Written by Walker Kahn, Maria Manansala, and Ada Inman
SECTION I. The Problems & Progressive Local Solutions
Despite its enormous wealth and scientific prowess America as a whole is not, comparatively, a particularly healthy nation, Gross inequalities in the distribution of virtually all material determinants of health is the signature reason for this. Our peculiarly unkind healthcare insurance system is another. Domination of our health care by predatory for-profit corporations is the basic reason for that. The Affordable Care Act (aka “Obamacare”) sought to improve on this social failure, while broadly yielding to the political power of its root cause, by simultaneously improving standards on providers and insurers and subsidizing the individuals unable to afford insurance on its new terms. But despite its early successes in widening access, its effective coverage declined over 2016-19 and then COVID 19 spiked up the ranks of uninsured through sudden loss of access to employer sponsored health insurance.
Even in this generally unhappy mess, however, women face gender-specific hurdles to accessing necessary healthcare. These owe both to their distinct biological capacity to produce and nurture new life (birth, lactation), their share of household work in social reproduction (care of children and infirm), and the disrespect and oppression by male-dominated societies still offer them. Throughout the country, Republican-dominated state governments are hard at work making their situation worse, most visibly by curtailing legal access to safe abortion services. Given the complacency exhibited by the Federal government in the face of these laws, it is imperative that local leaders act to improve women’s health and public health.
What can local government do? While the broad terms and rules of public access to healthcare are set at the state or national level, local governments have influenced both the application of those rules and the more foundational social determinants of health in progressive ways. They can, for example, work to reduce racial health disparities (especially those associated with maternal mortality), improve access to reproductive healthcare, expand paid leave and sick leave where able, and reduce obstacles to care created by gender bias and anti-LGBTQ bias, racial discrimination, and economic disadvantage. Also, and very important in gaining political support for them, the women-centered policy innovations presented here have enormous positive spillover effects on others in communities. They not only improve women’s health but community health.
SECTION 2. Available Local Levers & Targets for Reform
While the legislative powers of counties, cities, and towns are constrained by state and federal law (see the ProGov21 Home Rule roadmap for more information on preemption), local officials and community leaders still have tools they can use to improve women’s health. Where possible, local governments should pass laws expanding paid sick days and paid family medical leave, so that women aren’t forced to choose between their job and their own health, or the health of their family members. Local governments in some states can and should pass laws requiring local employers to provide high-quality, affordable, comprehensive health insurance to employees and their families, (including nontraditional families) that cover reproductive health necessities like birth control and contraception. Similarly, living wage laws requiring employers to pay workers fair wages will improve the health of women, as well as all other workers. For more on local government health policies, see the ProGov21 Health roadmap. In states that preempt these legislative efforts, local governments can improve women’s health by establishing procurement policies that mandate recipients of local procurement dollars and their subcontractors meet certain requirements around health care, paid sick leave and family leave, and wages. The ProGov21 Procurement roadmap has more information on how local government’s can use their spending to drive positive social outcomes.
Local governments must recognize and support the importance of full-spectrum reproductive healthcare, including abortion and contraception, to women’s health. They should actively publicize information about the services available at women’s health clinics, as well as the deceptive practices of “crisis pregnancy centers” that do not provide comprehensive healthcare. Local elected officials should act as liaisons between clinics and local law enforcement to coordinate protection for clinic staff and customers from harassment and violence. Zoning policies should be written to explicitly identify abortion clinics as healthcare facilities. Counties and municipalities can provide funding for reproductive education and healthcare, including abortion, contraception, and treatment of sexually transmitted infections. These funds should be made available to undocumented and documented residents alike, but only through health centers that provide accurate information and care without bias or stigma, and crisis pregnancy centers should explicitly be excluded. Local governments can also allocate funding to ensure all residents have access to high-quality menstrual hygiene products, including tampons and pads, regardless of their ability to pay.
Counties and municipalities can promote women’s health by creating comprehensive wellness plans that incorporate wellness into every government department and coordinate across departments to promote public health in all aspects of city planning. These plans create a framework for public health through strategies like planning housing and public spaces together to promote walkability, and planning medical facilities and transit together so that all people—and especially those who are pregnant—can attend medical appointments via reliable, efficient public transportation. Wellness plans should include public awareness campaigns on sexual and reproductive health that are sex-positive, and do not stigmatize or shame people.
Bias, ignorance, and criminalization present significant impediments to women’s health. Local municipal and county officials should partner with school board members to fund and support sex education courses that put young women in charge of their reproductive health and inform them of their contraceptive choices. These courses should also teach about gender identity and LGBTQ+ issues, so that students learn to navigate a healthcare system that often discriminates against trans and other LGBTQ+ individuals. Local governments can also pass shield laws that protect sex workers from arrest and prosecution when they report crime. Local governments should not prosecute pregnant people for the outcome of their pregnancy, and laws should be passed and enforced to ensure that incarcerated people have access to comprehensive reproductive healthcare, and the shackling of incarcerated people who are pregnant, in labor, or postpartum, should be banned.
