Democratic Consulting Firm Teams Up with Hospital Industry To Battle Nurses Union

Originally published in The Intercept on October 19, 2018.
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The hospital industry has partnered with a major Democratic consulting firm in an unusual alliance against Massachusetts’s nurses and the bulk of its progressive infrastructure.

At issue is a ballot initiative that aims to improve patient safety by limiting the number of patients that can be assigned to a single nurse.

If passed, the initiative, known as Question 1, will make Massachusetts the second state in the country to have nurse staffing limits in place. (The exact nurse-to-patient ratio would vary depending on the hospital department.) But, as Election Day inches closer, the initiative’s supporters and opponents are engaged in a heated battle over the costs of implementing the initiative, and what it would mean for patients.

For more than two decades, nurses across the country have argued that they can’t do their jobs effectively — or safely — when they’re tasked with caring for too many patients at any given time, as is often the case. More recently, Rep. Jan Schakowsky and Sens. Barbara Boxer and Bernie Sanders have sponsored bills to establish “nurse staffing limits” in order to curb the number of patients assigned to nurses who work in hospitals and, thereby, improve care.

Most local labor groups and the Massachusetts Democratic Party have come out in support of Question 1. Its backers include Boston Mayor Marty Walsh; U.S. Sens. Elizabeth Warren and Ed Markey; and U.S. Reps. Katherine Clark, Jim McGovern, Joe Kennedy III, and Michael Capuano. A majority of likely voters polled by Suffolk University and the Boston Globe in mid-September supported the ballot initiative.

But a formidable opposition campaign, funded by the hospital industry and led by a prominent Democratic consulting firm, threatens to derail the nurse staffing effort. The opposition campaign, rallying under the banner of “the Coalition to Protect Patient Safety,” has raised more than $13 million since January; 95 percent of those funds have come from the Massachusetts Health and Hospital Association. Through an aggressive advertisement blitz, the coalition has worked hard to argue that Question 1 could destroy the state’s renowned health care system.

Republican Gov. Charlie Baker recently said he’ll be voting “no” on the measure, citing hotly disputed cost projections. Recent polling also reflects a shift in public opinion, suggesting that the opposition’s campaign is working. For the first time this year, polls now show that a majority of likely voters oppose Question 1, including a University of Massachusetts Lowell/Boston Globe poll from October that found 51 percent plan to vote against it.

The opposition campaign has led to confusion even among nurses, whose support for Question 1 has significantly declined. (There are 83,000 registered nurses in the state, though the ballot initiative would not affect all of them.) An April poll, commissioned by the Massachusetts Nurses Association, found that 86 percent of registered nurses planned to vote “yes” on the ballot initiative. But a new poll, published this week by WBUR, found that just 48 percent of nurses are backing Question 1, while 45 percent are opposed and 7 percent are undecided.

ONE OF THE biggest points of confusion right now is how much Question 1 would cost, with opponents and supporters battling back and forth with wildly different estimates.

A study conducted by Boston College nursing economist Judith Shindul-Rothschild found that the total cost of implementing the proposed nurse-to-patient staffing limits in Massachusetts would be about $35 million to $47 million per year, necessitating a 2-7 percent increase in the number of nurses employed. After studying data from the Massachusetts Health and Hospital Association and matching data comparing staffing levels and costs with the California hospital industry, Shindul-Rothschild concluded that most hospitals could easily comply with the law by shifting some money away from administrative expenditures. “At the end of the day, we estimate that after implementing the limits of Question 1 our state’s hospitals would still retain a mean profit margin of $15 million a year,” she told MassLive.com. Shindul-Rothschild is a former president of the Massachusetts Nurses Association, which backs Question 1.

But a report commissioned by the Massachusetts Health and Hospital Association puts the costs much higher, at $1.31 billion in the initiative’s first year and over $900 million per year thereafter. The report, published in April, argues that those costs would be paid by residents in the form of higher insurance premiums, copays, and taxes.

The opposition campaign got a boost in October, when the Health Policy Commission, a state agency charged with monitoring health care delivery in Massachusetts, put out estimates that Question 1 would cost somewhere between $676 million and $949 million per year. The Health Policy Commission is the agency that would be tasked with developing regulations to implement the law if it passed.

Question 1 supporters have called those Health Policy Commission figures bogus. In an interview with The Intercept, Shindul-Rothschild said the biggest difference between her figures and those calculated by the Health Policy Commission is that the commission’s model assumes that nurse staffing limits will produce far greater levels of wage inflation — upward of 6 percent. “Not only did they assume 6 percent wage inflation, but they assumed it for every nurse working in Massachusetts, regardless of if they work in hospitals or not,” she said. “They said if wages go up in hospitals, they’ll go up across the board for every nurse, no matter where they work. I’m a nurse on faculty at Boston College, and there’s no way they’re increasing my salary by 6 percent.”

One reason the Health Policy Commission’s model assumes greater wage inflation is based on what California experienced after it implemented nurse staffing ratios. But unlike California at the time, Massachusetts has a surplus of registered nurses, with 3,000 to 3,500 new ones graduating every year. Many of these nurses end up moving out of state because they can’t find local employment, and a 2012 report published in the American Journal of Medical Quality found that Massachusetts was one of just two states in the country to have no nursing shortage.

The Health Policy Commission’s analysis is “fully consistent with the HPC’s statutory purpose and mission and is not intended to promote or oppose the pending ballot question,” said spokesperson Matthew Kitsos.

But since its founding in 2012, the Health Policy Commission has not conducted similar studies for other ballot initiatives that could have impacted health care, and the commission has also stayed quiet on more than 300 bills in the Massachusetts legislature that would have affected health care cost and delivery. Kitsos did not answer questions about why the Health Policy Commission avoided past health care legislation.

The Massachusetts Nurses Association slammed the Health Policy Commission study. “The HPC didn’t use third-party validated data, it used hospital industry data which it specifically said it would not rely on for its own analyses of hospital mergers,” said Julie Pinkham, the executive director of the Massachusetts Nurses Association, which represents 23,000 registered nurses. “I don’t want them to do an analysis, because it’s not their role, but if they are going to do an analysis, then use actual, real-time staffing data.”

For Pinkham, the nurse staffing debate has been laced with sexism. “If there were 23,000 men saying, ‘Hey, look, this is unsafe,’ do you think they would make you wait over 20 years to fix it?” she asked. “They treat us like we’re just these nice girls, trying to do a nice thing, but that we don’t know what we’re talking about and can’t handle numbers.”

The debate over the cost of implementing a nurse staffing limit is unlikely to be settled prior to Election Day, but Massachusetts voters can look to California for an example of how such a policy would work. The Golden State passed a nurse staffing limit law in 1999, and it’s been in effect since 2004. The hospital industry, which bitterly fought the law’s passage in California, has successfully defeated similar attempts in other states since then.

Researchers have found that California’s law improved care — especially for poor patients — and contributed to a greater decline in mortality than other states have seen.

Linda Aiken, the director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing, said California has “the best nurse staffing in the country” in terms of patient outcomes. One study Aiken conducted looked at how outcomes would change in New Jersey and Pennsylvania if they adopted California’s nurse-to-patient ratios; she determined that in-patient mortality would drop in those states by 10-13 percent.

“We’ve done many studies in the U.S. and around the world and found for each additional patient that a nurse takes care of at one time, there’s a 7 percent increase in the patient’s likelihood of dying,” she told The Intercept. “There’s good evidence that California’s staffing improved directly as a result of the [1999] legislation, and that over time it led to a greater decline in mortality in California compared to other states.”

What works in California won’t necessarily work the same way in other locations, but Aiken pointed out that Ireland and Wales have also followed California’s lead and adopted nurse staffing limits. She suggested that opposition in the U.S. is based more on ideological resistance to government mandates than anything else. There are some, however, who argue that the research evidence is not clear enough to justify changing policy. Hospital executives, including nurse administrators, generally oppose nurse staffing limits, arguing they’re too blunt of an instrument and hinder needed flexibility.

Dewey Square Group, a prominent political consulting firm that often works with Democratic candidates, liberal groups, and labor unions, is leading the opposition campaign. Consultants from the firm have been paid over $800,000 since April for their efforts, according to state campaign finance data.

Dewey Square is leading “a progressive campaign” that “helps people in need of quality, affordable, accessible health care along with the nurses and doctors who provide it,” said spokesperson Ginny Terzano. Their coalition comprises “more than 170 health care organizations and every hospital in Massachusetts,” Terzano added.

Among those groups is the Organization of Nurse Leaders, which represents 700 nurse administrators, and the Massachusetts chapter of the American Nurses Association, a group that, unlike most similar groups, has not disclosed how many registered nurses it represents. (The nurse trade group did not return The Intercept’s request for details.) Both groups have fought past legislative efforts to establish nurse staffing limits in Massachusetts.

In 2016, Dewey Square was hired by the Massachusetts Teachers Association to run a campaign on behalf of labor and progressive groups against a ballot measure that would have raised the state’s cap on charter schools. The measure, rejected by more than 62 percent of voters, failed. That the consultants who led the 2016 campaign on behalf of liberal groups are now leading the campaign against those same organizations has sparked intraparty turmoil in the state.

Barbara Madeloni, who stepped down as president of the 110,000-member Massachusetts Teachers Association this past summer, told The Intercept that she “doesn’t know how [Dewey Square consultants] sleep at night” while leading the opposition campaign. “The ways they’re running it, their comfort with distortions and misinformation, and that they’re aligning with people who are really looking to undermine the well-being of the patients of the commonwealth — well, they’re just exposing themselves as mercenaries,” she said. “Quite honestly, there’s a part of me that’s embarrassed to have ever worked with them.”

Terzano of Dewey Square dismissed the idea that their work opposing Question 1 puts them at odds with organized labor. “We may have a different policy position than some labor organizations on this issue but we continue to work alongside labor on a number of issues,” she said. “And I would say it’s also important to note that not every relevant labor union has taken a position on Question 1.”

