Why single-payer is a feminist issue

January 18, 2018

With the one-year anniversary of Women's Marches ahead, Erica West and Emma Wilde Botta look at an important connection between two struggles for social justice.

THE RENEWED energy and organizing around achieving a single-payer health care system in the U.S., where everyone has health coverage through a Medicare-for-all system, is exciting.

This development provides many opportunities for the left, and one of them is to push for this burgeoning movement to be an explicitly feminist one.

While women have myriad health needs, such as heart disease, cancer, diabetes and depression, an examination of reproductive health care illustrates the sexism that women often face and shows how essential it is for advocates of women's equality to join the fight for single-payer health care.

Single-payer could be a huge step forward in the fight against oppression. It is our job as socialists to draw the connections between different struggles and bring them to the forefront of this fight.


IN A recent Vogue article, tennis superstar Serena Williams gives a harrowing account of her near-death experience while giving birth.

Shortly after delivering, Williams felt out of breath and recognized, based on her past experience of blood clots, that she was likely suffering a pulmonary embolism. After initially doubting her, medical staff performed the appropriate tests and luckily were able to catch blood clots in her legs before they traveled to her brain.

Nurses and activists march for a single-payer health care system
Nurses and activists march for a single-payer health care system (Michael Fleshman)

Williams is one of the greatest athletes in the world and a multimillionaire. Yet this wasn't enough to protect her from the danger of giving birth in this country.

Despite being the richest nation on earth, the U.S. has a staggeringly high maternal mortality rate: 26.4 deaths per 100,000 live births. By comparison, Finland's maternal mortality rate is 3.8 deaths per 100,000 live births. Every year in the U.S., between 700 and 900 women die from causes related to pregnancy and childbirth. For Black women, the numbers are even worse.

This is only one indicator of the inadequacy of the U.S. health care system for women. Here is another: In 2011, about half of all pregnancies were unintended. About four in 10 of these unintended pregnancies ended in abortion, according to an article in the New England Journal of Medicine.

Despite being an essential component of reproductive health care, abortion has been under attack for decades.

Following the Supreme Court's 1973 Roe v. Wade decision that recognized the right to decide whether or not to end a pregnancy, Congress passed, and Democratic President Jimmy Carter signed into law, the Hyde Amendment, which bans the use of federal funds for abortion unless the pregnancy is the result of rape or incest, or the pregnant person's life is in danger.

The Hyde Amendment already severely restricts poor women's access to abortion, but an onslaught of state laws and restrictions has rendered abortion access nearly nonexistent in many parts of the country.

Since 2010, over 300 state laws aimed at restricting abortion have been passed. Fourteen states have banned abortions after 20 weeks in violation of Roe vs. Wade's legal standard.

In 27 states, those seeking abortion must endure a mandatory waiting period, ranging from one to three days, before receiving the procedure. These waiting periods disproportionately impact working women, women with children, and women who live in rural areas.

Many people are unaware that a simple combination of pills can end pregnancies within the first 10 weeks. Medication abortion, often called the abortion pill, is prescribed by a medical professional and can be administered at home. Despite its proven efficacy and safety, 27 states have circumscribed access to medication abortion.

Any fight for single-payer health care must unabashedly support safe and free abortion, on demand.

Another aspect of the health care system where women face sexism and discrimination is when accessing care as a transgender person. Trans women face serious hurdles to appropriate care.

In health care settings, transgender people report high rates of discrimination and abuse. A lack of focus on trans health care has resulted in very few medical professionals with the expertise to provide competent care. Because trans women may have health needs related to physically transitioning from their assigned sex at birth, the expression of their gender identity is linked to health care access.

Health insurance plans often contain gender-specific language in order to avoid covering transgender health care needs. For decades, Medicare excluded gender-confirming care from coverage, calling it "cosmetic" and "experimental" rather than medically necessary. It wasn't until 2014 that Medicare began covering gender affirmation surgery. Many states currently have laws that restrict Medicaid coverage for gender-confirming therapies.


