Women’s Health and ACA: Where are we now?

ACA White House

As we enter into the third quarter of 2014, it seems like a good time to review the changes enacted by the Affordable Care Act (ACA) and what good/bad impacts these changes have had for women’s health and underserved groups. It’s a larger discussion than to be had here for sure, but engaging in the conversation is important in ensuring that we continue to push for not only accessibility, but equity in health care as well.

infographic-how-aca-affects-women-e1368557320211The passing of the ACA signals a significant advancement in women’s health and public policy in general, ensuring that millions of women now have access to affordable health coverage. Women no longer pay more than men just for being women (e.g., gender rating). Unbelievably, for the first time in history – this overt gender discrimination is now prohibited in federally funded health care. Women will also not be denied coverage for pre-existing conditions, such as a Caesarean section or having received medical treatment for domestic violence. Lifetime dollar-value caps are no more, maternity coverage is now considered an essential health benefit and preventive services have been expanded to include contraceptives, mammograms and cervical cancer screenings with no deductibles or co-pays. Although the contraceptive mandate has stirred controversy in public discourse, the fact that birth control is available on both public insurance and private plans without out-of-pockets costs represents progress. Employers (non-religious) are not only required to provide birth control as part of insurance plans offered to employees, companies must also – and this is a big one for anyone who has ever breastfed – offer hourly employees a clean, safe space in which to pump (e.g., not an office closet or restroom).

And what about older women? One of our fastest growing demographics? They benefit too through a host of programs to support caregivers (typically women). Dual-eligibles will also maintain a more integrated balance between Medicare/Medicaid and will be able cover more prescription drug costs.

With these benefits, its hard to imagine that the ACA is anything but a resounding success. Still, coverage gaps remain. Of the currently uninsured, approximately 20% are women. Furthermore, the failure of some states to expand Medicaid eligibility benefits will undoubtedly affect women’s health in profound ways. All in all, the report card is not yet conclusive as to whether individual mandates and state expansions fully address the needs of women in this country. There is a sizable proportion of women who will be excluded from receiving any benefits due to immigration status or costs associated with buying insurance on the individual marketplace.

minority woman21 Many women fall between a space where they fail to meet eligibility criteria for Medicaid and can’t afford to purchase private insurance on the exchange, even with tax credits and subsidies. And while primary care at federally qualified health centers is available, access and quality depend on geographic location. Its possible for women with limited options to continue to receive clinic and inpatient care at the remaining public hospitals and some non-profit hospitals that provide charity care, yet this is far from ideal and free clinics are few and far between. In addition to that, abortion is still not federally supported and accessibility and affordability varies on the health exchange. Drug coverage continues to be a priced at a premium and even though certain medications are subsidized by pharmaceutical companies, ultimately, mandating insurance coverage for the poor and underserved – many of whom are struggling to meet ends – is a difficult imperative. Ironically enough, the two ways in which the ACA was close to gaps – provide access and expanded benefits (at reduced cost) – are precisely the areas in which the most marginalized still find themselves lacking, with Medicaid expansions in many states (26) at a standstill.

Of course, its not simple to overhaul a national system that historically, was never intended to provide universal access to care. And the ACA shouldn’t be blamed for the complicated and dysfunctional system it took centuries to create. Some parts of the ACA are working; but others still need tweaking. For those of us working in the community and serving underserved populations, its important to not only understand these shortcomings, but also to advocate on behalf of women, children and the un(under)insured who may be navigating a complicated system or shut out altogether.

Disrupting Hair Habitus

bourdieu, 1977Could “hair habitus” be a thing? Or as one reviewer suggested, “acceptable presentation habitus”? In any case, I’m curious how hair intersects with the concept of habitus and health intervention research. Habitus originates from Bourdieu (1977), in which he argues that certain mundane acts are an elaborate performance. What do we perform, you ask? Well, there’s no short answer because there are a myriad of ways we perform gender, social class and identity every day. In essence, habitus refers to implicit practices and routines that structure the logic of everyday life.

In this way, I think about how Black women’s relationships to hair are formed differently across class lines. Perhaps the primary question is, are they? Are attachments to hair and specifically hairstyle, more salient for certain class groups? Of course, these theoretical musings are not simply rhetorical questions. They matter in the sense of understanding and breaking cycles involving health, class and the racialized gendered body. From my standpoint, hairstyling and daily grooming is a significant daily performance. For Black women in particular, our hair conveys messages to the world about who we are and how we want to be seen. Yet I struggle in articulating a theory that expresses the way in which hair is in conversation with our bodies and our health. How do we meaningfully incorporate ideals of beauty, femininity, hair and health?