Terzano was referring to 1199SEIU Massachusetts, which represents 60,000 health care workers in the state — and has notably taken a “neutral” position on the initiative. But even 1199SEIU hasn’t been sitting on the sidelines since the start. In fact, the union worked directly with the Massachusetts Nurses Association in July 2017 to draft the ballot initiative language. SEIU’s input resulted in language that ensures that the nurse staffing limits could not be implemented by eliminating other health care workforce jobs. (Administrative positions, however, may be reduced if the initiative passes.)

According to 1199SEIU President Tim Foley, the union’s change in perspective is due to “concerns about reforms not focusing on the staffing needs for the entire health care team as well as the potential unintended consequences on the health care workforce and health care services.”

SEIU nurses in California have come out in support of Question 1, saying that fears of health care workforce cuts in their state did not materialize after transitioning to nurse-to-patient ratios. In a recorded video, the executive director of the SEIU Nurse Alliance of California emphasized that no hospitals closed and no services ended as a result of implementing nurse-to-patient ratios.

Sal Rosselli, the president of the National Union of Healthcare Workers and the former president of the SEIU United Healthcare Workers West, the statewide local union for health care workers in California, also endorsed Question 1 in Massachusetts.

“Fourteen years ago, when our RN safe patient limits law was being passed here in California, many hospital executives were spouting the same line of doom and gloom as they are today in Massachusetts,” he wrote in a statement. “Our union represents mostly non-RN hospital workers. The truth is there were no layoffs of non-RN caregivers and no hospital closures as a result of California’s law. The only outcome was that it made care much better for patients.”

Madeloni, the former Massachusetts Teacher Association president, who now works as the education coordinator for Labor Notes, said “it’s really troubling” that 1199SEIU Massachusetts has not joined the coalition of labor groups on this. “Solidarity matters, and we should never accept a lack of funds and the incitement of fear that if some workers get something good to do their jobs well, that means other workers will lose. We engage the fights that are going to help each other, we do that however we can do it, and we don’t hold back.”

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Hawaii’s Long Term Health Care Bill Could Serve as a National Model

Originally published in The American Prospect on January 12, 2016.
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Hawaii may soon become the first state in the union to offer universal long-term care for seniors, as state legislators prepare to roll out a bill that would tackle the nation’s elder care crisis head-on.

Slated for introduction in the 2016 legislative session, Hawaii’s innovative bill could become a national model for states looking for ways to help families afford the high costs of elder care. Across the country, as millions of baby boomers hit retirement age, they are beginning to feel the strain of paying for health care. A full 10,000 Americans have turned 65 every single day since 2011, and will continue to do so until 2030—a trend that is dramatically altering the demographic landscape of the United States.

“There’s an important role for government to play,” says Kevin Simowitz, the political director for Caring Across Generations, a national organization that aims to help people age with dignity and independence. “Most people simply don’t have the individual means to pay for the care they need.”

These population trends have been particularly marked in Hawaii. While the number of seniors aged 75 and older increased by 47 percent nationally between 1990 and 2012, Hawaii saw a 116 percent increase in that age cohort during this same period.

A coalition of retiree groups, labor unions, and religious organizations in Hawaii has been leading the public campaign for Hawaii’s new health care program.

“I think if we have enough push from the public we can make it happen because the will of the people, I would hope, will supersede all potential barriers,” says Clementina Ceria-Ulep, the chair of the Nursing Department at University of Hawaii at Manoa, and a leader with Faith Action for Community Equity, a faith-based community organization.

Aloha State residents boast a distinct cultural tradition of caring for and cherishing their “kapuna”—a Hawaiian word that refers to the elderly. Indeed, Hawaiian leaders have been reckoning with the challenges of elderly care for far longer than most states on the U.S. mainland.

Now, after decades of debates, state audits, and legislative campaigns, Hawaii residents and lawmakers say the time is right for action on the proposed universal care benefit. Supporters of the bill argue that it would not only help ease the financial burden on families caring for seniors, but also create more high-quality home care jobs for the mostly women and immigrant workers who tend to shoulder these responsibilities.

“Hawaii has a tradition of being at the forefront of health care policy,” says Simowitz, of Caring Across Generations. “Long before the Affordable Care Act, Hawaiians had a plan to make sure that workers had quality affordable health care. This would not be the first time they’ve done something a little bit provocative and groundbreaking.”

Simowitz says that the idea of a universal long-term care program could spread to other states, in the same way that grassroots movements to promote paid sick leave and increase the minimum wage have taken off.

“It is a breakthrough to have legislators move this conversation from kitchen tables in peoples’ houses to conference tables at the legislature,” he says. “We need this to be a public policy conversation.”

Hawaii’s program would work like this: Every person who files a Hawaii state income tax for ten years would be eligible to receive $70 a day, for a total of 365 days. The benefit would be underwritten by a slight increase in the state’s General Excise Tax, a tax on all businesses’ gross income. Hawaii’s thriving tourist industry would help boost the fund. That’s because tourists, who also pay the General Excise Tax, would fund roughly 35 percent of the long-term care program but would never claim the benefit themselves.

“Our target was to look at what it would cost to help someone get four hours of home or community care,” explains Dr. Lawrence Nitz, a political science professor at the University of Hawaii at Mānoa, who conducted research on long-term care financing for the state. “Seventy dollars means you could plan to go to work, you could take time to meet your child’s teacher. It’s enough to help people avoid losing their jobs, while still balancing care responsibilities.”

Most people need some form of long-term care as they get older. Long-term care refers to assistance with activities of daily living, such as bathing, eating, using the toilet, and getting dressed. It also includes help with tasks like shopping, cooking, and cleaning.Despite a common misconception, Medicare does not cover the cost of long-term care services, meaning that the majority of Americans must pay out of pocket.

Hawaii’s proposed social insurance program would not cover the cost of nursing homes or assisted living facilities, which can easily reach $100,000 per year. However, it would offer more money and flexibility to families that are already providing long-term care.

In 2011, the AARP’s Public Policy Institute found that the average caregiver is a 49-year-old woman who works outside the home and spends nearly 20 hours per week providing unpaid care to a parent over nearly five years. The report found that two-thirds of family caregivers are women, and that the total economic value for all this unpaid work was an estimated $450 billion annually.

Hawaii State Senator Roslyn Baker plans to introduce the long-term care bill in the upcoming legislative session. It’s not the first time that Baker, who has been active in elderly care issues since the 1990s, has introduced long term care legislation. But now, due to growing political support and a string of research studies supporting the program’s the feasibility, Baker predicts that the bill has a good chance of passing.

“We think the timing is right, even though it’s an election year,” Baker told The American Prospect. “We’re going to work to help people understand exactly what the funding mechanism is, how small a tax burden it is, and just how it will help lots and lots of people afford the care they need.”

Cecile Richards: Grace Under Fire at Planned Parenthood

This story originally appeared in the The American Prospect’2016 Winter issue.

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On a warm Tuesday morning in late September, Cecile Richards, the 58-year-old president and CEO of Planned Parenthood, went before Congress to defend her organization. A few months earlier, the Center for Medical Progress, an undercover anti-abortion group, had released a series of doctored videos that purported to show Planned Parenthood illegally profiting from the sale of fetal tissue. Planned Parenthood denied the accusations, but outrage spiraled furiously among conservatives. Republican officials launched state and federal investigations, while presidential candidates and members of Congress called for defunding Planned Parenthood entirely, threatening to shut down the government if their demands were not met.

Riding this whirlwind of righteous anger, Republicans eagerly anticipated their confrontation with Richards. Yet when she came before the House Oversight and Government Reform Committee, Republicans suddenly found Richards grilling them, not the other way around. “Mr. Chairman, you and I do disagree about whether women should have access to safe and legal abortion,” she said, staring into the eyes of Jason Chaffetz, the Republican from Utah who chaired the hearing. “At Planned Parenthood, we believe that women should be able to make their own decision about their pregnancies and their futures—and the majority of Americans agree. We trust women to make these decisions in consultation with their families, their doctors, and their faith, and not by Congress.”

A week later, Chaffetz admitted that after formally investigating Planned Parenthood, he and his colleagues had been unable to find any evidence of financial wrongdoing. Eight states that launched their own investigations have also failed to produce any smoking guns. The absence of evidence, however, hasn’t deterred GOP-controlled state governments from attempting to cut funds for Planned Parenthood, or moderated Republicans’ demonization of the organization.

These attacks, though, have only inspired Planned Parenthood’s supporters to rally to its defense. Three days before Richards testified, a progressive coalition delivered a petition in support of Planned Parenthood to Senate Democratic Leader Harry Reid and Senator Elizabeth Warren; it had more than 1.2 million signatures. On the day of Richards’s testimony, hundreds of thousands of advocates across the country organized rallies and Internet campaigns to demonstrate solidarity, in what would be Planned Parenthood’s first ever “National Pink Out Day.”

In 2016, the battle over reproductive rights will almost surely grow more intense. The Supreme Court is set to rule on two major cases: one concerning contraception coverage, and the other on abortion access. The latter, both sides agree, may be the most consequential case for abortion rights since 1992, when the high court ruled that states could not impose an “undue burden” on women who wish to end a pregnancy. State legislatures, which enacted 288 abortion restrictions between 2011 and 2015, will no doubt continue to test the limits of what such “undue burdens” really mean.

2016 also marks the centennial anniversary of Planned Parenthood, an organization that has become the target of an anti-abortion movement that steadily grows more aggressive and violent. The FBI reported an increase in the number of arson attacks and vandalism incidents at abortion clinics in the wake of the Center for Medical Progress videos, and the president of the National Abortion Federation said abortion providers have seen “an unprecedented increase in hate speech and threats” since the videos were released. In late November, a man opened fire in a Planned Parenthood clinic in Colorado Springs, injuring nine people, and killing three. After the shooting, the suspected gunman invoked the doctored videos, telling local authorities, “no more baby parts.”