ACCESS TO health care is heavily influenced by health insurance. Our current multi-payer, fragmented system leaves a shocking 9 million women without coverage. A disproportionate number of these women are transgender due in part to high rates of unemployment and poverty.

Women predominantly receive insurance through their job (35 percent) or through their partner's job (24 percent). That means that for a majority of women, their access to a basic, essential right is dependent on employment or their relationship with an employed person.

This is unacceptable. It's easy to see, for example, how the need to leave an abusive relationship could be hindered by the desire to keep health insurance. Meanwhile, almost one in five women rely on Medicaid, the federal public health program for the poor that has been under increasing attack.

The ongoing struggle for equality and bodily autonomy took a few steps forward with the passage of the Patient Protection and Affordable Care Act (ACA) under Barack Obama in 2010.

Prior to the ACA, many insurance companies considered pregnancy a "pre-existing condition" and used this as an excuse to deny women health care coverage at a time when they especially need it. Insurance companies also routinely charged women more than men of the same age for covering the same procedure.

While flawed in other critical ways, the ACA at least banned these hallmarks of discrimination against women. But Obamacare has been under assault.

For example, since the passage of the ACA, insurance plans must cover the full cost of prescription birth control. But in 2014, a Supreme Court ruling allowed corporations a religious exemption.

In another step backward, the ACA reinforces the current Hyde Amendment restrictions and explicitly excludes abortions from the list of essential health benefits that private policies available from the ACA marketplace must include.

Single-payer would significantly improve women's health by mandating coverage of all essential reproductive care and all LBGTQ health care. It would take away financial barriers to preventive care and cover all forms of contraception.

Universal coverage would also ensure health care access for undocumented people, who generally underutilize health care due to fears of revealing their immigration status.


THE FIGHT for single-payer won't be easy.

In California, a promising single-payer bill (SB 562) was tabled by Democratic Assembly Speaker Anthony Rendon last year, despite having wide support in a legislature where the Democrats dominate. Rendon falsely claimed that stopping a victory for single-payer was necessary to confront the threat of the Republican assault on the ACA at the federal level.

There doesn't seem to be any indication that Democrats will prioritize passing the bill now, after the Republican crusade to "repeal and replace" Obamacare collapsed.

The Democratic Party's hesitation and silence around the potential of SB 562 speaks volumes about its true motivations.

But as disappointing as the decision of party leaders was, what's worse is those who supported them. Many feminists consider Planned Parenthood their ally, but after SB 562 was shelved, Planned Parenthood released a statement in support of the decision, arguing that we need to instead focus on defending the ACA.

There are serious limits to the single-payer struggle relying exclusively on legislative proposals. As the Hyde Amendment after Roe and the Republican assault on Obamacare prove, even if a single-payer law were passed, statewide or nationally, we would need a mass movement to protect the gains we win.

But the left has experiences it can look to--for example, the grassroots mobilizations to defend abortion rights and women's health care when the anti-choice movement attempted to control the streets.

There are other challenges and opportunities ahead on this issue. The health care industry has a disproportionate number of women, particularly women of color, working in it.

Seeing these workers as an integral part of the fight for single-payer is essential. Stressful, sometimes dangerous, workplace issues are related to the failures of the health care system. Health care unions such as National Nurses United are leading the way in connecting improved working conditions with the struggle for single-payer.

Additionally, social conditions at large affect health care access, including reproductive choice. Forty years of attacks on unions and social services like health care and public education make it difficult for people to raise children. How many people choose not to have children, not because they don't want them, but because they fear they can't afford to raise them?

If we are going to win single-payer, we can't rely on the Democratic Party or liberal nonprofits to wage the fight for us. We need to build a working-class movement that unequivocally stands in solidarity with all struggles against oppression.

E-mail alerts

Further Reading

Today's Stories

From the archives