let's talk about hair_oprahA second tenet is that habitus is shaped by social and economic conditions. Perhaps one primary strategy for transforming the dissonance between *some* Black women who struggle with maintaining hair and a daily exercise practice, for example, includes disrupting habitus. According to Bourdieu, mundane acts of everyday life can be restructured to accommodate new interests and practices. So for example, if we encourage women to exercise at work, then we must design interventions that focus on the challenges associated with integrating workplace-exercise with daily grooming practices. We must purposefully restructure our routine in a way that successfully incorporates physical activity. Exercise interventions cannot be disconnected from the sociocultural contexts in which we live. By providing models that integrate structure and “real world” application, we are able to design culturally appropriate ways to meet the needs of women’s health.

theory into practiceAs public health professionals, it is imperative to acknowledge, not discount, the reality that hair management for some women is a barrier to exercise. In moving forward, our aims should include disrupting the notion that one cannot both preserve hairstyles while exercising. To do so requires identifying strategies that incorporate flexible planning and social support into intervention research.

Policing bodies: The larger discussion behind Black women’s hair in the military

Black hair is multidimensional, layered and complex.

We get a sense of this complexity with the recent media attention given to the military’s hairstyling guidelines that unfairly target Black women. The truth is, the military is not different from larger society’s expectations and constructions of idealized or “acceptable” presentations of hair. There’s a long history here, and it’s been covered before so I won’t rehash it.

There are multiple issues with the military’s styling guidelines; I will focus on two. First, the framing of the guidelines suggest that all women should be able to achieve the same hairstyling, regardless of ethnic/racial background or even more practical considerations, such as hair length and texture.

Army Black HairAccording to Troy Rolan, an Army spokesman, “The updates in appearance standards were crafted, in part, with the help of African-American female soldiers and are intended to clarify the professional look of soldiers.” Question: Is it logical for a few African American women to “clarify” how all African American women should wear their hair? I’m sure this goes without saying, but Black women are not all the same and neither is their hair. African American hair textures are quite diverse. And while I appreciate the military’s emphasis on neatness, their standards are contradictory. (Dread)Locs, for example, are neat and can be worn down. Yet they are banned according to military guidelines. What gives? As Imani Perry puts it, “While it is reasonable for the military to expect some degree of conformity and neatness in hairstyles, those expectations ought to take into account the variety of natural hair textures people have.”


Perhaps the larger issue in this debate feeds into the messaging we communicate to society and more importantly, to our young Black girls about hair and work-identity performance. Are we telling our young girls that in order to serve your country, you must manipulate or even chemically alter the state of your hair? Moreover, that the way you wear your hair may jeopardize your job or job security? Yet Black women are unfairly subject to this policing of their bodies, both in and outside the military confines. How are Black women in the workplace compelled to either conform to or perform Eurocentric standards of beauty in ways that suppress their identities and natural sense of self? When an employer mandates that hair be worn in a specific, “acceptable” manner, what does that mean? Does that mean that one cannot be their authentic selves?

Essentially, military officials may do well to first understand the complexities of how African American hair grows naturally, and then design guidelines that accommodate that diversity. Hairstyles should not be demeaned or subject to criticism simply because they are perceived to be different. Instead the approach to grooming standards – whether in corporate America or the military – might focus less on gendered-racial policing disguised as regulation and more on job performance.

Just a thought –

Silence at the intersection

cece-mcdonaldI recently posted a link for Free CeCe (a documentary-in-progress by Laverne Cox and CeCe McDonald) to a listserv of friends and colleagues. CeCe McDonald is a Black transgender woman and activist. She was sentenced to 41 months in a male prison for stabbing a man who attacked CeCe and her friends in Minneapolis, Minnesota. CeCe’s case generated a significant amount of media attention and public discussion surrounding the victimization and harassment suffered by trans-women and particularly trans-women of color (WOC). Cece was released from prison in January 2014 after serving 19 months, and in her subsequent media appearances CeCe used her platform to discuss her life experiences as a trans-woman, her prison sentence and regaining her life.

In my e-mail post, I solicited opinions about CeCe. I was curious what a group of college-educated, middle class, African American thirty-something professionals thought about CeCe’s (and other trans-WOC) experiences that often entail violence and abuse? How do we think about the voices of Black LGBT*Q folks at the intersection? Where do we place sexuality in the politics of antiracism efforts? And how do we teach our peers and children about acceptance and the importance of being allies?

Good questions, right? I thought so too. Until a day, then 2 days passed. No response. A week. Still no response. The silence was deafening. A group of very knowledgeable people who definitely had opinions on a wide range of issues and not one. single. comment. about my post? Surprised and outraged, I followed up. “What gives? Why the silence?”

Then, someone offered this:

“For most people, until they know someone, until it affects them directly, or until it is right in their own back yard do people rarely care (or pay attention to) specific issues. Until then, it’s just an abstract thought that you may be aware of but not really motivated to do anything about.

