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Speaking for the Systematically Silenced: Modeling Solutions to Expand Reproductive Healthcare Access for Low-Income and Undocumented Women

a note on the sensitivity of this project : the project you are about to see is controversial. if you agree with me, great. if you don’t, I’m not asking you to.

all I ask is that you give me, and more importantly, the women I’m writing about, a shot. just listen. i tried to focus on as much factual information as pos ible, but anything with such a high human toll will be a bit emotionally charged.

and of course, change doesn’t come by smoothly–struggle and controversy define it. on a related note, this project, and the idea of women’s healthcare in general, might make you uncomfortable. good. you can learn a lot when you step out of your comfort zone. thank you, and I hope you find something interesting!

 

Article 2. Everyone is entitled to all the rights and freedoms set forth in this declaration, without distinction of any kind, such as race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth, or other status…”

 

Article 9. No one should be subjected to arbitrary arrest, detention or exile.”

 

Article 25. Everyone has the right to a standard of living adequate for the health and well-being of himself [herself/theirself] and of his [hers/theirs] family, including food, clothing, housing and medical care and necessary social services…”

 

December 10, 1948. Palais de Chaillot, Paris: Following the destruction and devastation of the Second World War and the Shoah, the world adopts a ground-breaking and novel universal code. On this day, the United Nations General Assembly passes the Universal Declaration of Human Rights. The goals were noble, the words lofty. But what do they really mean today?

 

For millions of women living in the United States today, the ideals espoused in Paris, 1948 are nothing more than ideals. In the supposed cradle of the Free World, reproductive freedom varies from mediocre to terrible. It is distributed without regards to equality but with regards to sex, gender, sexual orientation, income, race, language, and immigration status. Healthcare is politicized, and personal health decisions are often made by the politicians. Even where laws directly affecting healthcare are more liberal, other barriers to healthcare exist for low-income and undocumented women.

 

The barriers

Poverty

My own community of Miami is pictured as a post-card perfect paradise of palm trees, nightclubs, and beaches, but it has a dirty secret, poverty. As of 2014, 20.4% of Miami-Dade County residents live in poverty, yet prices around the county (driven up in part by tourism) don’t always reflect this. And the situation isn’t improving–this is actually a rise of between 4 and 6 percentage points from 2006 levels. And healthcare, as anyone living in the United States knows and feels, is really, really expensive. Reproductive healthcare is especially expensive, and even more so if you’re one of the 15.9% of South Floridians living without insurance. Or, you could have (and pay into) state insurance, but abortion services aren’t covered.

As a Game Theory student, I decided to model this information mathematically, and used economic data to calculate the real-life costs of various reproductive health services. Here is an info graphic I made to humanize these costs.

GOA Catalyst by Natalie Fredman

Lack of Insurance

Immigrant Women Need Health Coverage, Not Legal Barriers

Systematic failures and legal issues

A lot of health mishaps come from a simple lack of knowledge. Each year, millions of young women and girls face unwanted pregnancies and sexually transmitted diseases which stall their educations and trap them in the cycle of poverty. Children are precious gifts when wanted, but unwanted pregnancies can delay or completely stall a mother’s education, limit socioeconomic mobility, and pose serious health risks. However, the high effectiveness of contraceptives and extent of medical knowledge available today means that much of this is highly preventable. While other barriers (as you’ll see in this presentation) remain in place, lack of knowledge among the general public, particularly young people, is a major one.

Now, this seems easily fixable. The United States has a system that disseminates information to tens of millions of young people every day: public education. However, it’s not so simple. Thanks to arcane laws, Florida’s public school sexual education is nothing short of absolutely pathetic. Sexually transmitted diseases are a major issue, thanks in part to the complete lack of any state-mandated STD education and contraceptive education (as Florida curriculums must emphasize abstinence). Not only do students receive a lack of information about these important topics, they actually receive misinformation. Distortions of truth and flat-out lies are common in abstinence-only programs. The issue doesn’t only extend to Florida-of the 33 states that require HIV-prevention education, only 13 actually require that education to be medically accurate.

It’s not much easier for the self-educating young woman. In Florida, legal barriers mean abortion is often inaccessible. Contraceptives are expensive, and minors in most cases can’t even obtain access to them without parental notice.

