Healthcare in America has never been just. Inequity and racism are built into the system, and black women often bear the unjust burden. Our pain is taken less seriously; we are often misdiagnosed and untreated, and black women are three times more likely to die in childbirth. From provider bias and medical mistreatment to the structural barriers that prevent us from accessing health care, it is no surprise that our communities face greater health disparities.
Black women often advocate for their own safety and health—but we shouldn’t have to. The Affordable Care Act (ACA) ensured more equitable and affordable access to care for millions who had been uninsured or underinsured. Yet as we face an unprecedented public health crisis in the COVID-19 pandemic, the ACA is hanging by a thread—and so is healthcare for those of us who have, for many years before the ACA, already faced an unjust, unequal healthcare system.
Ten years ago on March 23, the U.S. enacted the Affordable Care Act (ACA), aka Obamacare. While by no means perfect, the reforms of the ACA moved us closer to a system in which healthcare is a human right for all, not a privilege for the wealthy and well-connected. Sexual and reproductive healthcare—basic healthcare for women—is no different. Today, we are fighting an administration whose years-long attacks on our communities and public health infrastructure has hampered our ability to manage the COVID-19 pandemic—which could have far-reaching consequences for black and Latinx communities in urban neighborhoods—who are more likely to have low incomes, and thus, be uninsured.
Ten years ago, the situation would have been even worse. Thirty percent of women had a condition considered “declinable”—things like cancer, hypertension, diabetes, or even pregnancy and experiences with sexual assault and domestic violence—and black women often experience higher rates than their non-Hispanic white peers. In short, being a woman was a preexisting condition, and because women of color face worse health outcomes in a social and economic system built on racism, being a black woman made it even harder to get coverage for care.
Since the ACA was enacted, the proportion of black women of reproductive age without health insurance fell by 36 percent, and 30 percent of black women who were previously uninsured are now enrolled in Medicaid. The ACA’s policies meant more women of all races had insurance, and more of their health needs were covered than ever before. Sexual and reproductive health care for people of all genders improved under the ACA, and women’s lives are better for it. As of 2015, at least 15 million black women gained access to guaranteed no-cost birth control. And for women having children, the ACA was a significant improvement. Maternity care must be covered as an essential health benefit by individual market health plans. Prior to 2013, just 12 percent of plans on the individual market included maternity benefits. The infant and maternal mortality rates declined in states that expanded Medicaid under the ACA, especially among black babies and women.
Yet the Trump-Pence administration and anti-abortion politicians across the country have worked to systematically undermine every one of the ways black women’s health has improved. The administration promoted rules eliminating the guarantee that health insurance through employers will cover birth control, and made it easier for health insurers to avoid covering essential health benefits like maternity care, mental health care, and emergency services. Later this year, the Supreme Court is scheduled to hear a case, Trump v. Pennsylvania, that could allow employers and universities to refuse to cover birth control under the ACA exchanges. And the administration is supporting another case that challenges the legality of the Affordable Care Act. All this because Trump’s allies in Congress failed to repeal the ACA despite trying dozens of times.
We need politicians to do better. We need health coverage for the 12 percent of black women who are still without insurance—starting with action by the states that have so far refused to expand Medicaid coverage, including states in the South where so many black women live. And while insurance coverage is important, it won’t fix the structural racism that fuels health disparities. We need policies that address the staggering—and growing—rates of maternal mortality among black women. We need safe, legal abortion to be not just a right on paper, but an accessible healthcare service covered by insurance and available no matter where you live or how much money you have. We need the full range of birth control to be universally available without out-of-pocket costs. And we need quality, equitable, and affordable preventive healthcare for black Americans—who have higher health disparities due to economic inequality, and consequently, are more at risk to die from COVID-19.
As black women leading reproductive health and rights organizations, we’re committed to the advancement of black women’s health. We’ve been outspoken on harmful policies that restrict our access to care, and have publicly supported policies, like the ACA, that create positive health consequences for all women.
After 10 years, the ACA has shown that we can improve health for women in our communities. But as the COVID-19 pandemic highlights in stark terms, we also know that the work of protecting our lives and health is not on us alone. We need our elected and policy leaders to ensure that the next 10 years are just as transformative for sexual and reproductive health. Our hope is that the ACA’s enduring legacy is not that it was the start of expanding healthcare in this country, but the beginning of another huge leap toward justice—a leap we need now more than ever.