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Sexual and Reproductive Health Rights, Access & Justice: Where Nursing Stands

      Executive Summary

      Although the American Academy of Nursing (Academy) has for decades played a major role in advocating to protect the sexual and reproductive health (SRH) of all women and men regardless of race, color, sexual orientation, or social economic status, many government officials are aggressively pursuing ways to create barriers to evidence-based SRH care access. The Academy continues to “resist and respond” to these tactics, in the form of statements, policy briefs, amicus briefs and coalition letters—raising the voice of Nursing against the dismantling of the Affordable Care Act (ACA) and longstanding national health goals, programs, and essential services. The widespread collaboration among health professional, legal, and advocacy groups continues to grow in support of protecting sexual and reproductive health rights of all women across our nation. The Academy, in collaboration with the American Nurses Association (ANA) and many other organizations, is leading the way in resisting and responding as evidenced by numerous position statements and policy advocacy and action.

      Introduction

      Since 1997 (
      Writing Group of the 1996 AAN Expert Panel on Women's Health
      Women's health and women's health care: Recommendations of the 1996 AAN Expert Panel on Women's Health.
      ), the Women's Health Expert Panel (WHEP) has issued a number of policy reports and made a series of recommendations on policies to improve women's health generally and, more specifically, policies to improve access to high-quality, evidence-based sexual and reproductive health care (SRH) care.
      Sexual & Reproductive Health (SRH) defined: Reproductive health is a state of physical, mental and social well-being, and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its function and processes. Specifically, people are able to have a satisfying and safe sex life and that they have the capacity to reproduce and the freedom to decide if, when and how often to do so (WHO, 2011, p viii; UK FSRH Model, 2015). These definitions extend beyond a narrow focus on maternal-child health to include the sexual and reproductive health of men and women across the life cycle with a special emphasis on adolescents and health equity and grounded in an understanding of SRH as a human right and social justice issue. A minimum package of SRH care accessible to all would include preconception care, sexual health promotion, contraception, pregnancy and unplanned pregnancy care, women's health/common gyn care, common GU conditions of men, assessment of specialty gyn problems, and delivered within a system of public health and primary care services.
      ,
      Reproductive Justice defined: the human right to maintain personal bodily autonomy, have children, not have children, and parent the children we have in safe and sustainable communities. (Loretta Ross; https://www.sistersong.net/reproductive-justice/)
      The evidence is clear that SRH care policies and evidence-based clinical preventive services are key to protecting, promoting, and maintaining the health and well-being of women across the lifespan, while reducing the burden of disease, disability, and death (
      • Stolp H.
      • Fox J.
      Increasing receipt of women's preventive services.
      ). However, recommendations are in jeopardy due to the actions of the current Administration in the White House.
      The Administration refers to the Trump/Pence White House and their appointees working within the Department of Health and Human Services (DHHS) and other federal Departments.
      The affront to women's health in the past 18 months has demanded that the WHEP focus on immediate crises. We have done so by resisting and responding to the Administration's political interference marked by the roll-back of women's health rights and the dismantling of the Affordable Care Act (ACA) along with other longstanding national health goals and programs. The Administration has chosen regulatory sabotage and policy destruction as its means to an end. We highlight the “resist and respond” efforts by the WHEP of the Academy in this policy brief that is, in effect, a summary of the policy and advocacy stances we have taken.
      While we read much about the draconian effects of tax cuts
      American Nurses Association (2018). Blog: A budget to nowhere. Capitol Beat. Available at http://anacapitolbeat.org/2018/02/13/a-budget-to-nowhere/
      on the ACA, what we know far less about – though no less important—is the reshaping of the federal health infrastructure and people's health more broadly (
      • Halloway S.
      • Taylor D.
      We all need to be worried about the attack on national health policies and programs.
      ). For example, concerns abound about how the Administration's undoing of gap insurance allows insurance companies to deny coverage for pre-existing conditions. Further concerns center on the new division of the Department of Health & Human Services Office of Civil Rights which is tasked with expanding discriminatory practices that threaten essential health services. These insults are being felt in the myriad federal agencies that are simply not on the national radar; they are quietly making infrastructure changes the consequences of which are not known by most citizens.