It’s even more a problem in the Black community since we tend to suppress/ignore issues even when they do affect us (dietary behaviors, depression, sexual assault, sexuality, etc.). AND because we (compared to other groups) strongly stick to a religious dogma that teaches us to blindly accept/ignore things and to pray away our “problems” instead of talking about them.

The key is having an open dialogue on all of these things which, in a way, makes the world smaller and makes relating to people/issues easier even if not directly affected. I think younger generations growing up with social media exposes them to topics that older generations (all of us included) didn’t have access to.”


Vigil Held For Transgender Woman Beaten And Killed In HarlemHowever, as on-point as the comment was, I still had questions. Are we now part of an “older generation” that is too set in traditional ways of thinking to grapple with these issues? Is not knowing an excuse for not caring? How can we begin to engage in difficult dialogues, and more importantly solutions, if we remain SILENT? I wondered what the other 99% of the listserv thought? Did they agree and if so, why didn’t they speak up? Again, why are we so SILENT?

As I consider my own research dealing with the complicated nature of intersectionality, I can’t help but notice that everyone has not come to join my party at the crossroads. In fact, many people don’t consider their identities (much less the identities of others) as intersectional. It was a sobering moment. A moment that makes me realize that beyond the academic labor, there is real work to be done on the ground in raising the consciousness of people living ‘at the intersection’ and outside of it. For instance, there is real work to help our brothers understand how to work together in helping to empower, not objectify and destroy, Black women. There is real work in getting the word out that (black) feminism is not a dirty word and yes, men, you too can join the movement. And, there is real work in paying attention to – and understanding the experiences of – the CeCe’s of the world.

The list continues to grow.

If Crenshaw really did conceptualize the term intersectionality from a schema of intersecting roadways, then it stands to reason that in all of its complexity, some people will be left in the median wondering where they fit (if at all). Isn’t it time we did something to translate and disseminate the message of what it means to be a true ally – and to “do intersectionality” – far and wide? While we debate the future of intersectionality, with the conceptual and measurement issues on one front, we also need to coordinate ways to do the work required to reach everywoman/man.

Carbado et al. (2013) explain:

“When Kimberlé Crenshaw drew upon Black feminist multiplicitous conceptions of power and identity as the analytic lens for intersectionality, she used it to demonstrate the limitations of the single-axis frameworks that dominated antidiscrimination regimes and antiracist and feminist discourses. Yet…the goal was not simply to understand social relations of power, but to bring the often hidden dynamics forward in order to transform them. Understood in this way, intersectionality, like Critical Race Theory more generally, is a concept animated by the imperative of social change.”

As we see, the very essence of intersectionality is historically steeped in centering perspectives as a tool of analytical, theoretical and social development. Our potential to be transformative depends on facilitating efforts to change structural invisibility and inequality. So what are we waiting for? Let’s get on with it.

Studying intersectionality quantitatively

Screen-shot-2013-05-31-at-00.15.091I came across a blog recently that details the complexity involved in studying intersectionality from a quantitative perspective. Anyone who has encountered such questions in their own work can identify with the frustrating nature of accounting for an anti-categorical approach that is already quite complicated in theory. And yes, I said anti-categorical. As a quantitative researcher, “anti-categorical” is paradoxical to what we do. We live by quantifying things!

So what is one to do if so quantitatively-inclined? How can we, as scholars, accurately represent intertwined identities in research? The very notion that social categories (e.g., race, SES, gender, sexual orientation) are not independent and unidimensional but rather multiple and mutually constitutive, is both reasonable and rational, but very difficult to measure. Over the years, I have had many conversations with people (just like me) who are overwhelmed at the idea of accounting for intersectionality from a quantitative perspective. “Oh the categories!” Or perhaps, “What size N would we need to have for something like that?!” While easily mind boggling, these questions also reflect a fundamental misunderstanding of the intersectional perspective.

Let’s review. First, as a health researcher it is important to acknowledge that the intersectionality framework did not originate from public health research, nor was it designed to specifically predict health outcomes or processes. However, its utility lies in the potential to examine and explore health disparities. The standard method of studying disparities is a comparative approach (e.g., Black/White or male/female differences). While useful to some extent, a comparative approach misses what I consider to be the most critically important questions. WHY are there mean differences between these two groups on say, chronic disease? To what extent is within-group variation shared between both groups? In other words, comparing health outcomes between two groups (A and B) can only give you half (at best) of the big picture. If we are concerned with preventative health strategies and fundamental causes, then we must also be concerned about questions that address the origins of such disparities.

researchmethodsB1Therefore, a significant challenge for intersectionality researchers is to adapt a perspective originally designed as an analytical theory into a model that might be useful to empirically examine say, social inequalities in health. Tall order, huh? Lisa Bowleg eloquently addresses this issue in a 2012 American Journal of Public Health publication:

“Thus, for public health and other social science researchers, the absence of theoretically validated constructs that can be empirically tested poses not only a major challenge but also tremendous opportunities for advancing the study of intersectionality from a public health perspective.”

