Publication
Reproductive Oppression in Health Care: Underlying Factors of Medicaid Inequities Annotated Bibliography
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The State Health Access Data Assistance Center (SHADAC) with support from the Robert Wood Johnson Foundation (RWJF) and in collaboration with partner organizations is exploring whether a new national Medicaid Equity Monitoring Tool could increase accountability for state Medicaid programs to advance health equity while also improving population health.
During the first phase of this project, a conceptual wireframe for the potential tool was created. This wireframe includes five larger sections, organized by various smaller domains, which would house the many individual concepts, measures, and factors that can influence equitable experiences and outcomes within Medicaid (see full wireframe below).
While project leaders and the Advisory Committee appointed at the beginning of the project all agree that the Medicaid program is a critical safety net, they specifically identified the importance and the need for an “Underlying Factors” section of the tool. This section aims to compile academic research and grey literature sources that explain and provide analysis for the underlying factors and root causes that may contribute to inequities in Medicaid.
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- Historical context of Medicaid inequities
- Information on how underlying factors perpetuate inequities in Medicaid
- Potential solutions for alleviating inequities within Medicaid
Once selected, researchers compiled sources in an organized annotated bibliography, providing a summary of each source and its general findings. This provides users with a curated and thorough list of resources they can use to understand the varied and interconnecting root causes of Medicaid inequities. Researchers plan to continually update this curated selection as new research and findings are identified and/or released.
Sections of the full annotated bibliography include:
- Systemic Racism
- Systemic / Structural Ableism
- Sexual Orientation, Gender Identity, and Gender Affirming Care Discrimination
- Reproductive Oppression in Health Care
- Impact on Vital Community Conditions (webpage forthcoming)
This page is dedicated to a single section from the full annotated bibliography:
Reproductive Oppression in Health Care
![reproductive oppression definition in white text on a teal box](https://www.shadac.org/sites/default/files/publications/Reproductive%20Oppression%20in%20Health%20Care%20Definition%208.8.24.png)
Underlying Factors Annotated Bibliography: Reproductive Oppression in Health Care
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Crear-Perry, J., Correa-de-Araujo, R., Lewis Johnson, T., McLemore, M. R., Neilson, E., & Wallace, M. (2021). Social and Structural Determinants of Health Inequities in Maternal Health. Journal of Women's Health (2002), 30(2), 230–235. https://doi.org/10.1089/jwh.2020.8882
Author(s): Joia Crear-Perry, National Birth Equity Collaborative, Washington D.C.; Rosaly Correa-deAraujo, Division of Geriatrics and Clinical Gerontology, National Institute on Aging, National Institutes of Health; Tamara Lewis Johnson, Office of Disparities Research and Workforce Diversity, National Institute of Mental Health, National Institutes of Health; Monica R. McLemore, Family Health Care Nursing Department & Advancing New Standards in Reproductive Health, University of California San Francisco; Elizabeth Neilson, Office of Disease Prevention, Office of the Director, National Institutes of Health; Maeve Wallace, Department of Global Community Health and Behavioral Sciences, Tulane University School of Public Health and Tropical Medicine
Article Type: Peer-reviewed Journal
The authors of this article make a distinction between structural and social determinants of health, describing structural determinants as the “cultural norms, policies, institutions, and practices that define the distribution (or maldistribution)” of social determinants of health. The authors explore these concepts in the context of social determinants of maternal health. They present a theoretical framework of determinants of Black maternal health called “Restoring Our Own Through Transformation” (created by Jessica Roach, 2016) to illustrate a “web of causation” between structural and social determinants of health and wellness. Crear-Perry et al. explore structural determinants of maternal health that are features of the U.S. health care system including financial barriers to care, a shortage of primary care providers, and gaps in quality, while also considering policy levers that might improve structural factors to support better maternal health outcomes, like paid family leave, access to affordable and comprehensive health care (which could be measured using exposure to Medicaid expansion, having Medicaid coverage through 12 months postpartum, etc.), access to culturally appropriate care (e.g., with clinicians that have received education on structural determinants of health and health inequities—i.e. “structural competency” education), and investments in community-oriented primary care for diverse women of reproductive age (e.g., midwifery maternity centers, nurse practitioner practices, maternal and child clinics, etc.).
Morcelle, M.T. (2022). Reforming Medicaid Coverage Toward Reproductive Justice. American Journal of Law & Medicine, 48, 223–243. https://doi.org/10.1017/amj.2022.27
Author(s): Madeline Morcelle, Senior Attorney in the National Health Law Program's (NHeLP) Washington, D.C. Office
Article Type: Peer-reviewed journal
The author of this journal article argues that while Medicaid presents a powerful vehicle for reproductive justice, especially for Black people and people of color, its structure allows for discriminatory eligibility and coverage policies that worsen health inequities for adults and their children. Historically, women and people of color have been advocating against reproductive oppression and advocating for “...universal, comprehensive, and affordable health coverage and access, with strong nondiscrimination protections, for everyone.” However, the author describes how voices of those experiencing oppression need to be centered or part of an “open source” framework rather than a “bottom to the top” engagement to dismantle oppressive systems. The author explains how Medicaid was designed by whites in power to only provide access to health coverage for some, “...the ‘worthy poor’,” and that these discriminatory practices continue today through policy decisions, like making Medicaid expansion a choice, for example. The author also describes the lack of adequate benefits for certain populations. While advances have been made recently, namely the Medicaid postpartum coverage extension opportunity and options to cover some immigrant groups, reproductive justice voices and frameworks should be at the center of Medicaid reform efforts to stop reproductive oppression and advance health equity for all.