      Since taking office, the current administration has pushed policy after policy designed to take away rights of women to control their bodies and their lives. In addition to the continuing attacks to dismantle the ACA, the administration is doing its own grassroots work through stealth rewrites of national health goals, programs, and regulations in the form of discriminatory and restrictive regulations that reverse the DHHS mission to “protect the health of all Americans and to provide essential human services, especially for those least able to help themselves.” This violates the rights and access to care of the American people, especially women and vulnerable populations, as well as healthcare providers. Sadly, many of the current government leaders
      See website https://www.trackingtrump.org/impact for up-to-date information about the impact of the Administration's sabotage of our healthcare system especially as it relates to SRH.
      are pushing policies that will increase discrimination against patients and healthcare providers, cut family planning services (e.g., Title X program), restrict health insurance options, and many more regulatory and funding roll-backs that will impact 67 million women and girls and other vulnerable populations in America.
      Emily Gee. (April 5, 2017) Number of Americans with pre-existing conditions by congressional district. CTR for American progress. Web Access
      In the past decade, thousands of nurses have participated in the American Nurses Association's (ANA) grassroots advocacy network to oppose efforts to repeal, replace or dismantle the ACA with their messages and actions to protect the principles of healthcare reform.
      American Nurses Association Policies on Healthcare Reform and Policy Action Center RNAction.org
      The American Academy of Nursing has taken a strong position against political interference in healthcare
      Nurses respond to political interference in healthcare, April 27, 2018. Web Access
      with specific emphasis on policies that protect sexual and reproductive health.
      The ANA and the Academy share the common goal of improving health for all by, among other things, ensuring access to high quality sexual and reproductive health care for women that is comprehensive and evidence-based. The American Nurses Association (“ANA”) represents the interests of the Nation's 4.0 million registered nurses. With members in every State, ANA is comprised of state nurses associations and individual nurses. ANA is an advocate for social justice with particular attention to preserving the human rights of vulnerable groups, such as the poor, homeless, elderly, mentally ill, prisoners, refugees, women, children, and socially stigmatized groups. The American Academy of Nursing (the “Academy”) serves the public and the nursing profession by advancing health policy, practice, and science through organizational excellence and effective nursing leadership. The Academy influences the development and implementation of policy that improves the health of populations and achieves health equity including advancing policies that improve ethical and evidence-based standards of care and women's access to safe, quality sexual/reproductive health care without interference with the patient-provider relationship.
      Our resist and respond efforts are expanding to a strong collaboration between the Academy and the ANA in partnership with numerous other organizations dedicated to protecting healthcare rights and access.

       The Academy's Women's Health Expert Panel (WHEP) Addresses Political Interference in SRH Care

      The WHEP of the Academy has focused attention on political interference in women's health, especially SRH. Over many years, we have developed position statements, published papers, written policy briefs, contributed to or led amicus briefs, organized policy dialogues, and created and maintained collaborative partnerships. As many politicians across the country push for laws and regulations that restrict ethical standards of care and impose politics and ideology on evidence-based clinical care, we simultaneously act to protect patient-provider relationships and women's health services by representing the Academy on coalitions of nursing, medical, health, and advocacy organizations.
      The Coalition to Protect the Patient-Provider Relationship is comprised of nonpartisan, nonprofit organizations united in opposition to inappropriate interference in the relationship between a patient and their health care provider. The Women's Health Defense Table (WHDT) is a coalition of over 50 organizations working to promote access to quality, affordable health care, with an emphasis on the health care needs of women.
      Highlights of our work include:
      • Leading activities since 2013 to raise Nursing's voice for SRH rights and justice policies backed by science and to partner with nursing and advocacy organizations for strategic activism.
      • Engaging national nursing leaders to respond to ethical and evidence-based standards of care, women's access to safe, quality SRH care, and threats of political interference to the patient-provider relationship.
      • Raising the voice of nursing in support of evidence-based policies that 1) ensure that all people have full access to affordable, sexual and reproductive health services (
        • Berg J.A.
        • Taylor D.
        • Woods N.F.
        Where we are today: Prioritizing women's health services and health policy. A report by the Women's Health Expert Panel of the American Academy of Nursing.
        ), 2) facilitate expansion of clinical knowledge and evidence-based women's preventive health services especially related to preventing unintended pregnancies (
        • Berg J.A.
        • Olshansky E.
        • Shaver J.
        • Taylor D.
        • Woods N.F.
        Women's health in jeopardy: Failure to curb unintended pregnancies: A statement from the AAN Women's Health Expert Panel.