Nice way to take lemons and make lemonade. Did you catch that? As public health researchers, there are great opportunities to uncovering ways to study intersectionality! So, back to the original question of how to actually do that in practice. There are several possibilities. Bowleg suggests more use of qualitative or mixed-methods research in public health research (I’m a fan of this idea). Given that I research intersections, I have devoted considerable thought to the topic and one approach that has been very rewarding and fruitful for me is within-group analysis. I’m sure you might be thinking, “But how can we possibly find out anything interesting about ____ people if we don’t compare them to ____ people??!” Ah yes. I’ve encountered different variations of this question over the years, and to that I reply, “It’s simple. No one group is monolithic.”

In essence, we are all complex and if I am concerned with Black women’s health, for example, I cannot fully understand Black women if I am only comparing health outcomes between Black and White women. Within-group research (studying only one group) allows us to understand the wonderful complexity that exists within a group of people who share one social identity. For example, Black women are extremely diverse. However, that diversity can easily get lost if you don’t take into account education, class background, geographic location, and other features of the social context that shape the human experience. Furthermore, there is a tremendous amount to be learned from understanding variability between risk and resiliency. Not all Black women develop diabetes, cardiovascular disease and die young, but some do. Why? And why does upward mobility not yield the same beneficial effects in terms of infant mortality for educated Black women, as for White women? These important questions require a thoughtful and deliberate approach to not only examining disparities, but actually doing something to help prevent them.

Natalie Sabik and I will be presenting our work on intersectionality and physical functioning among older African American women at the Intersections of Race, Culture, Health and Mental Health Conference at Boston College, October 18-19th.

Note: Just ordered Evelyn Simien’s Black Feminist Voices in Politics – an intersectional analysis. Can’t wait to read!

Why we should be talking about hair

barbie-with-natural-hairThere is a pervasive sentiment that hair is a superficial aspect of beauty. Yet for many women of color, hair is quite the contrary. Hair is an expression of self – who I am and where I’ve been. Before I get too deep, let’s take a moment to recognize the obvious – all women, regardless of race, view hair differently. For Black women, however, this view may be shaped by historical significance (e.g., Black is Beautiful movement), family influences and social upbringing (preferences for straight and non-straight styles) or matters of convenience. Google ‘Black women and hair’ and I’m sure you’ll get more information than you could ever imagine about the complexity of Black women’s hair. Therefore, to downplay its relevance in our social conversation is insensitive and dismissive of the real way that hair matters to the lives of African American women.

Recently I came across this article, and while it saddened me, it certainly did not surprise me. Shaming anyone, much less a 7-year old child, about the way she chooses to wear her hair is unacceptable. I could deconstruct the baseless rationale given by the Deborah Brown Community School administrators regarding their harassment of Tiana Parker about her decision to wear locs. But that’s too easy. Instead, I wonder how different Millard Jones is from the rest of us. I wonder how, consciously or unconsciously, we as a society are imparting negative messaging about hair and beauty into the minds of our little girls and disempowering them in the process. Even more, I wonder what type of behavior we are modeling as Black women. When we run through the rain or avoid exercise/swimming because we don’t want to get our hair wet and ‘revert’ – are we sending a positive message? And while I overstand that economic considerations, such as salon costs and time for hair maintenance can be prohibitive, I would like to propose an alternative. Let’s shift the conversation. Let’s pen a new narrative for the mental and physical health of our children. Let’s model active behavior that can be achieved regardless of hairstyle. Let’s reaffirm that beauty comes from within. Let’s allow our girls to see reflections of themselves – in us.

I don’t claim to be wise, but if there is one thing I am certain of – children pay attention to what you do, not necessarily to what you say. So if we are telling our daughters, nieces and granddaughters that they are beautiful, but still we complain about doing their kinky hair, give them chemical relaxers at age 5, tell them to be careful not to ‘sweat their hair out’ and encourage them to wear their hair in ‘acceptable’ styles, then we are no better than the Deborah Brown Community School administrators. We are all reproducing a damaging cycle to the psyche that devalues the natural beauty of Black hair.

Perhaps if I were so inclined, I would design a public health intervention to visit cities and rural towns across the nation on a U R Enough Crusade. I don’t need tons of funding or a complicated research plan; just one bullhorn and a single message: You are enough. Your hair is enough. The way your hair grows out of your head is enough. Whatever way you choose to rock your ‘do, know that your hairstyle does not dictate your self-worth or value. That is all. Even without the bullhorn, I hope this message spreads (as it seems to be doing):

May your hair be enough to make you feel pretty, valued and empowered!

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