There’s so much more to systematic failures and legal issues, enough to spawn millions of projects on their own. If you’d like to find out more about this, I’d encourage you to visit the comprehensive online resources of the National Women’s Law Center.

Fear of deportation

Meet Maria. Maria lives in Southern California, where she has many of the traditional Americans markers of perceived success and stability: a job, a home, and two young children. But she’s missing one important thing: papers. She is undocumented, and could be deported at any time. Watch this video to learn more about her and her struggles as she must choose whether the risks she may face seeking healthcare are really worth it.

Language barriers

Medical talk is confusing enough for those who grew up speaking English, and even more so for those who are not fluent.

Medical discrimination

Historic and ongoing disparities in medical treatment as well as denial of patient rights make healthcare an unwelcoming place for many people of color. The disparities in treatment outcomes between Black and Latinx patients and white patients have barely changed in the last 50 years.

 

The solution: a model non-profit distributes free intrauterine devices

My message is one of equity, equality, and access, and recent events have affirmed my purpose even more. The American Health Care Act didn’t go through, but new versions will likely take out reproductive healthcare coverage as well. Right now, millions of women are wondering if they will be able to refill their birth control prescription, or get further care should they need. Their health, and lives, are in jeopardy. Low-income women, especially those without full-time jobs, risk falling further into the cycle of poverty. Undocumented women are afraid to go to get basic care because they could be deported, and many don’t have the insurance or means to pay the astronomical out-of-pocket costs for private healthcare. For poor women, health care has always been a dire situation. But now, millions of women are in crisis.

Public reform is a noble goal, but it will take time, especially given the current state of politics. These women don’t have time to wait on reform. They need health care now, as I’m typing this, and so the private sector must step in. This is where nonprofits come in. Their non-profit purpose and lack of governmental links is essential in serving these women, who could otherwise face exploitation and unattainably expensive care. They are more separated from the government than public clinics, which is essential for women facing deportation or related uncertainty. Thus, I’m focusing on a model non-profit. This non-profit would operate in the Miami area, with an aim to bringing reproductive health care and education to disenfranchised women.

Bringing in my game theory, I’ve used modeling to determine that an intrauterine device would be an effective solution for many women. While expensive, their time length of usage, high effectiveness, and ease for patients make them the optimal choice for a non-profit to promote.

The intrauterine device, and math behind it–addressing poverty and lack of insurance issues

The intrauterine device or IUD, is one of the most effective birth control methods. At around $850 each, they are expensive but can last between 3 and 12 years, depending on type. 

Methodology: I used the following calculations. This IUD is 99.8% effective against pregnancy. Only 50% of teenage mothers will attain high school degree by 22, while 90% of girls who are not teenage mothers will As a sexually-active teenager using an IUD has a 99.8% chance of not being pregnant, she has a 99.8%(90%)=89.82% chance of not being pregnant and graduating from high school before age 22. She has a 99.8%(10%)=9.98% chance of neither becoming pregnant nor graduating. . Only 49% of unintended pregnancies are carried to term. She has a 0.2% chance of becoming pregnant, giving her a 0.2%(49%)=0.098% chance of delivering a child. Thus she has a a 0.098(50%)=0.049% chance of having a child and not graduating, and a 0.049% chance of having a child and graduating. She has a 51%(0.2%)=0.102% chance of becoming pregnant and not having a child, and a 90%(0.102%)=0.0918% chance of becoming pregnant, not having a child, and graduating. Therefore, she has a total 89.82%+0.049%+0.0918%=89.9608% chance of graduating high school.

Sexually active women using no method have an 85% chance of  becoming pregnant in a year. Using the above data on graduation and birth rates, a sexually-active teenage girl not using an IUD would have an 85%(50%)(49%)=20.825% chance of getting pregnant, having a child, and not graduating, and a 20.825% chance of getting pregnant, having a child, and graduating. She has an 85%(51%)(90%)=39.015% chance of getting pregnant, not having the child, and graduating/ She has a 15%(90%)=13.5% chance of graduating and not getting pregnant, and a 15%(10%)=1.5% of neither getting pregnant nor graduating. Therefore, she has a total 20.825%+39.015%+13.5%=73.34% chance of graduating high school.