        ), and 3) assure that all women's health care, including reproductive health services, is grounded in scientific knowledge and evidence-based policies and standards of care (
        • Berg J.A.
        • Shaver J.
        • Olshansky E.
        • Woods N.F.
        • Taylor D.
        A call to action: Expanded research agenda for women's health.
        ; Writing Group of the 1996 Academy Expert Panel on Women's Health, 1997).
      • Advancing recommendations that bring attention to political interference in SRH research, practice, education (
        • Taylor D.
        • Olshansky E.F.
        • Woods N.F.
        • Johnson-Mallard V.
        • Safriet B.J.
        • Hagan T.
        Corrigendum to position statement: Political interference in sexual and reproductive health research and health professional education [Nursing Outlook 65/2 (2017) 242–245].
        ).
      • Partnering with patient and consumer advocates, nurse and physician organizations as well as groups representing clinics, insurers and policy makers to comment on the administration's regulatory sabotage—opposing proposals that take healthcare services backwards (e.g., inadequate insurance, roll back of preventive services, and discrimination against patients and providers).

       Responses to Political Interference in Sexual and Reproductive Health Rights and Access

      The Academy (along with ANA) has responded to these threats of political interference with the patient–provider relationship, ethical and evidence-based standards of care, and women's access to safe and quality SRH care. The ANA has joined with the Academy in some responses as noted in the following specific ways, highlighted below:
      • 1.
        2016, Amicus Brief (January 4, 2016;
        • Amicus Brief
        Brief of the Amici Curiae (National Physicians Alliance, American Academy of Nursing, Center for American Progress/Doctors for America, American Nurses Association, and Society for Adolescent Health in support of Petitioners in Whole Women's Health v Kirk Cole/Texas Department of Health Services, US Supreme Court Case No. 15–27.
        ): Whole Women's Health v Hellerstedt, US Supreme Court (SCOTUS)
        On June 27, 2016, the Court ruled by a 5-3 vote that Texas cannot place restrictions on the delivery of abortion services that create an undue burden for women seeking an abortion, therefore the sections of Texas law H.B. 2 challenged here are invalid.[24] The court struck key provisions of the law—requiring doctors who perform abortions to have difficult-to-obtain “admitting privileges” at a local hospital and requiring clinics to have costly hospital-grade facilities—as violating a woman's right to an abortion.[25] Observing that these provisions do not offer medical benefits sufficient to justify the burdens upon access that each imposes, the majority concluded: “Each places a substantial obstacle in the path of women seeking a pre-viability abortion, each constitutes an undue burden on abortion access, and each violates the federal Constitution.”[2]
        case (impacting standards of care, women's access to safe, quality SRH care and abortion clinic restrictions)
        12On June 27, 2016, the Court ruled by a 5-3 vote that Texas cannot place restrictions on the delivery of abortion services that create an undue burden for women seeking an abortion, therefore the sections of Texas law H.B. 2 challenged here are invalid.[24] The court struck key provisions of the law—requiring doctors who perform abortions to have difficult-to-obtain “admitting privileges” at a local hospital and requiring clinics to have costly hospital-grade facilities—as violating a woman's right to an abortion.[25] Observing that these provisions do not offer medical benefits sufficient to justify the burdens upon access that each imposes, the majority concluded: “Each places a substantial obstacle in the path of women seeking a pre-viability abortion, each constitutes an undue burden on abortion access, and each violates the federal Constitution.”[2]
      • The Academy and ANA participated as lead authors in an amicus brief to the U.S. Supreme Court opposing a deceptive Texas law requiring medically unnecessary restrictions on clinical practice. The ANA/Academy supported Whole Woman's Health, the lead plaintiff in the case, and was a signatory on one of 45 “friend-of the-court” (amicus) briefs against laws that make it nearly impossible for a woman who has decided to end a pregnancy to get the safe, legal, high-quality care she needs. Nurses, as health care professionals dedicated to supporting the health and safety of their patients, recognize that legislation restricting patient access keeps us from providing the patient care we are trained and dedicated to deliver.
        Read the amicus brief of the American Nurses Association/Academy and the Academy's press release from June 27, 2016 applauding the SCOTUS decision to reject Texas HB2. See article from the academy's President Berkowitz, Examining What's at Stake: The Supreme Court, Nurses and Abortion Care Provision published in Huffington Post Health (February 22, 2016 and quotes from health professionals on political interference in clinical practice [politics over quality health care]).
