Today is the 4^th of July, Independence Day. “We hold these truths to be self evident, that all men are created equal, that they are endowed by their Creator with certain unalienable rights, that among these are life, liberty and the pursuit of happiness.“

These stirring words, drafted in June 1776 by Thomas Jefferson, the principal writer of a committee of five— John Adams, Benjamin Franklin, Robert Livingston and Roger Sherman were the others—have inspired Americans for more than 200 years. Most people today assume the term ’men’ means all citizens. “Most” apparently doesn’t include five of the male members of the U.S. Supreme Court. Their June 30^th majority opinion gave many  U. S. companies the right to dictate, based on the religious beliefs of their owners, the types of contraceptive coverage female employees can access under their health insurance.  The dissenting minority included the three female members of the court as well as Justice Stephen Bryer. Justice Ruth Bader Ginsburg wrote a forceful, thirty five-page dissent calling the decision one “of startling breadth”. As Virginia Rutter wrote here at Girl W/Pen, June 30^th was “a terrible, horrible, lousy day.”

Things haven’t gotten any better. Yesterday Justice Sonia Sotomayor wrote a blistering dissent to the Court’s temporary order allowing Wheaton College a religious exemption to filing a required form under the Affordable Care Act.  Women, who understand the role of reproductive rights, including the right to use the method of contraception they and their physicians consider best for them as individuals, see through the careless reasoning of the five conservative male members of the Court. Justices Elena Kagan and Ruth Bader Ginsburg joined Justice Sotomayor who wrote that the order was at odds with the June 30^th Hobby Lobby decision. “Those who are bound by our decisions usually believe they can take us at our word. Not so today. After expressly relying on the availability of the religious-nonprofit accommodation, ….the Court now, as the dissent in Hobby Lobby feared it might, retreats from that position.”

Clearly if women thought we had gained full equality, the Supreme Court decisions of the last few days have put that fantasy to rest.

Political historians have long pointed out that the terms ‘man’ and ‘citizen’ were often considered synonymous, meaning, in fact, only men and only certain men. In the newly formed United States, women were citizens, but citizens who could not vote and whose first loyalties were not to the nation or the community, but to their husbands and fathers. Abigail Adams’ plea to her husband John in March 1776 as he worked to shape the new government, “…remember the ladies, and be more generous and favorable to them than your ancestors. Do not put such unlimited power into the hands of Husbands. Remember all Men would be tyrants if they could” fell on deaf ears . Historian Linda Kerber has pointed out that the “revolutionary generation of men who so radically transgressed inherited understandings of the relationship between kings and men, fathers and sons, nevertheless refused to revise inherited understandings of the relationship between men and women, husbands and wives, mothers and children. They continued to assert patriarchal privilege as heads of households and as civic actors” (Kerber, 1998, No Constitutional right to be Ladies).

Women eventually organized, just as Abigail Adams had warned her husband. “If particular care and attention is not paid to the Ladies we are determined to foment a Rebellion, and will not hold ourselves bound by any Laws in which we have not voice, or Representation.” It took another 140 years before the 19^th Amendment guaranteed women’s right to vote in 1920; but the women and men who fought for women’s suffrage eventually won the battle. In 1923 Alice Paul, a leader of the suffrage movement, drafted the Equal Rights Amendment.  She saw the ERA as another step necessary to assure equal justice under the law for all citizens. The wording is brief, clear: “Equality of Rights under the law shall not be denied or abridged by the United States or by any state on account of sex.”

In 1876, referring to the U. S. Constitution, signed only a few months after the July 4^th Declaration, Susan B. Anthony noted “It was we, the people; not we, the white male citizens; nor yet, we, the male citizens; but we, the whole people, who formed the Union.”

It’s an old feminist adage that ‘feminism is the radical notion that women are people.’ (see here and here)  Fighting for the passage of the ERA, ratified by only 35 of the 38 states needed before the 1982 deadline imposed by Congress, may seem far too quixotic an undertaking in the current political climate. But let’s remember the long battles for the right to vote, the continuing struggle for racial equality, the ongoing battle for equal rights for members of the LGBT community. The struggle for human rights and dignity takes lifetimes, set backs hit hard. But human rights are truly lost only when we give up, give in, surrender.

Sometimes I’m tempted. But not today, not on the 4^th of July, not with Abigail Adams and those who followed in her footsteps to inspire us.

Looking ahead to Mother’s Day and Father’s Day, I encourage readers to check out Chloe Bird‘s latest post for The RAND Blog. In “Assessing and Addressing Women’s Health and Health Care,” Bird explains the knowledge gaps and emphasizes the benefits of changing our approach to health research:

Gender-stratified research can produce more effective decision tools and interventions, and in turn improve both women’s and men’s health and health care.

I have featured her work on women’s cardiovascular health in a past post: it’s an excellent example of why we need to pay attention to sex/gender differences when aiming to improve health care.  Bird cautions of the dangers of failing to make the necessary revisions:

Until access, quality, and outcomes of care are tracked by gender, inequity in treatment will remain invisible and consequently intractable.