SECTION III: Current Reforms and Tools to Fight for Them
Around the country, local governments and activists are taking charge to achieve gender equity within healthcare. In the fight to improve women’s reproductive health access, cities like Columbus, New York City, West Palm Beach, and Pittsburgh have established clinic protection laws that protect the women and providers attending abortion clinics. A local ordinance in San Francisco aims to protect women seeking reproductive healthcare through prohibiting fake clinics from making misleading statements or posting deceptive advertisements about their services. In a similar vein, Hartford, CT and New York City both have ordinances that require fake clinics to disclose whether there is a licensed medical provider on-site providing care. In Kalamazoo, MI, the first Reproductive Health Fund was created with the intention to support women with their full range of reproductive and sexual health care needs. Lastly, St. Louis, MO passed a Reproductive Health Non-Discriminiation Ordinance that protects people from discrimination in employment and housing based on their reproductive health decisions, including abortion. The Mayors Guide to Accelerating Gender Equality outlines additional steps that cities have taken to ensure that women have full access to reproductive healthcare including outreach initiatives, healthcare hotlines, and educational campaigns.
Expanding paid family and sick leave programs is vital in supporting women’s healthcare needs, especially in the midst of the COVID-19 pandemic. Paid leave programs have far reaching benefits for public health as a whole. This is evidenced through the eight states and the District of Columbia which have all enacted paid family and medical leave programs. Allegheny County, PA and Seattle, WA are the most recent cities to create paid leave policies for public employees. In Allegheny County, six weeks of paid parental leave is given to full-time employees who have worked for a minimum of one year. Seattle offers employees four weeks of paid parental leave.
In order to ensure that women have access to the best healthcare available, it is important to address inherent biases and discrimination within our healthcare systems. Trans women seeking healthcare frequently face discrimination based on their gender identity. One way to address this is through teaching about gender identity and LGBTQ+ issues during sex education courses. In California, recent policy encourages public school teachers to talk about gender identity with kindergartners and give advice to LGBTQ+ teens navigating relationships and safe sex. In the healthcare setting, San Francisco removed exclusions that banned employee access to medically necessary transgender specific care under employee health care plans. Additionally, Multnomah County, OR issued an executive order to remove transgender exclusions in employee coverage and make sure transition-related surgeries are covered in employee plans. Jersey City, NJ and Phoenix, AZ have also included transgender-inclusive medically necessary health benefits for municipal employees.
People of color experience racism within our healthcare system resulting in lower quality care and higher mortality rates. In Minnesota, inherent biases are being combatted within the healthcare system by requiring health care providers to track racial and ethnic disparities in treatment for a wide range of conditions. In Boston, the Boston Public Health Commission highlights racial and ethnic disparities by neighborhood as to inform healthcare providers of specific local needs. HealthPartners makes racial equity a strategic priority by creating health equity sponsor groups to monitor healthcare equity initiatives as well as hires equitable care champions to train on implicit bias and cultural humility within the healthcare system.
SECTION IV: Taking it to the Next Level
When tackling gender-based health disparities, local policymakers must also address disparities among women, influenced by race, social class, and gender identity. Black women are more likely to experience complications throughout the course of their pregnancies than white women. Compared to white women, Black women are four times more likely to die from pregnancy-related complications. A variety of factors may contribute to this disparity. Firstly, discrimination and structural racism in the healthcare industry lead to Black women receiving poorer quality care than their white counterparts. Secondly, Black women are paid 48 to 68 cents for every dollar white, non-hispanic men receive. As a result, many of them are unable to afford health insurance, and in 2017, 13.7 percent of Black women were uninsured. Without insurance, many Black women do not seek medical help for health-related issues prior to pregnancy, leading to poor maternal outcomes. See our Wages and Benefits roadmap to learn more about how you can bridge the racial and gender pay gap, and ensure health insurance for all working Americans.
Moreover, low-income people of color, particularly Black mothers, are evicted at a disproportionately high rate. According to a study conducted in Milwaukee County, Black women comprised only 9.6 percent of the population, but represented 30 percent of all evictions. Eviction is associated with poor health, and makes Black mothers and their children more at risk of food insecurity, drug-abuse, mental health problems, and increased mortality. Establishing free legal counseling in eviction cases, raising the minimum wage, and making housing more affordable are all actions policymakers can take to help women and their families avoid eviction.
Poverty is, in and of itself, a significant barrier to health. Poverty increases the likelihood of chronic health conditions, and exposure to air and water pollution. Impoverished women, in particular, have limited access to reproductive and sexual health services, such as contraceptive care, abortions, and sexually transmitted infection (STI) treatment and prevention. An organizing guide by The Institute for Reproductive Health Access outlines how stakeholders can protect reproductive healthcare for low-income women at the federal, state, and local level.
Transgender and gender non-conforming individuals experience discrimination when accessing healthcare. The National Transgender Discrimination Survey found that 19 percent of survey respondents had been denied care due to their transgender identity, while 28 percent of faced harassment and violence in medical settings. In addition, 50 percent of respondents reported having to teach their medical providers about basic aspects of transgender health, due to a lack of provider knowledge. In order to protect and advance healthcare for transgender communities, including transgender women, local policymakers should develop policies that end violence against transgender people, increase funding for community health centers, provide transgender-sensitive staff training, and more.
SECTION V: Allies and Helpers
- Women’s Fund of Rhode Island invests in women and girls through research, advocacy, grant making and strategic partnerships designed to achieve gender equity through systemic change.
- Institute for Women’s Policy Research: A national think tank that builds evidence to shape policies that grow women’s power and influence, close inequality gaps, and improve the economic well-being of families.
- National Women’s Law Center fights for gender justice—in the courts, in public policy, and in our society—working across the issues that are central to the lives of women and girls.
- National Center for Transgender Equality advocates to change policies and society to increase understanding and acceptance of transgender people.