Richards, who has spent a decade at Planned Parenthood’s helm, toils at ground zero of the culture wars being fought across the country. Every day she is flooded with hundreds of hateful messages on social media, calling her evil, a Nazi, a monster, a murderer. In 2006, Jim Sedlak, the vice president of American Life League and one of the nation’s most ardent Planned Parenthood critics, predicted she would never last more than a year or so as Planned Parenthood’s leader. (A mere “place holder” president, he dubbed her.)

Yet ten years later, Richards remains self-assured in her post, guiding the nation’s largest reproductive-rights organization through the most politically fraught period it’s ever faced. She comes well-suited for the challenge. Richards brings to her role decades of experience in political organizing, and a career as a premier coalition builder across liberal America. She brings as well a strategic and moral vision that has impelled her to push Planned Parenthood beyond where it’s been, to lead more forcefully in the broader cultural and economic battles for women’s autonomy and equality.

IN 2006, JUST THREE WEEKS after Richards started her new job as Planned Parenthood’s president, South Dakota’s governor signed a bill outlawing abortion, the nation’s first state-legislated ban. (It was soon struck down in federal court.) “Listen, the reason I took this job is, I feel like we need to go into the 21st century,” she told The Washington Post that year. “Clearly, with some folks in the country, we’re going to get there kicking and screaming.”

Hiring Richards, in many ways, signified a new moment for Planned Parenthood. The abortion issue had been growing increasingly more politicized and polarized since the mid-1980s. (In the 1970s, the share of pro-life Democrats actually exceeded that of Republicans.) The partisan polarization of recent decades first became evident in 1984, and by the 1990s, political scientists were noticing a new and statistically significant relationship between voters’ abortion attitudes and whom they cast their ballot for in elections.

The three presidents who preceded Richards came in with backgrounds in health care, nursing, and Planned Parenthood itself. Richards’s resume, on the other hand, listed years of experience in organizing, campaigning, and electoral politics. While Planned Parenthood had been inching toward political advocacy in the 15 years before Richards arrived, she came in prepared to steer Planned Parenthood to the front lines.

In practice, this meant investing more in strategic communications and developing a new generation of youth leadership; it also meant engaging more forcefully in political campaigns. In 2008, Planned Parenthood endorsed Barack Obama for president—its second presidential endorsement ever—and Richards spoke at the 2008 Democratic National Convention. That same year, the organization launched the One Million Strong Campaign—a massive effort to mobilize pro-choice voters. Partnering with Catalist, a progressive voting database, Planned Parenthood worked to build the first national voter model designed to specifically target pro-choice women.

Planned Parenthood’s political spending has also increased throughout Richards’s tenure. While the organization’s overall election spending has grown, its direct campaign expenditures have also come to represent a larger piece of the pie. Today, with Richards shaping its political programs, the organization not only spends more money in elections, but it also takes greater control over how its money is spent.

For its critics, these efforts serve as incriminatory proof that Planned Parenthood falsely bills itself a woman’s health-care network. Richards does not buy these accusations, but she can’t readily ignore them either. As both the CEO of one of the biggest national health-care organizations, which relies substantially on government reimbursements, and as the leader of a massive nonpartisan political outfit, engaged in one of the most polarized fights in the United States, Richards must always remain extra careful to keep the organization’s two halves legally separated, particularly when Republicans control both Congress and a majority of state governments. Forty percent of Planned Parenthood’s $1.3 billion in annual revenue comes from Medicaid and Title X, a federal family-planning program.

“Cecile had to grow into her [role] as CEO of a major health-care provider, that was something she had to learn,” says her husband, Kirk Adams, who served as vice president of the Service Employees International Union and is now executive director of the Healthcare Education Project in New York. “But on the other hand, she has always been first and foremost an organizer, and she continues to do that at Planned Parenthood at a very high level. It’s just fundamentally how she approaches a problem.”

As an organizer, Richards looks at the numbers—one in five women in the U.S. have relied on Planned Parenthood at some point in their life for health care. Learning how to motivate those patients to become advocates, volunteers, and pro-choice voters is what makes Planned Parenthood a “movement” in a way that your local hospital is not.

This strategy carries certain risks, but if you ask Richards how the politics and the direct health services fit together, her eyes light up. “We’re a better health-care provider because we’re a movement that advocates and pushes forward, and we’re a better movement because we have real experience every day with folks coming in and asking for care,” she says, grinning. This symbiosis, she’s convinced, only makes the organization stronger.

THE REALPOLITIK INHERENT in Richards’s vision of Planned Parenthood has at times created tensions with other parts of the reproductive-rights movement. This was evident during the 2009 health-care reform debates, when the entire law seemed to hinge on whether Congress could find a political compromise around abortion. Richards and Planned Parenthood were at the center of the debate, fighting fiercely for the law’s passage. Richards took great pains to emphasize that covering contraception and women’s general health services—or 97 percent of what Planned Parenthood does—were the organization’s primary priorities. In effect, she accepted that abortion would not be treated like all other health-care services during those very heated, public fights.

In the end, to the frustration of many reproductive-rights advocates, legislators passed the historic health care law with a provision that permitted states to ban abortion coverage in private plans in their state insurance markets. Today, 25 states have done just that.

Pro-choice members of Congress shared Richards’s sense of what was politically possible. “It appeared questionable that the Affordable Care Act would pass, up until literally the last hours, because of the issue of abortion,” recalls Democratic Representative Jan Schakowsky, a member of the House Pro-Choice Caucus. “I think the ACA is as good as it can be; I think we did what we had to do if we had any hopes of passing the bill. I do not think we compromised too greatly or too soon: This was down to the wire on the day that the legislation passed.”

Erin Matson, the co-founder of Reproaction, a reproductive-rights activist group, disagrees. The health-care reform debate, she says, is a perfect case study in why reproductive-rights advocates lose. “The whole strategy from pro-choice leaders [during the ACA debates] was ‘Let’s just be reasonable.’ Give me a break! When has that ever stopped the right?” Matson believes the women’s movement has been too co-opted by the Democratic Party, and that Planned Parenthood’s strategy of stressing that “just 3 percent” of their services were abortion-related “was a classic example of accepting that abortion is shameful.”

Nonetheless, the Affordable Care Act has brought about tremendous advances for women’s health. Insurance companies can no longer consider pregnancies “pre-existing conditions,” and more preventative services are now covered under health insurance. In 2011, the White House issued a new regulation adding birth control to the list of mandatory services an employer’s group health plan must offer, providing a major economic lifeline to millions of women.

AT A TIME WHEN the reproductive wars have become a key driver of the country’s political divisions, Richards’s background and experience leave her supremely well-positioned to lead Planned Parenthood. Born in Waco, Texas, in 1957, Richards lived most of her early childhood in Dallas until her parents relocated their family—Cecile, then 11, and her three younger siblings—to Austin. While her mother, Ann Richards, Texas’s one-term governor in the early 1990s, was a heroic figure to liberals across America, her father, David, was also somewhat of a state icon. An unapologetic labor and civil-rights lawyer, David litigated many social justice cases, including a voting-rights case before the U.S. Supreme Court.

Richards likes to say her house was just like any other, except the dining table was used for stuffing envelopes and sorting precinct lists, rather than eating. (This isn’t quite true: The Richards family often threw big dinner parties, perhaps one reason why Cecile loves to cook and bake.) But it is true that she was politicized at a young age. Her first dance, at age 12, was a fundraiser for the United Farm Workers. By the time she was in middle school, administrators were reprimanding her for wearing a black armband in protest against the Vietnam War.

In 1972, Sarah Weddington, a young feminist lawyer based in Austin, decided to run for state legislature. Weddington asked Ann Richards, who worked as a housewife, to help manage her campaign. Cecile, then 14, worked with her siblings and mom to help get Weddington into office. (Not long after her victory, Weddington would go on to present the oral argument in Roe v. Wadebefore the Supreme Court, the momentous suit that legalized abortion in the United States.)

As an undergrad at Brown University, Richards continued to direct her energies toward activism. On campus, she protested apartheid in South Africa, and nuclear power plants in New Hampshire. “It’s not like college got in the way of her organizing,” her brother Dan once quipped.

After graduation, Richards went to work in the labor movement. She spent the next decade organizing janitors, garment workers, hotel housekeepers, and nursing home staffers in Louisiana, California, and Texas. That experience, she says, provided her with “really the biggest education I ever had.” Those low-wage workers, she notes, are very much the same women who rely on Planned Parenthood for health care.

The values Richards learned in the labor movement are the same ones that inform her vision of Planned Parenthood. “It’s not only about direct services, which is incredibly important, but it’s also about empowering the folks who are turning to [us] for health care,” she says. “When you think of how many people have been to Planned Parenthood in this country, from every walk of life, if those patients were empowered to participate in our democracy, a lot of the conversations that are happening in Congress right now would not be happening.” Richards wants to provide women not only with STD screenings, abortions, and pap smears—she also wants to help those patients find their political voice.

In 1982, she met Kirk Adams, a fellow union organizer. She became his boss, and three years later, his wife. In 1990, Richards and Adams worked on Ann Richards’s gubernatorial campaign, and stayed in Austin throughout Ann’s time in office. After one term in the statehouse, George W. Bush beat her in a landslide in 1994.

Her mother’s loss was painful, but Richards didn’t rest for long. She founded a new grassroots organization in 1995, the Texas Freedom Network, which aimed to curb the growing influence of the Texas religious right, particularly those activists seeking control of the school boards. “She always put herself in the line of fire, fighting for the most progressive values, in tough places, and in tough times,” says Steve Rosenthal, a former AFL-CIO political director. It was no easy fight, and Richards received heaps of vitriol from well-funded conservative opponents, foreshadowing her time at Planned Parenthood. Undeterred, she traveled all over Texas, rallying like-minded supporters who opposed teaching Bible stories in science class, expanding abstinence education in schools, and using public vouchers to send children to private schools. The Texas Freedom Network “started as a file box of names in Cecile’s kitchen and grew to many thousands of people,” her successor told the Texas Monthly in 2004.

Later on, Richards, Adams, and their three kids moved to Washington, D.C., so Adams could take a national position with the AFL-CIO. In 2002, Richards took a job working as deputy chief of staff for Nancy Pelosi, who was named Democratic whip in the House. Richards held that position for 18 months, though she says the experience helped her realize she was better suited to effect change from outside Congress, rather than within.

