Margaret Sanger’s dream of controlling the fertility of the poor is coming to fruition, thanks to the federal government.
Margaret Sanger was the founder of Planned Parenthood and a population control activist. She advocated that the “unfit”—the poor and the disabled—should have their fertility controlled. In her view, “hap-hazard, uncontrolled parentage leads directly and inevitably to poverty, overcrowding, delinquency, defectiveness, child labor, [and] infant mortality.” Sanger emphasized the financial burden that the marginalized classes impose on the broader society, asserting that “if they are not able to support and care for themselves, they should certainly not be allowed to bring offspring into this world for others to look after.” In other words, to wipe out poverty, society should wipe out the poor—by wiping out the ability of poor people to have children.
These same cost-saving arguments are being used by the federal government to justify targeting low-income women for contraception, especially long-acting reversible contraceptives (LARCs).
LARCs are Margaret Sanger’s dream solution. LARCs, such as IUDs and implants, have a 99 percent effectiveness rate. In effect, they chemically sterilize young women for years. For IUDs, the sterilization lasts as much as five to ten years; for implants, it’s up to three years. Unlike other contraception, which a woman can discontinue using whenever she likes, if a woman wants to stop using a LARC, she must return to a healthcare professional to have it removed.
On both the state and federal level, the provision of LARCs to low-income women and teens is increasingly being pushed as a means to reduce the birthrate of the poor. In my last Public Discourse article, “Attention, Low-Income Women of Oregon: Your Reproduction is Now the Government’s Business,” I raised the alarm about a contraceptive metric being implemented by the state of Oregon. In today’s article, I address troubling but increasingly popular efforts to enact national contraceptive standards for all Medicaid providers, Title X-funded clinics, and federally funded home visiting programs.
Medicaid “Quality” Measure on Contraception
Efforts are underway within the federal government to enact a contraception “quality” measure within Medicaid that would have a widespread impact on the fertility of America’s low-income women.
In August 2015, an advisory body to the US Department of Health and Human Services (HHS) recommended that HHS adopt a Medicaid quality measure for adults that would measure use of the “most effective” or “moderately effective” contraception by women between the ages of twenty-one and forty-four who are “at risk of unintended pregnancy.” This contraception measure was the advisory body’s top priority for inclusion in the Medicaid performance measures for adults.
Only contraception deemed “highly effective” (e.g., LARCs) or “moderately effective” (e.g., injections) would be included within the measurement. Healthcare providers with a low percentage of female patients of childbearing age using such contraception would be rated as giving lower- quality care. A similar contraception quality measure, including a separate sub-measure of the use of LARCs, was recommended for teenagers as young as fifteen.
If enacted, these standards would put heavy pressure on Medicaid providers to increase their patients’ use of “effective” contraception, especially LARCs, in order to meet quality standards.
It gets worse. The advisory body recommended that HHS adopt a Medicaid quality measure that would measure the percentage of women using “highly effective” or “moderately effective” contraception within ninety-nine days after giving birth. In its report, the advisory body mentioned approvingly that “11 states have made specific policy changes to encourage placement of long-acting reversible contraception immediately postpartum, with the potential for others to follow.”
It is not clear when HHS will act on the recommended Medicaid contraception quality measures, but the agency seems to be taking steps in that direction. In September 2015, HHS awarded grants to thirteen states and one US territory for the collection and reporting of data to the federal government on the use of effective contraception and LARCs by women on Medicaid. The government is also working with an outside entity to standardize contraception data within Electronic Health Records, which could further facilitate the collection of this data.
Title X-Funded Family Planning Clinics
The federal government’s promotion of LARC to low-income women isn’t limited to Medicaid, however. The Title X family planning program will also have a disproportionate impact on minorities nationally.
The federal Title X family planning program provides funding to nearly 4,200 centers nationwide. At the recommendation of both the US Department of Health and Human Services’ Centers for Disease Control and Prevention (CDC) and the Department’s Office of Population Affairs (OPA), Title X-funded clinics around the country are aggressively promoting the use of LARCs by low-income women.
Both the CDC and the OPA have been particularly focused on increasing the use of LARCs by adolescents. After analyzing the use of LARCs by females aged 15-19 seeking contraceptive services at Title X-funded sites, the CDC concluded in April 2015 that “continued efforts are needed to increase access and availability of these [LARC] methods for teens.” According to the CDC report, among the states “Colorado had the highest percentage of teen clients using LARC (25.8%), followed by Alaska (19.6%), District of Columbia (17.9%), Iowa (16.6%), Hawaii (14.4%), and Vermont (13.8%).” The acting director of the Office of Population Affairs pointed out that the “Title X National Family Planning program helps to increase teens’ access to long-acting reversible contraception.”
