The "other" Within: Health Care Reform, Class, and the Politics of Reproduction

• Jurisdiction: United States,Federal
• Publication year: 2011
• Citation: Vol. 35 No. 02

SEATTLE UNIVERSITY LAW REVIEWVolume 35, No. 2WINTER 2012

The "Other" Within: Health Care Reform, Class, and the Politics of Reproduction

Janet L. Dolgin(fn*) and Katherine R. Dieterich (fn**)

I. Introduction

Americans have long been reluctant to develop a system of universal health care,(fn1) and they remain reluctant about implementing the Affordable Care Act, promulgated in 2010.(fn2) The United States spends more on health care per capita than any other nation,(fn3) yet the results of that expenditure are wanting.(fn4) Various explanations for the gap between spending and results refer to economic factors,(fn5) special interests,(fn6) political commitments,(fn7) and dedication to finding private solutions for public conundrums.(fn8) None of these explanations is wrong. None, however, tells the full story.

This Article offers a different explanation and focuses on the nation's opaque class system. It suggests that dedication to assumptions about class is an essential component of the nation's longstanding resistance to constructing a more equitable system of health care coverage.(fn9) This Article describes the nation's class ideology and how that ideology is reflected in national discourse about health care reform. Specifically, it illustrates these matters through the lens of American society's reactions to poor women in need of reproductive care.

The process leading to the Affordable Care Act's passage, as well as state and federal legislative responses in the year following the Act's passage, do not bode well for these women and their essential health needs. The political process of health care reform seemed to displace concern about the matter actually at issue-health care coverage-with concern about abortion and family-planning services for poor women.(fn10) Cliff-hanging negotiations about abortion coverage shaped the final congressional vote on the Act, and the law's passage depended on President Obama's executive order, which restricted the use of funds made available pursuant to the law for abortion coverage.(fn11)

Ten months later, the 112th Congress initiated its session in the House with the introduction of a bill to repeal the health care reform law completely,(fn12) and soon after, the House considered another bill aimed at cementing the ban on abortion funding through the health care reform law.(fn13) At the same time, many states passed or at least considered bills that limited funding for abortion and general reproductive care.(fn14) These laws disproportionately affect poor women.(fn15)

Thus, passage of a health care reform law reshaped and reinforced a narrative about poor women and their reproductive lives-a narrative that instantiates the nation's ideology of class. It is a narrative grounded on Americans' commitment to a highly competitive class system, the shape and boundaries of which remain obscure. It reflects the nation's intense anxiety about socioeconomic status in a universe where signs of status shift rapidly and are often murky.

Part II of this Article discusses the vulnerability of poor women who lack full coverage for reproductive health care. These women are likely to receive inadequate or even harmful care. Additionally, poor women are likely to receive that care later than women with adequate health care coverage or with other economic resources. Section A recites the disturbing tale of an abortion clinic in Philadelphia that served mostly poor, minority women. The story involves reproductive care at its very worst. Section B considers, more generally, how the nation has wrested reproductive control from poor women in the United States. It then examines the complicated ideological strands that lie beneath reproductive health care available to poor women.

Part III reviews responses to reproductive care for low-income women during the last decades of the twentieth century and provides the historical background needed for contextualizing the discussion in Part IV. Part IV reviews the role that abortion politics, and reproductive politics more generally, has played in the passage of, and in post-passage responses to, the health care reform law-the Patient Protection and Affordable Care Act.(fn16) This role has included federal and state challenges to public funding for family-planning services for poor women.(fn17)

Finally, Part V elaborates on material introduced in Part II. It considers assumptions about class that undergird opposition to health care reform. This Part argues that many assumptions that underlie opposition to health care reform also underlie opposition to public funding for abortion and family-planning services. In short, the abortion politics that marked the last weeks of congressional debate prior to passage of the Affordable Care Act provided a platform upon which the nation could contemplate the benefits and detriments of more universal health care coverage.

II. Poverty and Reproductive Choice

The politics of reproduction includes the social and jurisprudential debate about contraception, sterilization, and infertility, as well as the debate surrounding abortion and family-planning laws. Reproductive politics directly affects family life, relationships between men and women, and the self-identity of women. It also directly affects the health of women and children, and, more specifically, may affect the timing of childbearing as well as the number of children that a woman will bear. And reproductive politics also encompasses a host of other significant issues. During the last half century, the politics of reproduction has served the interests of those concerned with broadening (or limiting) welfare, challenging (or cementing) traditional understandings of gender and family, glorifying (or deflating) medicine as a profession, determining childbearing patterns, and cementing (or exposing) class and racial dis-crimination.(fn18)

Although reproductive politics affects virtually all women and most men, its consequences have been particularly harsh for poor women.(fn19) The politics of abortion provides a poignant example of how disparities in the national health care system are created on the basis of economic status, albeit in another name. On its face, discourse about abortion in the United States has concentrated primarily on the ontological status of the embryo and the fetus, as well as on the value and social implications of safeguarding a "traditional" vision of family.(fn20) These issues would seem to render discourse about abortion similarly consequential for all socioe-conomic groups. But the politics of abortion and reproduction reflect a set of assumptions about class deeply ingrained in the discourse. The result has not served poor people well.

It is unsurprising that poor women are the primary victims of reproductive politics. They are stigmatized not only because they are poor but also because they are poor women.(fn21) Assumptions about poverty and the reproductive lives of poor women merge; each set of assumptions intensifies the other. American society has long envisioned that a woman's personal reproductive history is an essential parameter of her per-sonhood. That notion has particular implications for poor women. Society attributes poverty to women's reproductive irresponsibility far more than men's. Moreover, American society has viewed nontraditional family choices among low-income people as evidence of "lower-class" irres-ponsibility.(fn22) In that context, society views poor women as "bad" mothers.(fn23) These assumptions reflect a wider tendency in American society to attribute poverty to irresponsibility in general and to laziness in particu-lar.(fn24)

Section A of this Part argues that poor women who are anxious to abort a pregnancy but who are without coverage for the procedure are profoundly vulnerable.(fn25) The implications of the painful story described in section A are far-reaching insofar as the social and legal responses to abortion identified in that section are reflective of responses to reproductive care for poor women more generally.(fn26) Section B of this Part considers the wider context within which law and society in the United States deprive poor women of control over their reproductive choices.

A. The Worst of Care

In early 2011, a Philadelphia judge accepted a grand jury report that recommended that the city's district attorney prosecute Dr. Kermit Gos-nell, his wife, and members of his staff for crimes allegedly committed at Gosnell's abortion clinic, the Women's Medical Society.(fn27) The grand jury called Gosnell's clinic a "filthy fraud"(fn28) and recommended that he be tried for several counts of murder and infanticide.(fn29)

Gosnell ran the clinic for decades, but the state investigated the clinic's abortion business-and its often disastrous consequences for poor women-only by accident, as part of a drug-trafficking investigation involving prescription medications.(fn30) According to reports, patients at Gosnell's clinic were overdosed with dangerous drugs.(fn31) The grand jury described that Gosnell "spread venereal disease among [the patients] with infected instruments, perforated their wombs and bowels," and caused at least two deaths.(fn32) The grand jury also concluded that unlicensed clinic employees routinely provided care to Gosnell's patients.(fn33)

Further, the grand jury reported "official neglect" by the state's oversight agencies(fn34) and asserted that "[e]ven nail salons in...