WHEN RICHARDS LEFT Capitol Hill in 2003, she took a job leading a new organization, America Votes—a coalition of progressive organizations that would work together to turn out voters for the 2004 presidential election. There had always been big, active progressive organizations, but their leaders mostly operated in silos, and did not talk to, or even know, one another. I asked Steve Rosenthal, one of America Votes’s founders, why they picked Richards to head this unprecedented $250 million effort.

“We thought we needed someone who was politically astute, who had the ability to work with people at a very basic level, who could get the trust of the organizations and mobilize them all into a new organization,” he says, explaining there was “really nobody else” they could have imagined fitting the bill.

At America Votes, Richards continued to do what she did best: organize. Specifically, she coordinated an electoral strategy among the nation’s largest and most influential unions and progressive groups—ranging from the American Federation of Teachers and the NAACP, to the Sierra Club and NARAL. She sought to help leaders understand how their efforts were, and really always have been, interconnected. She helped delineate which demographic and geographic groups each organization would target, and which would be most effective in delivering a message to a particular set of voters and getting them to the polls. It was a level of coordination hitherto unknown among the nation’s progressive organizations, and putting it together required diplomatic skills of the highest order.

Another innovation progressives introduced in the 2004 campaign was an effort to specifically target single women. The organization Women’s Voices Women Vote had recently formed, and aimed to draw attention to unmarried women, a growing political constituency largely ignored by progressives in previous cycles. Page Gardner, the group’s founder, pointed to the 22 million single women eligible to vote in 2000 who did not cast ballots. Single women, Gardner found, more strongly identify as “pro-choice” than married women. This mattered, as reproductive rights were already a major issue in the 2004 campaign, with critical judicial appointments on the line.

Despite these novel efforts, however, George W. Bush was re-elected, and the future of America Votes hung in the balance. Some of the biggest funders and backers wanted to scrap the project, and start with something fresh for 2008. Richards, who recognized how important this type of initiative was for the progressive movement, began appealing to all the major donors and partners, to convince them that this was not a project to abandon. “Just to be totally blunt, Cecile is the reason the organization still exists,” says Rosenthal. Greg Speed, the current president of America Votes, agrees. “I thought it was going to end after 2004,” he admits. “Cecile didn’t let that happen.”

I asked Richards why she felt it was so important to keep the organization alive after John Kerry lost. “How could we go back to a day where everybody goes, ‘Oh we’ll just do our own thing and see how it works out?’” she answers. “[2004] was really the first time that a lot of these big progressive groups had ever sat at the table together, and thought, ‘OK, how can we do our work in a smarter way, use our resources better, learn from each other?’ It was fascinating because not only did people build relationships that they perhaps did not have before, but there were even heads of progressive groups that had never door-knocked before that election!” Richards thinks one of the most important legacies of that campaign was building a common understanding of what grassroots advocacy and mobilization is really about.

When America Votes first formed, Planned Parenthood was only just beginning to dip its toe into politics. Though its founder, Margaret Sanger, was a radical birth-control activist in the early 20th century, Planned Parenthood itself eventually grew to be seen as a responsible, noncontroversial organization; family planning was considered bipartisan, sensible policy after World War II. Indeed, for many years Planned Parenthood garnered strong support from elite members of the Republican Party: Barry Goldwater’s wife was a founding member of the Planned Parenthood affiliate in Arizona.

These political dynamics began to change after the Supreme Court legalized abortion in 1973, and the religious right, a strongly anti-abortion faction within the Republican Party, increased its power over the course of the 1980s. In response, Planned Parenthood established a political arm in 1989, and a political action committee in the late 1990s. In 2000, Planned Parenthood started to experiment with ads in battleground states, and by 2004, it made its first-ever presidential endorsement.

In deepening the organization’s political activities and solidifying its place in the progressive universe, Richards has drawn on her experience at America Votes. “To see how much [Planned Parenthood] has changed, even in the past ten years … I’m not saying that’s all a result of America Votes, but it certainly opened my eyes to what the opportunities were, partnering with a lot of these organizations,” she says. “In some ways, that was probably part of the reason I came to Planned Parenthood.”

IN 2010, THE TEA PARTY soared to power, running on promises to dismantle the new health-care law, cut taxes, and ban abortions. In 2011, as the new crop of conservatives took power in statehouse after statehouse, those lawmakers introduced more than 1,100 reproductive health and rights-related provisions, according to the Guttmacher Institute, of which 135 were enacted in 36 states by the year’s end. Ninety-two of the new provisions restricted access to abortion, shattering the previous record of 34 abortion restrictions adopted in 2005. In Congress, the House voted to defund Planned Parenthood, and threatened to shut down the government entirely if a rider to defund the organization was not included in the federal budget deal. Congressional Republicans have been trying to defund Planned Parenthood ever since.

Republicans also started pushing for “religious freedom” exemptions for businesses and insurance companies, so that they would not have to offer birth control under their plans. As Katha Pollitt notes in her 2014 book, Pro: Reclaiming Abortion Rights, despite the fact that reliable contraception remains the most effective way to prevent abortion, “not one major anti-abortion organization supports making birth control more available, much less educating young people in its use.” In 2014, after a series of legal challenges, the Supreme Court ruled that closely held corporations could be exempt from providing employees with contraceptive coverage. This summer, the Supreme Court will decide if the government can even require nonprofits simply to fill out a form if they object to the birth-control mandate on religious grounds. “We’ve always known that the right wing has been anti-abortion but some people thought, well, that doesn’t extend to contraception,” says Schakowsky. “We know better now. … That was made clear for the world after the Affordable Care Act.”

In early 2012, the Susan G. Komen Foundation, under pressure from conservative activists and with a new anti-abortion senior vice president, announced that it would no longer fund breast cancer screenings at Planned Parenthood. The backlash was swift and unprecedented—Planned Parenthood raised $3 million in three days, and a deeply embarrassed Komen reversed its decision within the week. A whole new generation of supporters moved to social media to defend Planned Parenthood and express their outrage.

While Planned Parenthood and its allies pushed back against attacks on women’s health, other activists were growing worried about the tone and direction of the public conversation. They recognized that the reproductive-rights movement needed a new and bolder strategy—one that aimed to change cultural attitudes around abortion, not just laws and regulations.

Debra Hauser, the president of Advocates for Youth, an organization that focuses on young people’s sexual and reproductive health, says that in late 2010 and early 2011, as the Tea Party swept into power, her group heard from frustrated youth leaders who wanted to respond in some way to the incessant political attacks on abortion. They noticed that while many were worried about the future of reproductive health care, very few people were actually talking about abortions as such. The escalation of the right’s anti-choice rhetoric, says Hauser, was making any such discussion more difficult. “Honestly, the fear-based strategies and the vehemence makes it very, very difficult for people,” she says. “I think all of us have internalized some fear and shame [about abortion] that can be so immobilizing.” She and her team understood that this stigma, which limits the societal conversation, ultimately impacts how legislators think about abortion, too. New laws requiring women to undergo transvaginal ultrasounds and mandatory waiting periods, so they could “think more carefully” about their decisions, were little more than efforts to shame those who didn’t want to carry to term.

Advocates for Youth began to lay the groundwork for a public storytelling campaign, in which people could share their abortion experiences if they felt it was safe to do so. The effort was named the “1-in-3 Campaign”, because the Guttmacher Institute found that a third of all U.S. women will have had an abortion during the course of their lives. “If you tell one abortion story, people tend to shut it down. They say, ‘Oh well she could have done this, or she should have done that,’” says Hauser, who researched how storytelling has impacted other social movements. “But when you start to hear multiple stories at once, it becomes much harder to dismiss.”

Hauser admits that, initially, some mainstream reproductive-rights groups quietly pushed back on this de-stigmatizing campaign. But by 2013 and 2014, the groups started to embrace the strategy, and even more diverse efforts began to take shape. A new anti-stigma organization, Sea Change, formed in 2014 to conduct social science research on reproductive stigmas, with the goal of ultimately reducing them. Another organization, SHIFT, formed in 2015 to amplify the voice of abortion providers—those who understand the complicated ways in which women relate to abortion as both a medical and a cultural experience. These efforts began to effect a real change in the zeitgeist—new film narratives and TV plots started to emerge, featuring women who ended their pregnancies in relatively nontraumatic ways.

And all of this activism has created the space for more women to come forward with their own stories. In 2014, in an essay entitled, “Ending the Silence That Fuels Abortion Stigma,” Richards described her own abortion experience in Elle magazine. She was already raising three kids at the time—Lily, and twins Hannah and Daniel—and felt an abortion “was the right decision” for her and her husband. She said it “wasn’t a difficult decision.”

“Rarely do you see a leader of an organization putting her own skin in the game like that,” says Steph Herold, the managing director of Sea Change.

I asked Richards why, after leading Planned Parenthood for eight years, she had felt the time was right to share her own story. Though she had never hidden the fact that she had an abortion, she said she never really thought to share it so publicly, in a major women’s magazine, in part because her abortion was never a defining part of her life. And it still isn’t.

But she’s glad she spoke out. “Women now come up and tell me their stories about having an abortion—and boy, if this makes them more comfortable about sharing that story with me, or with anyone else, and helps them lift whatever burden is on them, hallelujah!”

Richards’s decision to tell her own story is part of a new effort within Planned Parenthood to take on abortion stigma. “I think the biggest change that I’ve seen in Planned Parenthood is that instead of emphasizing that abortion is only a small percentage of their services, they’re saying that they’re proud to provide abortion care,” says Herold. “They’re moving to a point where they say, ‘Yes we provide all kinds of health care, and abortion is just one service in the spectrum of all health-care services we provide.’” Indeed, this past October, Richards published a piece in Cosmopolitan, articulating that message in a way Planned Parenthood has generally avoided in the past. “If we want women to have fulfilling careers and economic stability, we have to give them full access to the full range of reproductive health care, including abortion,” she wrote. “Of course abortion services are health care.”