As we move forward with the Affordable Care Act, it is important to pay attention to the new assessments and tracking of the quality of care.  In the words of Bird, “This tracking should take gender into account so that disparities in health care and outcomes become visible and get the attention they deserve.”

New controversy about free condoms inspires this month’s column, a critique about student health and public health by Chloe E. Bird, Ph.D., senior sociologist at the nonprofit, nonpartisan RAND Corporation and co-author of Gender and Health: The Effects of Constrained Choices and Social Policies (Cambridge University Press).

Today’s extra edition of the monthly “Bedside Manners” column features a follow-up post from one of our past guest authors: Chloe E. Bird is a senior sociologist at the nonprofit, nonpartisan RAND Corporation and co-author of Gender and Health: The Effects of Constrained Choices and Social Policies (Cambridge University Press).

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In light of the current debate over women’s reproductive rights and care, it is increasingly clear that the benefits of the Patient Protection and Affordable Care Act (ACA) for access to comprehensive health care will not accrue equally to women across the country. Simply put: There is more agreement on what must be included in comprehensive health care for men than on whether and to what extent contraceptive and reproductive services must be included in comprehensive health care for women.

While it has long been recognized that comprehensive care for men includes sexual and reproductive health, the same has not been true for women. For example, women’s health insurance plans have typically allowed exclusions in this area even for pregnancy, and even when it is not a “preexisting condition”; indeed, there are no comparable accepted options for excluding entire aspects of health care for men while providing them for women.

Yet although the ACA assures women access to primary care and many reproductive services without copays, the debate over reproductive services continues. Recent political discussions on access have typically not included discussion of increases in women’s education, employment and career continuity attributable to contraception.

In the context of this debate, the Timely Access to Birth Control bill (AB 2348), which has been approved by the state legislature and is now awaiting Governor Brown’s signature, may appear to some to be a luxury that California can ill afford. But the reality is that over the mid to long run, AB 2348 would very likely save the state a significant amount of money. The bill allows registered nurses to dispense highly reliable hormonal contraceptives, including the pill. If enacted, doctors and nurse practitioners would be freed up to focus on more complex patient visits. If passed, the bill would increase women’s access to reliable contraceptives and reduce the costs of delivering that care.

In a Mother’s Day piece for Ms. Magazine Online, I pointed to the savings contraception generates for employers, insurers, and taxpayers. A public dollar invested in contraception saves roughly four dollars in Medicaid expenditures—or $5.1 billion in 2008—not to mention the broader health, social and economic benefits. Moreover, a 2010 study in California of a Medicaid family planning program found that every dollar spent saved the public sector over nine dollars (PDF) in averted costs for public health and welfare over five years. Rather than getting caught up in the national political debate over reproductive health coverage, California legislators should consider the significant cost savings as well as the social and economic benefits of improving timely access to reliable contraception.

On the national front, the goal of the ACA is to expand access to healthcare for Americans, especially those who currently lack health insurance; but the law also prioritizes improvements in the quality of care and reductions in costs. As we look for ways to provide efficient, high-quality, and cost-effective health care to more Americans, we can’t afford to ignore women’s health issues, including reproductive health care and the cost savings that contraceptive access provides.

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Cross-posted with the author’s permission from RAND’s blog

On this historic day, the US Supreme Court’s ruling on health care is being hailed as “a victory for all Americans” – but will all Americans benefit equally from the new health care law signed into law by President Barack Obama? No, not those, like Obama, who are male.

The ACA’s list of “Covered Preventive Services for Adults” includes screenings for only two sexually transmitted infections (STIs): “HIV screening for all adults at higher risk” and “Syphilis screening for all adults at higher risk.” They do include “Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk,” and “Immunization” for the STIs Hepatitis B, Herpes and Human Papillomavirus (HPV). All sexually active boys and men are potentially at risk for contracting a wide range of STIs, including HIV: the interpretation of “higher risk” could keep many from receiving necessary care.

If you scroll down this page, you’ll find the longer list of “Covered Preventive Services for Women” which includes additional sexual and reproductive health care screenings related to breast cancer, cervical cancer, chlamydia, contraception, gonorrhea, plus extra screenings HIV and HPV.  This laudable list is capped off by “Well-woman visits” described as, “preventive care visit annually for adult women to obtain the recommended preventive services that are age and developmentally appropriate….” Why would a man not benefit from these types of services?

A google search for “well-man visits” turns up nothing on U.S. government websites and only one company’s description of their “Well Man Examination” policy: it includes only “Digital rectal exam; and Screening PSA test (age 40 or older).” Younger men could benefit from an examination for testicular cancer, “the most common cancer in American males between the ages of 15 and 34.” None of these tests are mandated under the ACA.

