copy of Our Bodies, Ourselves, most recently reissued in 2011.
  • Frame 3 is very complex and difficult to read – by design. For information on Certified Professional Midwife licensure, we refer you to The Big Push for Midwives. The ladies marching in the old photo are, alas, not really midwives, but members of the International Ladies’ Garment Workers, taking part in the Shirtwaist Makers Strike of 1909. Consider that to be artistic license on our part.
  • Frame 4 situates midwifery care inside the larger struggle for Reproductive Justice. We highlight the work of Tewa Women UnitedBlack Women Birthing Justice,  Strong Families, and every person who has stood up for Black Lives Matters. These individuals and organizations are all worthy of your support. Finally, the plant pictured is the Rose of Jericho, pointed out by Bellies and Babies as being particularly helpful to women in labor.

We are grateful to Marinah Farrell, LM, CPM, of Arizona, and President of the Midwives Alliance of North America, for her very helpful critique and suggestions. Thanks for midwifing our graphic, Marinah!

 

Source: Graphic and Fact Sheet: U.S. Midwives – Now You See ‘Em, Now You Don’t – AwakenMichigan


News and links, May 4, 2014

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