Several weeks after the Cosmopolitan piece came out, I asked Richards for her thoughts on the “only 3 percent” talking point, and if she worried it unwittingly contributed to abortion stigma. Planned Parenthood is an unabashed, unashamed provider of safe and legal abortion, she says, and she’s “incredibly proud” of that fact. “It’s just super-important to me that people understand that women have a whole range of health-care services that they need and being able to make decisions about reproduction is pretty fundamental,” she adds.

THE EFFORT TO FIGHT stigma coincides with another development in the reproductive-rights movement: a shift away from rhetoric about “choice” and “rights” to broader themes of justice, access, and security.

After the 2012 election, the Democratic Party started to really grasp what Page Gardner had been trying to communicate for the past decade. Single women, a growing portion of the electorate, proved to be game-changers in Obama’s re-election campaign; he won their vote by a margin of 36 points, despite losing married women to Mitt Romney. In 2013, Democrat Terry McAuliffe was elected governor of Virginia, in large part because he won single women by 42 points. (He lost married women to the Republican candidate.) Campaign research conducted the following year revealed that women’s health and economic security were issues that strongly motivated both the progressive base and swing voters. Researchers also found that drop-off voters (those less likely to vote in midterms) were more motivated to cast a ballot if they felt they were going to be voting against a candidate who would endanger women’s health.

The New York Times ran a story in 2014 detailing how mainstream reproductive-rights groups were in the midst of reframing their advocacy to connect with more voters. The article—“Advocates Shun ‘Pro-Choice’ to Expand Message”—explored how Planned Parenthood had taken the lead in conducting public opinion polling after 2011, in order to find talking points, like “women’s health” and “economic security,” that resonated with more people. In 2013, Planned Parenthood released a video, “Moving Beyond Pro-Life vs. Pro-Choice Labels.”

Gretchen Borchelt, the vice president for health and reproductive rights at the National Women’s Law Center, says that policy-makers have long separated economic issues from reproductive rights, which has meant that reproductive-rights groups generally worked apart from other progressive organizations. “But separating these issues doesn’t make sense; it doesn’t speak to the reality of people’s lives,” she says. “There has been growing recognition of this in the last few years, making it a pivotal moment to push forward policy solutions that place reproductive rights alongside the other policies that help women and their families thrive.”

Still, the struggle to push the reproductive-rights movement in new directions has not been without challenges. Even as the Democratic Party and mainstream groups like Planned Parenthood have been linking their advocacy more with other progressive issues—either because they recognize its inherent value, its strategic worth, or both—some smaller organizations that have been making these arguments for years have, at times, felt sidelined. After the Times story ran in 2014, Monica Raye Simpson, the executive director of SisterSong, a reproductive justice group led by and focused on women of color, published an open letter calling out mainstream groups for failing to acknowledge their decades-long work making connections between reproductive choice and women’s health and economic prospects.

“We appreciate that you push us to do this more, and to do it better,” Richards wrote back in response. “And we hear you when you say that we are not doing enough.” A few months later Richards and Simpson met in person, and published a joint statement pledging to build a stronger partnership.

I asked Simpson how things have played out in the year and a half since that meeting. “We’ve really seen mainstream organizations reaching into the women-of-color-led organizations to get our expertise, and actually have us at the table and shape the conversation,” she says. While Simpson acknowledges there’s still a long way to go in terms of truly making the reproductive-rights movement “intersectional” (a social justice concept that means reckoning with different forms of oppression and how they impact, and compound, one another), she does feel Planned Parenthood “is starting to show up more” for them.

One way that Planned Parenthood is “showing up” for a broader range of constituencies is through its membership in the All Above All coalition, a growing political effort to overturn the Hyde Amendment—the 40-year-old law that prohibits federal spending on abortions. Women of color and low-income communities most affected by Hyde have been leading the campaign.

During Cecile Richards’s testimony this past September, she told the House Oversight and Government Reform Committee that in her opinion, the Hyde Amendment “discriminates against low-income women.” Erin Matson, who has been frustrated by some of the rhetorical timidity of the reproductive-rights community, was surprised and encouraged by Richards’s comments. “That’s not how Planned Parenthood talked about Hyde in the past,” she says.

A WEEK BEFORE THANKSGIVING, Planned Parenthood’s political arm launched its 2016 election effort, pledging to spend at least $20 million defending reproductive rights. “We will organize and mobilize to elect lawmakers who are in our corner,” Richards announced in a video ad.

Most public opinion analysts suspect that the conservative strategy of targeting anti-choice voters in Republican primaries may backfire in the general election. An NBC-Wall Street Journal poll conducted in August found that Planned Parenthood has a significantly higher favorability rating than any other group or individual tested—including the Supreme Court, President Obama, both political parties, and key Republicans running for president. Handfuls of other recent polls and surveys have reported nationwide majorities opposed to defunding the organization.

Even on abortion, despite the high-profile attacks, public opinion hasn’t substantially changed. The percentage of Americans who believe abortion should be legal in all circumstances, in some circumstances, or under no circumstances has stayed relatively constant since Gallup first started asking the question in 1975. In 2015, Gallup found that 29 percent of Americans believe abortion should be legal under all circumstances, 51 percent believe it should be legal under some circumstances, and 19 percent believe it should be legal under no circumstances. While Republican candidates are staking out positions to appeal to those who oppose abortion under all circumstances, it turns out that not even all those voters are on board with the GOP attacks. A recent YouGov poll found that more than a third of Americans who support strict abortion restrictions nonetheless hold a favorable opinion of Planned Parenthood.

Republican presidential candidate Ben Carson, who compared supporting a woman’s right to choose to supporting slavery, has made clear that he’d like to see Roe v. Wade overturned, along with laws that permit women to terminate pregnancies in cases of rape or incest. Marco Rubio, a candidate favored among GOP elites, also wants abortion to be made illegal with no exceptions for rape or incest. But in a CNN/ORC national poll taken just before the 2012 presidential election, 83 percent of all voters—and 76 percent of Republicans—said they favored allowing abortions in cases of rape or incest. “The RNC is not happy about this Republican primary,” says Anna Greenberg, one of the nation’s top Democratic pollsters. “This is not a strategy [for them], it’s a disaster.”

The anti-abortion rhetoric stands not only to motivate the progressive base, but also to agitate independent voters. Independent women in particular tend to be more socially liberal and economically conservative, and Greenberg notes that a lot of the misogynistic and anti–reproductive rights rhetoric has actually helped Democrats more effectively communicate with this swath of the electorate.

“While backing Republicans into a corner might gin up some primary votes, [these positions are] wildly, wildly unpopular with the general public,” says Erica Sackin, Planned Parenthood’s director of political communications. “When Romney said the first thing he’d do as president is defund Planned Parenthood, he lost the 2012 election by the largest gender gap in history.”

Planned Parenthood wants to help elected officials understand that being forthright in their support for abortion and reproductive rights is both better policy and smart politics. In effect, the organization, along with other women’s groups, is now engaged in its own anti-stigma work on the electoral level, pushing leaders away from the “safe, legal, and rare” abortion mantra that pro-choice Democrats used, starting with Bill Clinton’s 1992 presidential campaign. The Democratic Party officially removed the phrase from its platform in 2012, and advocates are now urging politicians to think of abortion more along the lines of “safe, legal, and where we live.”

Richards believes the country has arrived at a real inflection point. “It’s just abundantly clear,” she says, that the assaults on Planned Parenthood are not about the organization as a health-care provider, but about “folks who resent that women actually have the legal right to make their own decisions about their pregnancies. That’s what they’re mad about, and they’re really mad.”

The stakes are high, but Richards is looking forward to the challenge. “I’m just grateful we’re getting to what is actually the real fight,” she says. “I believe this country is not going to go backwards. It has been incredibly inspiring to see young people, who I do think live their lives in a more public way, who really do want to throw off judgment and shame about so many things, including abortion. To me, that is a bright new day, and I hope, I think, it’s all going to come together in one place.”

California’s New Crisis Pregnancy Center Law Creates a Roadblock for Anti-Abortion Activists

Originally published in In These Times on October 30, 2015.
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Earlier this month, California Governor Jerry Brown signed the nation’s first statewide law to regulate crisis pregnancy centers (CPCs). CPCs are facilities that work to counsel women out of having abortions, offering them resources like diapers, baby formula and maternity clothes, but also often disseminating misleading or outright false medical information. Boosted by government funding under George W. Bush, they have proliferated over the past 15 years, with an estimated 3,500 nationwide—outnumbering real abortion clinics 3-to-1.

California’s Reproductive Freedom, Accountability, Comprehensive Care and Transparency (FACT) Act, which overwhelmingly passed the state assembly in May, is being hailed as a landmark victory in a nationwide effort to push back against the rise of CPCs.

The new law, set to take effect January 1, will govern California’s nearly 170 CPCs, about 60 percent of which operate with no medical license. The law requires unlicensed facilities to post a notice—in “no less than 48-point type”—stating that they have neither a state medical license nor licensed medical staff. Licensed CPCs, for their part, will be required to inform women about available public assistance for contraception, abortion and prenatal care.

Whether or not the law can withstand a court challenge, however, remains to be seen. The decades-old movement to regulate CPCs has been repeatedly thwarted by First Amendment challenges.

Although CPCs began cropping up in the late 1960s as individual states lifted their bans on abortion, the clinics flew under the radar until the 1980s and 1990s, when they became a subject of a heated debate that went all the way to halls of Congress. Detractors argued that CPCs’ strategies to lure in women—such as offering free non-diagnostic ultrasounds and staffing their non-medical volunteers in white lab coats—amounted to false advertising. Defenders said their actions were protected speech.

The passage of the Personal Responsibility and Work Opportunity Reconciliation Act in 1996—or “welfare reform”—increased federal funding for abstinence education and helped to fuel the expansion of CPCs, as In These Times reported in 2002. The law enabled the Bush administration to funnel $60 million in federal abstinence-only funds to crisis pregnancy centers between 2001 and 2005, often doubling or tripling the centers’ annual budgets.