Looking again at government resources, the inequity jarring. In addition to having a website devoted to National Women’s Health Week in May, the U.S. Department of Health and Human Services also sponsors an Office on Women’s Health website.  If you’re on the homepage of the U.S. Department of Health and Human Services and search for “men’s health” you will not find a men’s health website.  However, their Office on Women’s Health website (somewhat ironically) features the U.S. government’s only resource webpage for men’s health, including a link to men’s sexual health. On this page, it focuses more on aging and sexual dysfunction, with only one small link to sexually transmitted infections. This “sexual health” page seems to patronize and condescend to men, doubting their abilities to care about and seek sexual health care:

“Sexual health is a source of concern for many men. Yet some men are not comfortable talking to their doctors about sex.” And, later on, “Remember that problems with sexual health are medical problems, and your doctor can help.”

If you live in King County, WA, then you might be in luck: their Public Health website features a fairly detailed description of “physical examinations for men.”  If you don’t feel comfortable seeking these examinations from your regular doctor, then check out Planned Parenthood: a national organization that provides men’s sexual health exams. While I’m not sure how many U.S. teen boys and men would think of Planned Parenthood clinics as their home base for sexual health care, U.S. health policymakers should look to them for guidance. Depending on the specific PP clinic, their services might include:

• checkups for reproductive or sexual health problems
• colon cancer screening
• erectile dysfunction services, including education, exams, treatment, and referral
• jock itch exam and treatment
• male infertility screening and referral
• premature ejaculation services, including education, exams, treatment, and referral
• routine physical exams
• testicular cancer screenings
• prostate cancer screenings
• urinary tract infections testing and treatment
• vasectomy

U.S. men, where is your outrage? Where are the protests demanding equality in sexual and reproductive health services? Why is there no U.S. Office on Men’s Health? A little digging online unearthed the failed “Men’s Health Act of 2001” which articulated the need for an Office of Men’s Health. If this act is not a priority for today’s politicians, then I encourage you to do your part to raise awareness about the need for accessible, affordable and comprehensive men’s sexual and reproductive health care. All of us — men, women and children — will benefit from better men’s sexual health.

Yesterday marked the one-year anniversary of President Obama signing the Affordable Care Act.  I encourage everyone to become familiar with what the Act has already accomplished, as well as the plans through 2015 (see an interactive timeline online).

Today, I dedicate this month’s column to reflecting on one of the new consumer protections that is scheduled to become effective January 1, 2014, No Discrimination Due to Pre-Existing Conditions or Gender:

Before the Affordable Care Act became law, insurance companies selling individual policies could deny coverage to women due to pre-existing conditions, such as cancer and having been pregnant. 

A WhiteHouse.Gov fact-sheet describes the ways in which, “The Affordable Care Act Gives Womem Greater Control Over Their Own Health Care.”  When I first read it, even as a feminist medical sociologist familiar with health care inequities, a few lines jumped out at me:

Right now, a healthy 22-year-old woman can be charged premiums 150 percent higher than a 22-year-old man.

Less than half of women have the option of obtaining health insurance through a job.

Today, maternity benefits are often not provided in health plans in the individual insurance market.

I appreciate the many positive effects this law has on women, men and children, but I find myself asking: why did the Affordable Care Act not include this provision — to eliminate discrimination to due to gender — among its original 2010 provisions?  A comparable provision was effective as of September 23, 2010 for children:

…health plans that cover children can no longer exclude, limit or deny coverage to your child under age 19 solely based on a health problem or disability that your child developed before you applied for coverage.

Now, don’t get me wrong, I’m all for protecting children’s rights to receiving coverage.  As a mom, I understand the instinct to want to protect one’s child before one’s self.  However, it feels like the policy-makers did not take into account the body of research on the direct correlations between maternal health and child health.  To put it simply, an unhealthy mom is not good for the health of her child — whether or not her child has excellent or poor health care coverage.

For example, a 2005 article in the journal PEDIATRICS documents research findings that,

“Maternal depressive symptoms in early infancy contribute to unfavorable patterns of health care seeking for children.” 

Another 2005 article examined the psychological and physical health of adult caregives of children with cerebral palsy and found that:

The psychological and physical health of caregivers, who in this study were primarily mothers, was strongly influenced by child behavior and caregiving demands…These data support clinical pathways that require biopsychosocial frameworks that are family centered, not simply technical and short-term rehabilitation interventions that are focused primarily on the child.

It’s easy to imagine the ways in which a child’s health might suffer if her/his primary caretaker has poor mental and physical health.  And, solely providing health care to the child did not necessarily improve the health outcomes of the caregiving moms.

One more example along the lines of the effects of maternal depression is the case of pediatric asthma.  A 2007 article in the Journal of Health Economics reports a study which shows:

…treatment of mother’s depression improves management of child’s asthma, resulting in a reduction in asthma costs in the 6-month period following diagnosis of $798 per asthmatic child whose mother is treated for depression.

Our health care system will likely save more money once we end insurance company discrimination on the basis of sex/gender.  Now, I recognize that not all women are mothers, but the overwhelming majority of mothers are women.  So, if the gendered division of labors in most families remains such that moms are primarily in charge of maintaing and protecting the health of their children, then wouldn’t we want these caregivers to have access to affordable, quality health care before 2014? 

That said, I am grateful that this law passed and hope that we will continue to work on ways to strengthen coverage for all Americans.