        13Read the amicus brief of the American Nurses Association/Academy and the Academy's press release from June 27, 2016 applauding the SCOTUS decision to reject Texas HB2. See article from the academy's President Berkowitz, Examining What's at Stake: The Supreme Court, Nurses and Abortion Care Provision published in Huffington Post Health (February 22, 2016 and quotes from health professionals on political interference in clinical practice [politics over quality health care]).
      • 2.
        2016, Amicus Brief (February 17, 2016;
        • Amicus Brief
        Brief of the Amici Curiae (American College of Obstetricians and Gynecologists, Physicians for Reproductive Health, American Academy of Family Physicians, American Nurses Association, et al., in support of the Government and Affirmance in Zubik v Burwell (US DHHS), US Supreme Court Case Nos. 14–1418, 14–1458, 14–1505, 15–35, 15–105, 15–119 and 15–191.
        ): Zubik v Burwell SCOTUS case (access to full range of prescription contraceptives)
        Zubik v. Burwell, a 2016 case before the United States Supreme Court on whether religious institutions other than churches should be exempt from the contraceptive mandate, a regulation adopted by the US Department of Health and Human Services (HHS) under the Affordable Care Act (ACA) that requires non-church employers to cover certain contraceptives for their female employees.
        14Zubik v. Burwell, a 2016 case before the United States Supreme Court on whether religious institutions other than churches should be exempt from the contraceptive mandate, a regulation adopted by the US Department of Health and Human Services (HHS) under the Affordable Care Act (ACA) that requires non-church employers to cover certain contraceptives for their female employees.
      • The Academy and ANA along with health professional and public health organizations filed an amicus brief showing evidence that access to the full range of FDA-approved prescription contraceptives is an essential component of effective health care for women and their families. Nursing, medical and public health organizations share the common goal of improving health for all by ensuring access to high quality medical care for women and families that is comprehensive and evidence-based. These preventive health services should include reproductive health care and services.
      • 3.
        2016, Position Statement (September 28, 2016;
        • American Academy of Nursing
        Statement on DHHS/Title X proposed regulations to amend 42 CFR part 59: Compliance with Title X Requirements by Project Recipients in Selecting Subrecipients.
        ): DHHS rules for Title X and SRH providers [protecting family planning funding and reproductive health provider regulations]
      • The Academy was in full support of the U.S. Department of Health and Human Services' (DHHS) proposed rule to clarify and strengthen the Title X family planning program, the nation's only dedicated source of public funding for sexual and reproductive health (SRH) services. The proposed DHHS/Title X rule clarified criteria for state governments to apportion Title X funds based on a provider's ability to perform SRH services effectively and eliminated discrimination against certain “focused reproductive health providers” (e.g., Planned Parenthood) that have demonstrated successful outcomes in reducing unintended pregnancy, improving SRH and providing essential preventive services. The proposed rule aligned Title X requirements with established Medicaid/Medicare criteria for qualified providers based on professional and facility scope of practice and licensing.
      • The DHHS proposal clearly outlined the evidence indicating that restricting specific providers of Title X services has harmful effects on access to gender-sensitive SRH services (e.g., pregnancy diagnosis/counseling, contraceptive services, basic infertility services, STD screening, and preconception health care) and is linked with increased pregnancy rates that differ substantially from rates of unaffected populations. Such restrictions also impact the education and training of health professionals and front-line health workers who provide these services since focused SRH providers serve as clinical training sites for medical and nursing students.
      • While President Obama approved the rules on December 14, 2016, they were quickly overturned by a Trump executive order in 2017.
      • 4.
        2017 (June), Position statement (
        • Taylor D.
        • Olshansky E.F.
        • Woods N.F.
        • Johnson-Mallard V.
        • Safriet B.J.
        • Hagan T.
        Corrigendum to position statement: Political interference in sexual and reproductive health research and health professional education [Nursing Outlook 65/2 (2017) 242–245].