In response, a number of investigations into CPC practices were launched. A 2006 congressional investigation, initiated by Rep. Henry Waxman (D-Calif.), looked specifically at CPCs that received federal funding, and found that most provided women with false or misleading medical information, which “often grossly exaggerate[ed] the risks.” (Federal funding for CPCs continues today, despite the Obama administration’s efforts to end it.) NARAL, a national pro-choice organization, has also been investigating CPCs for more than a decade, and has discovered that staffers routinely overstated the risks of abortion or simply lied—telling women that ending a pregnancy would lead to infertility, breast cancer or even suicide. A 2008 NARAL investigation into 11 crisis pregnancy centers across the state of Maryland found that “every CPC visited provided misleading or, in some cases completely false, information.”

Drawing on the Waxman report and NARAL’s investigations, in 2009, Baltimore passed the first-ever legislation designed to curb CPCs’ misleading advertising practices. Challenging CPCs from a false advertising perspective was, in part, a strategic decision. As Slate’s Emily Bazelon reported in 2009, “There’s a whole branch of law, commercial speech, to explain why false advertising gets less First Amendment protection.” The law required Baltimore CPCs to display signs—in both English and in Spanish—clarifying that they do not provide abortion or birth control referrals. Similar laws were soon passed in New York City, Austin, and San Francisco.

These ordinances were all challenged in court on First Amendment grounds. CPC backers argue that the regulations violate their religious freedom and their right to free speech. Baltimore’s law was struck down in 2011 and is still tied up in court appeals. Austin’s was overturned, as were key aspects of New York’s law. Given their free services and nonprofit statuses, judges have tended to see CPCs’ speech as “noncommercial”—a designation that generally receives greater constitutional protection than commercial speech. But San Francisco’s law, which passed in 2011, has thus far withstood legal challenge.

Pro-choice advocates in California treaded very carefully in drafting the FACT Act. “We paid a lot of attention to the bills crafted in other cities,” says Amy Everitt, the state director of NARAL Pro-Choice California. NARAL also enlisted the help of Attorney General Kamala Harris, a Democrat, to identify language that might be deemed unconstitutional.

Everitt explains that laws which require centers to post signs describing what they do not provide (such as abortion referrals) have tended to be more legally vulnerable than those that require facilities to distribute “neutral” information about available government services. So the FACT Act only requires licensed clinics to inform women of the many services available to pregnant women. In California, state Medicaid funds can cover the cost of an abortion, and millions of Californian women became eligible for Medicaid with the passage of the Affordable Care Act.

“In California, we have some of the best pro-choice policies in the whole country, but if women aren’t aware of what’s available to them, then they can’t use them,” says Everitt. “They need to find out about their options, and they need to find them out when they are actually out seeking care and information.”

Crisis pregnancy centers have already filed two suits against the Reproductive FACT Act. The law “is an outrageous and unconstitutional violation of both the right of free speech and the right of freedom of religion for our members in California,” said Thomas Glessner, the president of the National Institute of Family and Life Advocates, in an email quoted in Life News.“The Act unconstitutionally forces pro-life pregnancy centers, on pain of government penalty, to engage in government disclaimers that they would not otherwise provide.”

In response, Everitt notes that the state has a “public health interest” in ensuring that women can access high-quality reproductive care. “Women are seeking their options,” she says. “They are going online and they are looking for information to make their decisions about unintended pregnancy or pregnancy scares, and they were not getting the information they wanted in certain places like CPCs.”

Crisis pregnancy center advocates usually deny that CPCs mislead women, arguing that those who come to visit are well aware of the clinics’ anti-abortion slant. But investigations by reproductive-rights groups and Congress have found that CPCs often set up shop in close proximity to real reproductive health facilities and hide their anti-abortion agenda when women call seeking information. CPCs have also spent significant sums of money to advertise their services misleadingly in newspapers, on billboards, on social media and through Internet search engines.

While the fate of California’s new law remains uncertain, energized advocates are determined to build on their newfound political momentum. Everitt says she hopes their new law will serve as a model “for every state to pursue.”The new measures are “what it looks like to respect women,” adds Ilyse Hogue, the president of NARAL Pro-Choice America.“Empower us and trust us to make the best decisions for ourselves and our families.”

Pushing Civic Tech Beyond Its Comfort Zone

Originally published in the Fall 2015 print issue of The American Prospect.
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You’re walking down the street in New Haven, Connecticut, texting on your smartphone. As you turn a corner, you notice a big pothole in the middle of the road. Skimming through your cell, you log into SeeClickFix, an app for citizens to report non-emergency issues to local government. Snapping a photo of the pothole and geo-coding the picture with your GPS coordinates, you submit the report and continue walking, confident the relevant agency will tend to the matter. Other SeeClickFix users can also see that a new pothole has been reported, and where.

Potholes have symbolized the everyday problems that citizens call upon local and even national politicians to address. Senator Al D’Amato of New York was nicknamed “Senator Pothole” because of his reputation for tending to his constituents’ needs. It was a compliment—it meant he was available, responsive, and got things done, at least the small, concrete things his constituents cared about. But when it comes to taking action on local civic problems, there are now options besides contacting a public official. Tools like SeeClickFix allow citizens to gather local information and organize collectively based on what they learn. “If you as an elected official have established your power on the sole exclusive rights to that information, then our app is not something you’re going to be in love with,” says Ben Berkowitz, SeeClickFix’s CEO and co-founder.

SeeClickFix offers some interesting opportunities for citizens, such as allowing them to monitor whether the government has dealt with their concerns and “reopening” the complaint if they dislike how the government responded. “There’s an element of shifting power that’s baked into the code of SeeClickFix that makes it more of a service for people and less of a service for bureaucrats,” says Micah Sifry, co-founder of Personal Democracy Media, which focuses on intersections between politics and technology. SeeClickFix also provides useful services for governments—Jennifer Pugh, who works in the chief administrator’s office in the New Haven local government, said that her office’s adoption of SeeClickFix technology has allowed it to organize work orders more systematically. She hopes that in a few years, when a greater number of departments start to use SeeClickFix, they will be able to conduct new kinds of citywide analysis.

Moreover, in theory, SeeClickFix technology should one day allow journalists, political opponents, and independent groups to publish data comparing the responsiveness and performance of local governments, allowing citizens to see how well theirs stacks up in relation to others.

Some, perhaps hoping to stir up excitement, inflate the case for new technology—heralding it as the savior of government accountability and promoter of a more just democracy. “With these digital tools, citizens and their officials can revolutionize local government, making it more responsive, transparent, and cost-effective than it ever has been,” write Stephen Goldsmith and Susan Crawford in their book, The Responsive City: Engaging Communities through Data-Smart Governance. That exaggerated rhetoric about “revolutionizing” government shouldn’t be taken seriously; it only sets up people for later disappointment. But, in a more modest but still significant way, tools like SeeClickFix can help improve the accountability and performance of government—local government in particular. Accountability, however, is ultimately a political matter, and civic tech cannot simply steer clear of politics in the belief that technology will solve problems on its own.

The Obama Tech Letdown

Following his savvy 2008 campaign, Obama entered the White House with great expectations from the tech world. He was “the first Internet president,” as Omar Wasow, co-founder of BlackPlanet.com and now an assistant professor of politics at Princeton, called him. During George W. Bush’s second term, open-government advocates had begun to lay the groundwork for increasing transparency in the next administration, whichever party won the 2008 election. Their recommendations were just being finalized at the time of Obama’s victory. “We interacted quite a bit with the transition team and really conveyed to them that this was a bipartisan area the administration could take a lead on,” said Sean Moulton, the open government program manager at the Project on Government Oversight (POGO).

In his inaugural address, Obama declared that “those of us who manage the public’s dollars” will “do our business in the light of day, because only then can we restore the vital trust between a people and their government.” A day later, he issued two memoranda, one calling for greater government compliance with Freedom of Information Act (FOIA) requests, and another that committed his administration to bring about “an unprecedented level of openness in government.”

These memos sent expectations soaring in the worlds of civic tech and open data. Silicon Valley perked up its ears. “When the president of the United States says something like that, it becomes a big deal and a big business,” says Tiago Peixoto, an applied political scientist who researches democracy’s relationship to technology. We’ve seen the rise of for-profit companies—like SeeClickFix—that focus on improving government service delivery. “Civic hackathons” began to crop up in cities across the country and even at the White House, encouraging coders, entrepreneurs, and others to figure out ways to use technology for civic ends.

“[Obama’s administration] was the first time we ever had a U.S. chief information officer, a U.S. chief technology officer, and a U.S. chief data officer,” says Gary Bass, founder of the Center for Effective Government (originally called OMB Watch), a nonprofit organization committed to public accountability, transparency, and citizen participation. Suddenly government leaders were discussing how they could recruit top tech talent. The culture of the federal government seemed to be shifting.

But several years later, public trust in government has declined to historic lows. Much of that decline reflects the general hostility of conservatives to the Obama administration, not to its information policies. But even for liberals, the promise of an “open government” seems elusive. A 2015 Pew survey found that just 5 percent of Americans say the federal government shares its data very effectively. The civic-tech community, which had hoped to facilitate a democratic revival, is also puzzling over its lack of success. “I think civic tech started getting trendy with Obama, and it’s still trendy, but we haven’t had as big of an impact as we expected,” said Dan O’Neil, the executive director of the Smart Chicago Collaborative and one of civic tech’s early pioneers.

Local Experiments, New Tools

Still, there are plenty of examples of local governments experimenting with technology over the past few years to help increase its responsiveness and reduce government costs. With improved data analysis, New York City was better able to anticipate which buildings were at risk of catching on fire. Boston was able to speed up the time it took to deliver new recycling bins on request. Many companies, organizations, and individuals have also started leveraging government data to develop their own civic tools, from Waze, a crowd-sourced traffic-data company that provides users with timely and accurate travel information, to Nextdoor, a tool that uses census data to create private social networks for local neighbors to interact.

