The Politics of Women’s Health Care in the United States

By M. Palley

In a social and political environment that has become more accepting of gender equity, women's health issues have emerged in the forefront of the social policy agenda of the United States. The organized women's movement has been successful in many of its endeavors to improve opportunities for women in society in areas such as education, business, sports and the professions. As this book shows, they also have been successful in changing the definition of women's health and placing many elements of health care needs on the nation's policy agenda. During the late 1960s and early 1970s, abortion rights emerged as a central concern for many women's rights activists, some of whom took on women's other health issues. The Politics of Women's Health Care in the United States shows how the evolution of the women's health agenda has been a reaction to the empowerment of women in the years after the emergence of the contemporary women's movement in 1966 and the subsequent 'social reconstruction' of women from dependent to advantaged population.

• Language: English
• Publisher: Palgrave Pivot
• Release date: Feb 24, 2014
• ISBN: 9781137008633

Book preview

The Politics of Women’s Health Care in the United States

Marian Lief Palley

and

Howard A. Palley

THE POLITICS OF WOMEN’S HEALTH CARE IN THE UNITED STATES

Copyright © Marian Lief Palley and Howard A. Palley, 2014.

All rights reserved.

First published in 2014 by

PALGRAVE MACMILLAN®

in the United States—a division of St. Martin’s Press LLC,

175 Fifth Avenue, New York, NY 10010.

Where this book is distributed in the UK, Europe and the rest of the world, this is by Palgrave Macmillan, a division of Macmillan Publishers Limited, registered in England, company number 785998, of Houndmills, Basingstoke, Hampshire RG21 6XS.

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ISBN: 978–1–137–00863–3 EPUB

ISBN: 978–1–137–00863–3 PDF

ISBN: 978–1–137–00861–9 Hardback

Library of Congress Cataloging-in-Publication Data is available from the Library of Congress.

A catalogue record of the book is available from the British Library.

First edition: 2014

www.palgrave.com/pivot

DOI: 10.1057/9781137008633

For Elizabeth, Alex, Amelia and Charlotte who enrich and bring joy to our lives.

Contents

1 Rethinking a Women’s Health Care Agenda in the United States

2 Historical and Cultural Perspectives

3 The Role of Politics in Influencing the Women’s Health Agenda

4 Women’s Reproductive Health

5 The Politicization of Abortion

6 Violence against Women

7 Older Americans

8 The Politics of Disease

9 Conclusions

Index

1

Rethinking a Women’s Health Care Agenda in the United States

Abstract: Women’s health care issues are increasingly a part of the political agenda in the United States. The organized women’s movement has been successful in improving opportunities for women in a number of areas such as education, business, sports and other professions. It has often been successful in changing the definition of women’s health and placing many elements of women’s health care needs on the policy agenda of the United States. Among the areas now recognized as part of the women’s health agenda are inclusiveness of women as part of National Institutes of Health research projects, attention to the risks of hypertension and cardiovascular disease, violence against women, women and the diseases of aging and women as personal and professional caregivers. Also, an area of progressive attention as well as political reaction concerning women’s health is the subject of women’s reproductive rights—including the availability of abortion and, in some instances, contraception.

Palley, Marian Lief and Howard A. Palley. The Politics of Women’s Health Care in the United States. New York: Palgrave Macmillan, 2014. DOI: 10.1057/9781137008633.0002.

Being born female is dangerous to your health . . . [F]or most women living in poorer countries around the world it is devastating (Murray 2008, xiii). For poor women in the United States access to care is also not always available. Women’s health and the provision of care are limited in many societies by discrimination, sexism, gender inequality and inequity. The situation in the United States is quite different from that in less-developed societies. However, Katha Pollitt, when discussing the United States observed that [it’s] getting awfully crowded underneath the bus. You know, the metaphorical one women keep getting thrown under, along with their rights, their health and their money (Pollitt 2011, 12). Pollitt was referring to a 2011 congressional budget deal that temporarily saved gynecologic health care services for poor women at least until the next congressional budget cycle is debated when, she notes, the misogynistic fog machine [starts] all over again (ibid.).