Thus, an IUD has the potential to raise a teenage girl’s chance of graduating high school by 16.6208 percentage points–for which $850 seems like a bargain. She is a staggering 84.8 percentage points less likely to have an unintended pregnancy, and is 41.552 percentage points less likely to become a teenage mother. She is more likely to advance to higher education, and has greater potential for socioeconomic mobility.

Potential errors in methodology: The methodology ignores the potential correlation between pregnancy and likelihood to graduate. Also, it assumed general statistics on women using contraceptives are identical to those for teenage girls using contraceptives.

Over a long term, a 16.6208 percentage point increase in high school graduation rates, among many other benefits, will be evident to a healthcare non-profit. However, relatively small rates like this (<50% change) bring in an essential dilemma of game theory: planning for the long term, or large scale. Game theory relies on expected outcomes and probabilities, but in reality, a “player” will only receive one outcome. Sometimes, people decide to bank on the fact that a negative outcome–such as not graduating–is improbable enough when they don’t try to avoid it–less than a 27% chance–that they don’t have to “play” (make decisions) in a way to avoid it, when they could receive other benefits (saving money, for example) by not trying to avoid it. However, and this is the case here, often that improbable negative outcome is so negative that the player has a better expected payoff avoiding it. This is the case here. Unintended pregnancy can start a chain of events that trap women and families in poverty, starting by preventing educational attainment.

For $850, the non-profit could give teenage girls without insurance free IUDs. This is an expensive undertaking, but the organization could ask girls who are able to contribute or who have insurance to use it to the best of their ability, even if that means only contributing a small sum. Over time, the IUDs will save money over birth control pills (at $35 a month, and thus $420 a year, birth control pills are more expensive than an IUD after just over two years). They will free girls to lift themselves out of poverty.

Addressing systematic failures and legal issues

The non-profit would mostly occupy a medical role, but would value partnerships with political advocacy organizations when needed. In reality, some systematic failures aren’t addressable by a single non-profit. However, our non-profit could certainly take over where public schools and government failed to. Free educational classes are one highly effective, and cheap tool.

Building a culture of trust to address fear of deportation

The Health Insurance Portability and Accountability Act of 1996, or HIPAA, provides a lot of protection to patient privacy. In addition, the non-profit would use encrypted, highly secret records. For undocumented women who wish anonymity, they could file all records under an agreed-upon pseudonym. The key is that the women at hand must know this. Our model non-profit would emphasize its separation from the federal government and the fact that it isn’t a public hospital in its communications to the public. Multilingual flyers and door-to-door campaigns in high-immigration neighborhoods would advertise this, along with the non-profit’s services. The key is to build trust between the community and the healthcare workers, and this may take time.

Still, any undocumented person may rightfully fear scheduled appointments. Luckily, an IUD necessitates very little care after the initial insertion. There isn’t a constant prescription that must be picked up under a legal name, or constant visits to check up on it.

Addressing language barriers

Thanks to the rising amount of immigrants and first-generation Americans achieving higher education, there are many bilingual healthcare workers (who can also emphasize more with patients of certain backgrounds). Our non-profit would hire them, and focus on multilingual communications.

Addressing medical discrimination

We can’t undo the legacy of the past–a legacy of misinformation, mistrust, abuse, and violation of rights. But we can work to create a new legacy of an equal, equitable, and inclusive health care community by focusing on patients first. It’s hard to work past systematic biases, but a strong emphasis on equality and self-checking can help.

Conclusion

Reproductive health care is a nuanced topic, sitting at the unfortunate intersection of faith, politics, and medicine. Free IUDs aren’t a silver bullet, but they show amazing potential in the fight against poverty. More than ever, we need to band together to ensure that all women have access to the care they deserve.

Do something

Want to get involved in the fight for reproductive health care access? There are many ways you can help out, from political activism to donations to volunteering. Here are some active organizations working on all aspects of the fight for reproductive health care:

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COMMENTS: 2
  1. April 28, 2017 by Janet.Izzo

    I like your push for people to “do something”!

    • May 01, 2017 by Natalie F

      Thank you!!!

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