Apps like SeeClickFix offer a greater degree of civic opportunity than apps that allow you to track your packages in the mail or those that notify you when the next bus is expected to arrive. SeeClickFix users can earn “civic points” for utilizing different features, such as commenting on other people’s reports. Through the app’s “thanks” feature, citizens can send messages of gratitude to the government agency that addressed their complaint. Ideally these types of features can help to increase trust between citizens and government, an important ingredient for democratic participation.

One of SeeClickFix’s most admired features allows users to “reopen” a report they’ve filed if they’re not satisfied with how the government responded to it. People have praised the technology for empowering citizens with the last word.

I asked Jennifer Pugh, of the New Haven government, if there have ever been times when citizens reopen requests that her colleagues have closed, and she told me that it happened all the time. In many cases, she explains, the government is not able to provide what citizens are expecting, or the government does not agree with what an individual complainant has asked for. “We don’t have a lot of resources; we’re limited on money,” says Pugh. So New Haven often closes out requests on SeeClickFix, and if people reopen them, officials usually just leave them there. “The downside is that it looks like there is a lot of open issues out there, but in fact they’ve been dealt with. We just can’t come to an agreement about how to address it,” she says.

When citizens file complaints through SeeClickFix, there’s no guarantee that the government will do what the citizen has requested. These tech tools do not eliminate some of the basic challenges facing governments, like determining how to spend a limited budget of resources. But what SeeClickFix does offer is an easier way to raise issues, and a means for the public to better understand which requests have been addressed. This in turn creates new opportunities for activists and journalists to press for details on the government’s decision-making process. Why didn’t residents in this part of town have their pothole fixed? Why did you decline to put in the speed bump I requested when I am upset by the fast traffic on my block? Why did so many people from all over the city report vandalism on the same day? Such questions have become easier for the public to ask in the age of SeeClickFix.

Peixoto, who has been studying the intersections of democracy and technology for the past 14 years, thinks that when newcomers flooded the civic-tech space at the start of Obama’s first term, “there was no way to ensure that the critical mass of people would absorb the lessons we had already learned by then.” This has led to what Peixoto sees as “some naïve assumptions” repeated inside new civic-tech circles. Specifically, he points out that many civic-tech leaders overestimate what technology can do on its own. Some have encouraged technologists to dismiss the government entirely, or just treat it as a platform from which to launch civic projects independently. But researchers have learned that civic technology generally carries a far greater impact when it works in conjunction with the government, like SeeClickFix, rather than on its own. SeeClickFix’s government partnership helps to explain its steady growth and impact.

Why Civic Tech Isn’t Easy

It’s understandable why some civic-tech leaders feel unenthusiastic about dealing with the government. In Silicon Valley, technologists are encouraged to “fail fast, fail often.” But within the public sector, taxpayers don’t necessarily want their leaders taking big costly risks, and politicians in turn fear the backlash if innovations fail. The cultures are different.

There is also a talent pipeline problem—government simply does not have enough people coming to work for it who possess advanced technological skills. “You see so many agencies with so little knowledge and capacity around the technology, they don’t even know what they want or how to communicate with the contractors they hire,” said Moulton. The government bidding process itself is also notoriously difficult, precluding many smaller, and perhaps more talented, companies from competing for contracts.

Together, these issues create a government tech situation that is both expensive and dysfunctional. The best-known recent example was the disastrous rollout of the federal health insurance exchange website, Healthcare.gov. It not only went far over budget—originally estimated to cost $500 million, it hit $1.7 billion by its initial rollout in 2013, and exceeded $2 billion a year later—but the website also just didn’t work well at all. It continually crashed, stalled, and left customers unable to purchase health-care plans. Of course, once the website did start performing better later on, the news media had little interest in reporting on its successes.

In many ways, the embarrassing Healthcare.gov scandal served as a turning point for the Obama administration. “It was only after that that the alarm bell finally reached the Oval Office,” says Sifry. “This wasn’t working. You can’t just make good speeches. You also have to find good people who can deliver on those promises.” Since then, far more serious attention has been paid to federal information technology and government procurement.

In 2014, the administration created two new agencies in the executive branch—18F in the General Services Administration and the U.S. Digital Service (USDS) in the White House—both designed to improve the government’s technological capacity. The government has been trying to improve procurement issues for decades, but the tools and methods available today are different.

“From open-source tools to the refinement of methodologies like human-centered design and agile development, these are all things you wouldn’t have heard of two decades ago,” says Aaron Snow, the executive director of 18F. “These are all things that make it actually possible for us to accelerate the rate [at which] government improves its technological capacity.” While USDS technologists consult with agencies to figure out how to improve their work, the staff at 18F helps federal agencies become savvier about procurement. Speaking at the Personal Democracy Forum this past June—an annual conference for the civic-tech community—Haley Van Dyck, USDS’s co-founder, said her office has been deploying “hyper-networked teams across government” to disrupt and transform tech practices and agency cultures. And though 18F and USDS work specifically with federal agencies, they share their code freely online so that local governments can reuse and repurpose it for their own needs. At times, federal officials will use code first developed within local city agencies, too.

From Open Data to Accountability

In 2012, David Robinson and Harlan Yu, two technology consultants and open-government data theorists, published a law review article noting that the term “open government”—which was first used in the 1950s during debates that led to the passage of the Freedom of Information Act—has now blurred considerably and confusingly with the “open data” movement. “Today, a regime can call itself ‘open’ if it builds the right kind of website—even if it does not become more accountable,” they point out. Consequently, Yu and Robinson urge the public to distinguish more clearly between efforts to hold governments accountable and technology that enhances government services.

Tiago Peixoto built off of this analysis in an essay published one year later. For there to be government accountability, he argues, four things need to happen. First, government information must be disclosed—this is where open data would come in. Second, this disclosed information must reach members of its intended public. Third, citizens—not necessarily everyone, but a constituency large enough to influence government—must be able to understand the disclosed information and react to it. Fourth and finally, public officials need to respond to the public’s reactions or be sanctioned by the public through institutional means.

So with this in mind, can tools like SeeClickFix be used to create a more accountable government? In some cases, increased public transparency now exists within areas that were previously more opaque. That’s important.SeeClickFix users can compare how long they’ve been waiting for a streetlamp bulb to be replaced or for a pothole to be fixed. They can compare which parts of town had their requests answered more quickly. “It’s helpful to have a record of needs that are systematic and easy to measure,” says Robinson. News organizations can also launch investigations when reporters or watchdog groups notice that citizen complaints are going ignored.

Greg LeRoy, executive director of Good Jobs First, a watchdog organization that seeks to promote accountability for public programs subsidizing economic development, says he first understood how crucial transparency was for accountability back in the late 1970s, when he worked for National People’s Action (NPA), a grassroots social justice network. At the time, NPA pushed for the passage of the Home Mortgage Disclosure Act (1975) and the Community Reinvestment Act (1977). “There were allegations that banks were redlining communities of color, but there was no real evidence [before these laws were enacted] to prove it,” he said.

Technology on its own cannot get the government to disclose information, but it can prove extremely valuable for those who want to understand what is released. While LeRoy’s organization has been around since 1998, he says the rise of the Internet and data technology “has everything to do” with how his organization has changed over time. All states have their subsidy information in electronic form; they could share much or all of it online if they wanted to. The first state to do so, in small amounts, was Ohio in 1999. But governments have shown that without public pressure they will generally not disclose information or will release just small amounts of information to mollify critics. Good Jobs First has tried to overcome this resistance by conducting research, promoting public discussion, and encouraging activists to push for improved transparency laws. In 2007, they published their first national report card study—“The State of Disclosure.” By that time, 23 states had put some amount of subsidy information online. Three years later, when their next study was published, the number had increased to 37.

But “the data that states do put online,” LeRoy says, can amount to a “Tower of Babel.” States often hide information in obscure appendices, upload contracts in non-searchable PDFs, or publish audits that are impenetrable. As a result, Good Jobs First recognized that “transparency” could mean very little, in practice. But this is where new civic technology developed by third-party organizations has been invaluable. Good Jobs First was able to launch its comprehensive Subsidy Tracker tool in 2010 by compiling and organizing more than 100,000 records from across the country into one unified searchable database and getting additional subsidy program information through FOIA requests. “Technology has definitely been at the core of how we improve our data and make it more accessible for average citizens to understand,” LeRoy says.

The Center for Responsive Politics, another watchdog organization that focuses on money in politics, knows its ultimate objective is to move people into action—step three of Piexoto’s four-step process. “We use technology to provide information in lots of different ways,” explains Sheila Krumholz, the center’s executive director, because the group recognizes that presenting information in just one format won’t resonate with enough people. Krumholz thinks the organization has played a key role in educating citizens about the impact of money in politics, but says its challenge now is to figure out how to design the kind of “aha” moments that inspire people to act on what they learn, rather than simply tune out and disengage.

But inspiring people to act inevitably has political implications. Eric Liu, the CEO of Citizen University—a group that works with leaders, activists, and practitioners around issues of citizenship and organizing—says it’s not enough to make government more efficient. He encourages civic-tech leaders to reckon more with politics, power, and inequality. While it’s great to have an app that can help you find out when the next bus is coming, it would be even better, he argues, if you could activate the smarts and skills of people within civic tech to help push city leaders to develop a stronger public transportation system.

“Civic tech is excellent at transparency, civic tech is excellent at efficiency, civic tech is excellent at creating a sense of community,” said Liu in a speech at the Personal Democracy Forum this past June. “Civic tech is excellent at a lot of dimensions of what you might think of as customer service.”

The civic-tech community could help Americans create not only a more efficient government, but also a more politically accountable and fair one. Doing that would require the community to venture into political territory that it’s largely avoided up to this point. But if civic tech is going to make a big impact, there is no turning away from politics. It’s something investigative journalists have long understood: Making people with power uncomfortable is part of the job. It’s part of the job of civic tech, too.