Some general perspectives

Cobb and Elder in their seminal work on political agenda setting suggested that there are two basic types of political agendas: the systemic agenda and the institutional agenda. All issues that are commonly perceived by members of the political community as meriting public attention and as involving matters within the legitimate jurisdiction of existing governmental authority are included on what they refer to as the systemic agenda (Cobb and Elder 1983, 85). The set of items explicitly up to the active and serious consideration of authoritative decision-makers are included in the institutional agenda (ibid., 86). When issues reach the institutional agenda, the issue at hand has been recognized, defined as a problem and solutions have been considered (ibid.). Stone noted that placing issues on the nation’s policy agenda is a multi-tiered process and that [d]efining an issue . . . [is] a strategically complicated issue (Stone 2002, 229). This perspective was also reiterated by Kingdon when he observed that separate policy streams involving problems, policies and politics all must be understood in order to be an effective player in the policy process. Moreover, an open policy window is an opportunity for advocates to push their pet solutions or to push attention to their special problems (Kingdon 2003, 203). Thus, defining the issue for public consumption becomes a very important element of setting the agenda and determining not only how problems will be defined but also what solutions will be appropriate and relevant.

In a social and political environment that has become more accepting of gender equity, women’s health issues have emerged on the global agenda and on the social policy agenda of the United States. The organized women’s movement has been successful in many of its endeavors to improve opportunities for women in society in areas such as education, business, sports and other professions (Gelb and M.L. Palley 1996). In addition, as it will be shown in the pages that follow, they also have been successful in changing the definition of women’s health and placing many elements of health care needs on the nation’s policy agenda.

More and more women themselves are being recognized, as most political actors and analysts understand that they represent a significant force in politics. Moreover, the effect of the gender gap on the outcome of elections is apparent. Though women still constitute a minority of elected officials, increasingly they are running for, and winning, elections.

During the late 1960s and early 1970s, abortion rights emerged as a central concern for many women’s rights activists. Subsequently, some of these reformers took on other women’s health issues (Norsigian 1996). In part this was a function of the changing nature of the health care delivery system as well as a response to the changing demographics of society. It was also a reaction to the empowerment of women in the years after the emergence of the contemporary women’s movement in 1966 (Gelb and M.L. Palley 1996) and the subsequent social reconstruction of women from dependent to advantaged population (see page 6 for a discussion of social construction).

In a May 28, 1998 speech in which then President Clinton discussed subjects as diverse as nuclear weapons and a Patient’s Bill of Rights, the president focused his attention primarily on women’s health care needs. He noted that [t]hree quarters of all the health care decisions in this country are made by women (Clinton 1998). On the podium with him were 22 health care workers, only one of whom was a man (ibid.). Two observations seem appropriate regarding this event and the content of the talk. First, women’s health care is certainly on the nation’s policy agenda when the president addresses the issue so pointedly in a speech on the health care system. Second, women are a force with whom elected officials must be concerned. However, there is still some anxiety about the centrality of women’s health care needs that is apparent. President Barack Obama presented his State of the Union address to the nation in January 2011, and he noted that there would have to be some attention paid to curtailing spending. After his speech, NBC’s Brian Williams interviewed Senator Barbara Mikulski (D. MD). She expressed a concern that these cutbacks in discretionary spending not come at the expense of women and children’s health care needs (NBC Sports 2011).

By the end of the 1980s, demographic changes were becoming apparent. The baby boom population began to enter middle age and many more people, especially women, were living into old age. In January 2011 the very first of these baby boomers reached the age of 65 and became eligible for Medicare coverage. By the end of the first decade of the twenty-first century, the average life expectancy of an American white woman at age 65 was almost 20 years and for an African American woman it was almost 19 years (U.S. Census Bureau 2012).

It is not surprising that by the start of the decade of the 1990s the health care concerns and needs of this population began to be articulated by women’s health advocacy groups and women’s movement organizations as well as by some members of Congress. Put in somewhat different terms, as the baby boom population, a group that always insisted that it be heard began to age, demands that its new and emerging illnesses not be ignored were heard. This is a large population cohort and there is money to be made by commercial stakeholders in responding to its health risks (Skocpol 1997). The economics of the changing demographic map of the nation has led pharmaceutical companies to pay more attention to middle-aged and older women and their health care concerns. In other words, the profit motive, related to the increasing commercialization of health care, seems to have accelerated some new research on women’s health (Weiss 1997).

Certainly concerns about women’s health are not new. The medical establishment as well as the policy leadership of this country had never ignored women’s health. However, traditionally, female health was defined in terms of women’s sexuality. In other words, a woman’s role in reproduction and a woman’s role as a sexual partner were the defining characteristics of women’s health policy. Also, women’s reproductive life had been medicalized and was central to both the understanding and provision of female health services. What politics, demographics and economics seem to have provided women is the opportunity for an expansion and thus a redefinition of their health agenda. This reality that started to appear in the late 1980s and on into the 1990s has become even more apparent in the twenty-first century as the baby boomers have become older.