Is this the best that our society can offer to a fifteen-year-old girl? Implanting her with an IUD that will chemically sterilize her for ten years so that she can have sex with an unlimited number of partners before the age of twenty-five? Are we going to ignore any concerns about the detrimental emotional, psychological, and physical impact that such a lifestyle will have on her? And what about the impact on her spiritual well-being? Are all of these concerns to be discounted so long as we can be reasonably confident that our tax dollars won’t have to help pay for the birth and support of a potential child? How can this possibly foster the overall future well-being of this young woman?
The Federal Home Visiting Program
Even in the privacy of their own homes, low-income women cannot avoid the federal government’s eugenic policies, thanks to the fertility control implementation of the new home visiting program, the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program.
This nationwide home visiting program, which was established by the Patient Protection and Affordable Care Act (“Obamacare”), empowers federally funded home visitors to exhort low-income women to increase the intervals between their pregnancies, and then to report back on the success of their efforts to increase “inter-birth intervals.” Twenty-eight states intend to measure success on this measurement concept by either showing an increase in the use of contraception by the women visited (fourteen states) or by showing an increase in birth intervals (fourteen states). The state of Maryland measures its success solely by the use of long-acting reversible contraception (LARC) by the non-pregnant low-income women visited.
When Obamacare was being enacted, there was immediate pushback against using federal home visiting funds for fertility control. A critique of the House-passed bill warned:
These goals of the home visitation program have nothing to do with providing health care. Instead, they are based on the false premise that poor mothers’ childbearing is to blame for social problems. The proposed visitation program is eugenicist, deceptive, discriminatory against low-income women, and utterly inappropriate to the medical work of nurses.
. . . the U.S. House of Representatives seeks to tell low-income women who receive medical assistance how many children to have and when to have them.
If federally sponsored agents were to come into the homes of America’s financially well-off women and start telling them when they should and should not become pregnant, there would be an uproar. Apparently, since this new program targets low-income women, it is somehow acceptable.
A Disproportionate Impact on Minorities
Minorities are often disproportionately represented among those seeking federal government assistance. Usage statistics clearly demonstrate that all three types of programs described above—implemented through Medicaid, Title X-funded clinics, and home visiting programs—would affect and constrict the childbearing of racial minorities at an alarming rate.
In the United States, 31.8 percent of black women and 33.6 percent of Hispanic women are on Medicaid—more than double the percentage of white, non-Hispanic women on Medicaid (14.2 percent). The clients served by Title X-funded clinics nationally are disproportionately black and Hispanic. Twenty-one percent of their family planning clients self-identify as black or African American, and 30 percent of them self-identify as Hispanic or Latino, compared with only 13.2 and 17.4 percent of the general population, respectively.
Like Medicaid and Title X-funded clinics, federally funded home visiting programs are heavily used by racial minorities. Nearly two-thirds of the low-income mothers visited through the federal program are either black or Hispanic, with only a quarter of the mothers being non-Hispanic white. Because of this disparity, the population control policies being implemented through Medicaid, Title X-funded clinics, and the federal home visiting program will result in racially disproportionate outcomes. The association of lower incomes with minorities in the United States allows these programs to avoid the appearance of being racially motivated. Still, regardless of the intent of those who implement the programs, it is impossible to deny that the effect is to federally fund the chemical sterilization of disproportionate numbers of African American and Hispanic women.
Exposing the Implementation of Eugenic Policies
Recent news that the government-funded Smithsonian National Portrait Gallery was exhibiting a bust of Margaret Sanger as part of its “Struggle for Justice” exhibit was shocking at first. But upon further reflection, it seems totally appropriate in light of the way that Margaret Sanger’s spirit lives on in the federal government today.
Still, it is troubling that the federal government is so aggressively pushing contraception at a time when, as law professor Helen Alvaré puts it,
the Washington Post editorial section is worried that women are suffering because of a lost understanding of what sex even means, when Vanity Fair asks whether we have begun the Dating Apocalypse (instant sex but no relationship), [and] when the chairwoman of the Federal Reserve can write that contraception changes the mating market to women’s disadvantage.
To my female readers: if the information in this article alarms you and inspires you to take action, please know that there is plenty that you can do. Work to expose coercive family planning initiatives launched by your state or local government. Blog about it or write letters to the editor of your local newspaper. Alert the women in your state and let them know what is going on. Post about it on social media, and call your elected representatives to let them know that you object to these programs.
These federal population control policies are problematic for so many reasons: they are discriminatory against minorities, disregard the views of healthcare providers who object to the use of contraception on religious or moral grounds, are offensive to women who have chosen not to use contraception for personal or religious reasons, and reflect an ignorance of the body of research that evidences that widespread use of contraception does not promote the well-being of women in the area of human sexuality and in the mating market.
America’s low-income and minority women need champions as never before. One of those champions could be you.