Thompson, T. M., Young, Y.-Y., Bass, T. M., Baker, S., Njoku, O., Norwood, J., & Simpson, M. (2022). Racism Runs Through It: Examining The Sexual And Reproductive Health Experience Of Black Women In The South. Health Affairs, 41(2), 195–202. https://doi.org/10.1377/hlthaff.2021.01422
Author(s): Terri-ann Monique Thompson & Yves-Yvette Young, Ibis Reproductive Health, Tanya M. Bass, North Carolina Central University, Stephanie Baker, Elon University, Oriaku Njoku, Access Reproductive Care–Southeast, Jessica Norwood, The Runway Project, Monica Simpson, SisterSong Women of Color Reproductive Justice Collective
Article Type: Peer-reviewed journal
This article details a community-based participatory research approach to focus groups with nearly 50 Black women living in both Georgia and North Carolina (states chosen for having relatively restrictive reproductive health policies) to understand their experiences interacting with reproductive health care. The research team focused on three aspects of the participants’ experiences: access to health care, use of health care, and experience in health care – and how these experiences were connected to structural (summarized here) and individual racism. In terms of structural factors and access to adequate care, findings include that reproductive health clinics were often located outside of participants’ communities, making accessing care difficult. Focus group participants covered by Medicaid experienced issues with copayment being too burdensome. Lack of abortion coverage in some states was also a major concern for participants. In terms of structural racism and service use, authors report inconsistencies in what services are covered by different plans (both private and Medicaid coverage are mentioned), which impacted utilization. Focus group participants also reported that being a Black woman or living in a predominately Black community and receiving public assistance (or being uninsured) negatively impacted their health care experiences. Further, there was a perception that facilities caring for primarily publicly-insured individuals were lower quality. The authors urge for policy actions that alleviate these structural barriers, such as expanding federally funded Medicaid coverage, requiring abortion coverage, increasing reimbursement for doulas and midwives, and investing in hospitals that provide uncompensated care.
Ogunwole, S. M., Karbeah, J., Bozzi, D. G., Bower, K. M., Cooper, L. A., Hardeman, R., & Kozhimannil, K. (2022). Health Equity Considerations in State Bills Related to Doula Care (2015-2020). Women's Health Issues: Official publication of the Jacobs Institute of Women's Health, 32(5), 440–449. https://doi.org/10.1016/j.whi.2022.04.004
Author(s): S Michelle Ogunwole, Department of Medicine, Johns Hopkins University School of Medicine & John Hopkins Center for Health Equity; J’Mag Karbeah and Katy Kozhimannil, Division of Health Policy and Management, University of Minnesota School of Public Health; Rachel Hardeman, Center for Antiracism Research for Health Equity & Division of Health Policy and Management, School of Public Health, University of Minnesota; Debra G Bozzi, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health; Kelly M. Bower, Johns Hopkins University School of Nursing, & Johns Hopkins Center for Health Disparities Solutions; Lisa A. Cooper, Department of Medicine, Johns Hopkins University School of Medicine, Departments of Health Policy and Management, Health, Behavior, and Society, and Epidemiology, Johns Hopkins Bloomberg School of Public Health
Article type: Peer-reviewed journal
This article presents findings from a landscape analysis of state legislation related to doula care, including Medicaid coverage and reimbursement, with specific attention to whether legislation addresses racial health equity. It is well known that disparities in birth outcomes disproportionately affect Black and Indigenous birthing people. And evidence suggests that doula care is associated with improved birth outcomes. Authors draw on reproductive justice and public health critical race praxis frameworks in formulating study questions and methods. Reproductive justice refers to women having autonomy over their own bodes and the right to have and parent children safely and with access to community supports to realize optimal reproductive health. Public health critical care praxis theory acknowledges the legacy of white supremacy and racism as a root cause of health inequities in public health research. Authors draw on this theory to develop criteria for assessing whether doula care legislation is designed to address racial health equity. Criteria included reimbursement with plans to provide a living wage, collaboration with community-based doulas, training and certification requirements and funding, and emphasis on workforce diversity, promising practices, and metrics. Authors found that of the 73 bills introduced by 24 states between 2015 and 2020, just over half focused on Medicaid reimbursement for dual care. (Twelve bills in seven states became law.) However, only two states that passed Medicaid reimbursement for doulas also met some of the authors criteria for racial equity in their laws. Authors conclude that while proposals for increased access to doula care have increased over time, a racial equity lens is lacking. Authors suggest engaging doulas and considering racial equity policy assessments in the legislative drafting process.
[1] Women's Leadership and Resource Center. (2023). Reproductive Oppression Against Black Women | Women’s Leadership and Resource Center | University of Illinois Chicago. Wlrc.uic.edu; University of Illinois Chicago. https://wlrc.uic.edu/reproductive-oppression-against-black-women/