A distinction can be made between role change and role equity issues as they relate to the women’s rights agenda of the past three decades. Role equity issues are those policies which extend rights now enjoyed by other groups (men, other minorities) to women and which appear to be relatively delineated or narrow in their implications, permitting policy makers to seek advantage with feminist groups and voters with little cost or controversy (Gelb and M.L. Palley 1996, 6). Role change issues appear to produce change in the dependent female role of wife, mother and homemaker, holding out the potential of greater sexual freedom and independence in a variety of contexts (ibid.).

Women’s health care is presented as a role equity issue albeit with some redistributive elements. The politicization of abortion, rape and violence against women as well as the continued medicalization of reproductive health, including puberty, pregnancy and menopause indicate, however, that some role change elements still remain in the women’s health care debate. Nonetheless, since women’s groups and health advocacy organizations have been able to define women’s health care policy as essentially a role equity issue, women’s health is now part of our nation’s policy agenda.

Background

The visibility of women’s health as a policy issue and the emergence of women’s health care research has appeared prominently on the nation’s policy agenda in the past 20 years. There seem to be several reasons for this new public awareness. In June 1990 the Government Accounting Office report, National Institutes of Health: Problems in Implementing Policy on Women in Study Populations was released. This publication seems to have brought the issue of women’s health forthrightly to the attention of public policy decision makers. Though this report was relatively narrow in its scope, dealing primarily with an equity issue, the exclusion of women from research projects funded by the National Institutes of Health (NIH)—despite 1986 regulations that sought to forestall this situation—it served as a catalyst for action (Schroeder and Snowe 1994). The Congressional Caucus for Women’s Issues had requested the report as had Representative Henry Waxman (D. CA) who was then the Chair of the House of Representatives Subcommittee on Health and the Environment of the Energy and Commerce Committee. In the decade prior to the issuance of the report, the Congressional Caucus for Women’s Issues already had begun to question the paucity of research on women’s health. In 1990, Dr. Bernadine Healy was appointed Director of the National Institutes of Health. Dr. Healy was the first woman to be appointed to this post. Early in her tenure as Director of the NIH she required that all research protocols supported by the NIH include women in the sample population. Of course, research on ailments that are male specific such as prostate cancer were excluded from this rule.

The definition of a women’s health agenda emerged in an era when the social construction of women as a group was changing. Social constructionists examine the process of collective definition: the ways in which societies interpret, judge, and ascribe meaning to groups, conditions and events (Schroedel and Jordan 1998, 107). When Schneider and Ingram (1993) discussed the social construction of target populations, they distinguished between four types of target populations: advantaged, contenders, dependent populations and deviants. The advantaged are in the best position to receive beneficial policy outcomes because they are politically powerful and positively constructed whereas the contenders are politically powerful though they are negatively constructed. Dependent groups lack political power though they are positively constructed and the deviants are both politically weak and negatively constructed (Schneider and Ingram 1993).

Women traditionally were defined as a dependent target group. In the post-1966 era they began the process of reconstructing themselves as a more advantaged target population. In part this was a function of successful interest group and social movement mobilization by women’s rights organizations (Gelb and M.L. Palley 1996). Women became more engaged in asking questions that they tried to frame in terms of role equity. They then worked to move these issues onto the nation’s policy agenda. They could no longer be patronized or ignored, as they became more important participants in the political process. Their political power is measured in votes, wealth [and their] propensity to mobilize for action (Schneider and Ingram 1993), the defining characteristics of a target population’s power (ibid.).

In 1973, the Boston Women’s Health Collective published Our Bodies, Ourselves. This book had a very clear message: women must take responsibility for their own health. In the parlance of the social constructionists, they must show that they are not dependent. In addition, the book embraced empowerment—that is, the ability to control one’s own fate. It also provided practical information about women’s health.

In the years following the publication of this volume many things changed in the world of women’s health. As noted above, almost 20 years later, the first woman director of the NIH was appointed and she established rules that require all NIH-funded research to include women in the sample populations. Also, women were becoming more aware of the diseases that can afflict them and increasingly they were looking beyond their sexuality and their reproductive cycles as they defined their health status. Also, as the demographic profile of the nation began to change, and as commercialization of medicine had become more apparent, the profit motive increasingly had taken hold and drug companies began to target more of their research and marketing toward women (Hendren 1998).

In addition, in part as a result of the efforts of groups in the organized women’s movement to increase women’s awareness and to demand equal opportunities for women, the number of women who enter and then graduate from medical school has increased dramatically. More women are becoming physicians and some of these women doctors have begun to question the provision of health care to women. Some of these women health care providers also have become engaged in redefining women’s health needs. Thus organizations such as the American