‘Housing First’ Policy for Addressing Homelessness Hamstrung By Funding Issues

Originally published in The American Prospect on January 27, 2015.
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In an era of shrinking financial resources, policymakers, providers, and activists who work on homelessness prevention and care in the United States have been forced to develop new strategies. There was a time when officials at the Department of Housing and Urban Development (HUD) saw it as their responsibility to provide both housing and supportive services for homeless individuals, but now HUD now is refocusing its budget predominately on rent and housing—with the hope that other local, state, and federal agencies will play a greater role in providing supportive care. However, whether other organizations will actually be able to pick up those costs and responsibilities remains unclear.

The first major federal legislative response to homelessness was the McKinney-Vento Act of 1987, which passed both the House and Senate with large bipartisan majorities. The McKinney Act—which Bill Clinton later renamed the McKinney-Vento Homeless Assistance Act—provided funds not only for emergency shelter, transitional housing, and permanent housing, but also for job training, primary health care, mental health care, drug and alcohol treatment, education programs, and other supportive services. The consensus was that homelessness is a complex problem whose solution requires more than simply a roof and a bed.

The statutory goal of the McKinney Act was to gradually move homeless people toward stable housing and independence—a model that came to be known as “Housing Readiness.” Though this sprung from well-meaning intentions, it eventually became clear that this “gradual” approach frequently led to unwise and unfair ways of distributing welfare.

“We had this system that said homeless people essentially have to earn their way to permanent housing,” explained Ed Stellon, the senior director of the Midwest Harm Reduction Institute, and someone who has worked within the substance use and mental health treatment systems for more than 20 years. “Homeless people had to earn their way into transitional housing, make progress on certain goals, and finally when they were deemed well enough, they would earn their spot in permanent housing.”

A different model, known as “Housing First”, has been gaining steam over the past decade. What at first sounded revolutionary now feels fairly obvious: The Housing First approach posits that the only requirement for housing should be homelessness—that shelter is a right, not a privilege. “Plus, if you have conditions like out-of-control diabetes, congestive heart failure, or schizophrenia, housing is actually part of the solution,” adds Stellon. “It’s hard to make any meaningful progress on these chronic conditions without stable housing.”

Though exact estimates are hard to come by, HUD recently reported that as of January 2014, the chronically homeless numbered some 84,291, with 63 percent of those individuals living on the streets. HUD says this number has declined by 21 percent, or 22,937 persons, since 2010—in large part because of the embrace of Housing First. (Some, however, have accused the federal government of using data gimmicks to paint a more cheery picture of progress than has actually been made.)

Nevertheless, the reality is that at the same time policymakers are embracing the idea of Housing First, fewer affordable housing units exist than ever before. According to the National Low Income Housing Coalition, federal support for low-income housing has fallen 49 percent between 1980 and 2003, and the Joint Center for Housing Studies found about 200,000 rental units are destroyed annually. Research also suggests that a supply of 8.2 million more units would be needed to house extremely low-income households, up from a gap of 5.2 million a decade earlier. Though Congress recently authorized funding for the National Housing Trust Fund—an entity that was created in 2008 to fund affordable housing proects—its budget is nowhere near large enough to meet the demand.

“We’re not doing enough to expand housing availability, and HUD can’t expand its services unless Congress allocates it more funding,” says Barbara DiPietro, the director of policy for the National Health Care for the Homeless Council.

Given the fiscal climate, HUD is looking for new ways to spend its increasingly limited budget. Consequently, the agency is moving away from the supportive services that, through the McKinney-Vento Act, once accounted for most of its spending. In 1998, for instance, 55 percent of HUD’s budget was spent on supportive services, and 45 percent was awarded for housing. By 2013, just 26 percent of HUD’s competitive homeless assistance funds went to supportive services, and 66 percent was spent on housing. According to Ann Oliva, director of HUD’s Office of Special Needs Assistance Programs, the department’s goal now is to help local communities become more strategic with existing resources and available opportunities.

To do this, HUD has been working closely with other federal agencies, especially the Department of Health and Human Services (HHS), the Department of Veterans Affairs (VA), and the U.S. Interagency Council on Homelessness. In 2008, a joint program known as HUD-Veterans Affairs Supportive Housing (HUD-VASH) launched, combining housing vouchers for homeless veterans provided by HUD, with case management and clinical services provided by the V.A. Experts agree that HUD-VASH has been quite successful in helping both vets and their families, and it’s typically held up as the poster child for future interagency collaborative efforts. However, the program came with additional appropriated dollars, and it is typically easier to convince Congress to fund programs for impoverished military veterans compared to other downtrodden groups.

One of the most significant recent changes to homelessness policy has come through the expansion of Medicaid—a key feature of the Affordable Care Act. Now that nearly all individuals with incomes up to 138 percent of the federal poverty level are eligible for health insurance in states that opt for the expansion, agencies are scrambling to enroll thousands of homeless people so that they may benefit from new streams of mandatory government spending.

But Medicaid is, at its heart, a program controlled by the states. And with some states still vigorously opposed to expanding Medicaid—despite the ACA’s mandate for the federal government to pick up nearly all of the tab for the expansion—let alone some of the flexible legislative adaptations that HHS is encouraging, consistent and widespread changes to supportive services seem unlikely in the near future.

Though Medicaid expansion presents great opportunities for providing services to the homeless, some are concerned that the more flexible federal dollars currently set aside to work with homeless people will eventually just be funneled into the larger health insurance pool, with little, if any, allocated to doing what it takes to bring those with no homes into the government support system, which is needed in order to provide preventive care.

“Going out four or five times to visit with a woman living alone under a bridge, just trying to form a relationship and build trust with her so she will feel comfortable coming in to get more help—those types of health encounters are not typically billable through health insurance,” adds Stellon, who says outreach can be one of the hardest things for him to fund. “In our current system, it’s easier to pay for someone’s amputated fingers than to build a human relationship.”

Ultimately, there is only so much the government can do to advance the goal of Housing First with a depleting stock of housing units and a shrinking budget for supportive services.

“It’s a big mistake to come up with a good solution like Housing First and then to hamstring it because we don’t actually have the money for it,” says Todd Stull, the clinical director at a JOURNEYS | The Road Home, an organization that provides services and shelter to families and individuals in Illinois’s North and Northwest suburban Cook County. “One of the worst things you can do is get someone into housing for a short period of time and then they lose it. Then they lose trust in the providers.”

“We have not done well as a nation taking on poverty and implementing policies needed to address homelessness,” says Dr. Sam Tsemberis, the founder and CEO of Pathways to Housing, a national organization that first pioneered the Housing First model in 1992. “So we end up taking care of homelessness out of desperation, but we’ll be taking care of homelessness forever if we don’t take care of poverty.”

“We need more money,” adds DiPietro. “Until then, we’re just rearranging the priority list.”

The cost of sexually transmitted disease.

Originally published in the Baltimore Sun on April 1, 2013.

Doctors and patients alike are often uncomfortable talking about sexual health and sexually transmitted disease. But a new Centers for Disease Control and Prevention report shows that this squeamishness costs society millions of dollars spent trying to treat or cure diseases that could have been prevented, vaccinated against, screened for or detected at an earlier stage of development.

According to the CDC, about 19 million Americans each year are affected by sexually transmitted diseases and infections. Young people, ages 15-24, are disproportionately affected; they account for 50 percent of all new sexually transmitted infections despite representing just 25 percent of the total sexually active population.

The problem is particularly acute in Maryland, which has some of the highest rates of sexually transmitted infections in the country. Maryland ranks 9th highest among the 50 states in cumulative reported AIDS cases and 5th highest for syphilis, with signs that the problem is getting worse. Maryland has seen an upward trend of syphilis cases since 2002.

Conservative estimates from this CDC report show that the lifetime cost of treating eight of the most common STIs contracted in one year is $15.6 billion. Some STIs, like HIV require life-long therapy, and others, like the human papillomavirus, better known as HPV, can lead to cancer, which also demands costly treatment. Even among the STIs that are curable, the annual cost of treatment is $742 million. Chlamydia is the most common curable STI, with over 1 million cases reported each year.

These costs are almost entirely avoidable, but we also are operating in a culture where talking frankly about sex and its risks is not encouraged enough. The debates over sex education and the distribution of condoms in schools are well known, but a less obvious culprit in the spread of sexually transmitted infections is the failing of the health care system. According to a report from the National Cancer Institute, major hurdles to vaccination for example, are inadequate provider recommendations, a broken reminder system for urging patients to complete their doses, and concerns over cost and coverage.

According to the National Cancer Institute, in 2010 only 30 percent of American girls had received all three CDC-recommended doses of the HPV vaccines. Comparatively, in Canada, 50 percent to 85 percent of girls were vaccinated, and in the United Kingdom and Australia well over 70 percent of girls received the vaccination. These countries make efforts to provide access and affordable coverage but do not require the vaccine. The U.S. should follow suit and actively work to curb health care costs with preventative services. In 2007, Maryland established a task force to make recommendations for a state plan for the HPV vaccine, including possible requirements, cost and education efforts, but nothing came of it, and the task force was disbanded in 2009.

A positive development in the effort to stop the spread of STIs came in November, when the U.S. Preventive Services Task Force, a government-backed panel of scientists and medical professionals, made a new recommendation that every American between the ages of 15 and 65 be tested for HIV. Because the Affordable Care Act requires insurers to cover the preventative services that are recommended by this task force, regular HIV testing will now be covered as part of a routine check-up.

The idea that people would be tested for HIV just as routinely as they are screened for high blood pressure of cholesterol is promising, but it will only work if doctors and patients are willing to have what is often an uncomfortable discussion.

“Talking about [STIs and risk] at all in the ACA is big because it’s often not in the conversation,” said Barbara Conrad, chief of the Center for STI Prevention at the Maryland Department of Health and Mental Hygiene. “People don’t talk about things before they become real problems.”

The onus to change that will be on both doctors and patients, Ms. Conrad said. Patients may be too shy to raise the issue on their own, and doctors, pressured by the time constraints of medical visits, may not bring it up either.

We need to do better. For many, talking openly about sex, even with a doctor, may seem like a taboo. But that taboo hurts our economy and public health.