        ): Political interference in SRH research and health professional education (published in Nursing Outlook)
      • In response to state laws and political attacks that restrict ethical standards of care and impose politics and ideology on evidence-based clinical care, research and health professional education, the WHEP clarified the Academy's position and recommendations opposing political interference in SRH research, practice and health professional education. The Academy strongly opposes attempts by politicians and/or institutional administrators to regulate instruction and research related to SRH based on ideology rather than principles of academic freedom and practice or education standards related to SRH. Specifically, the Academy
        • Opposes political interference in evidence-based SRH care, education, and research;
        • Opposes the harassment and censorship of students and their faculty advisors who seek to understand and study the impact of legislation and policies on individual and community health outcomes related to restriction of reproductive choice or SRH services;
        • Supports university faculty and students' freedom to discuss issues of SRH and abortion in the classroom and provide instruction in clinical sites that provide a full range of SRH services;
        • Supports faculty and students' freedom to engage in scholarship and research activities related to SRH, including abortion; and
        • Supports faculty and students' freedom from restriction in pursuit of education and clinical training related to all evidence-based unintended pregnancy prevention and SRH care.
      • 5.
        2017, Position statement (October 26, 2017;
        • American Academy of Nursing
        Statement on the U.S. Department of Health and Human Services' Draft Strategic Plan for FY2018-2022 submitted to the DHHS Office of the Assistant Secretary for Planning and Evaluation, Strategic Planning Team.
        ): DHHS Draft Strategic Plan FY 2018–2022 (opposing regulatory restriction language in HHS Strategic Plan and Programs that prioritizes ideology over evidence)
      • In a letter [10/26/2018], the Academy expressed deep concern with the U.S. Department of Health and Human Services' (HHS) Draft Strategic Plan FY 2018–2022 particularly about several new additions and changes to the language and content that constitutes a substantial departure from past strategic plans by prioritizing ideology over evidence. The Academy's position addresses the Strategic Plan's implications for prevention, SRH, health equity, as well as the Plan's performance metrics. Specifically, the Academy recommended the following modifications:
        • Address disparities to ensure health equity: HHS must continue to undertake activities to identify and address health disparities with the ultimate goal of eliminating them.
        • Implement policies and guidelines for the provision of SRH care within an evidence based, broad framework of population-based public health, prevention and primary care regardless of delivery setting: The Academy supports the DHHS programs and initiatives that serve and protect all individuals across the lifespan.
          In this statement, the Academy recommends greater attention to unintended pregnancy prevention and management. The Academy's recommendations related to sexual and reproductive (SRH) healthcare illustrate a model for putting prevention into practice for all populations with an emphasis on adolescents, health equity and human rights.
          15In this statement, the Academy recommends greater attention to unintended pregnancy prevention and management. The Academy's recommendations related to sexual and reproductive (SRH) healthcare illustrate a model for putting prevention into practice for all populations with an emphasis on adolescents, health equity and human rights.
        • Eliminate discrimination in HHS programs and activities including refusals to provide reproductive health care or serve certain populations. Focus on promotion of the health of the public and the assurance that program beneficiaries have access to all essential services they need.
        • Support the National Prevention Strategy: Although prevention is mentioned in many of the Plan's strategies, there is no mention of the implementation and enforcement of the first-ever national prevention strategy to promote evidence-based interventions to improve health and wellness.
        • Establish data-driven, evidence-based measurable goals: Lack of measurable performance metrics limits government accountability and raises the question of the politicization of the Plan.
      • 6.
        2017, Position statements: DHHS regulations on (1) “Religious Exemptions and Accommodations for Coverage of Certain Preventive Services Under the Affordable Care Act” and (2) “Moral Exemptions and Accommodations for Coverage of Certain Preventive Services under the Affordable Care Act” (12/5/2017) (
        • American Academy of Nursing
        Statements on (1) Religious Exemptions and Accommodations for Coverage of Certain Preventive Services Under the Affordable Care Act, 82 Fed. Reg. 47,792 (Oct. 13, 2017) (to be codified at 26 C.F.R. pt. 54, 29 C.F.R. pt. 2590, 45 C.F.R. pt. 147), and (2) Moral Exemptions and Accommodations for Coverage of Certain Preventive Services Under the Affordable Care Act, 82 Fed. Reg. 47,838.
        )
      • On December 5, 2017, the Academy submitted comments opposing two Interim Final Rules (IFRs or the Rules) titled “Religious Exemptions and Accommodations for Coverage of Certain Preventive Services Under the Affordable Care Act,” and “Moral Exemptions and Accommodations for Coverage of Certain Preventive Services under the Affordable Care Act” published in the Federal Register on October 13, 2017, by the Department of the Treasury, the Department of Labor, and the Department of Health and Human Services (“the Departments”). These IFRs would allow virtually any employer and university to deprive women of contraceptive coverage, thereby harming women's health and well-being, including the largest group of healthcare providers, namely 4 million RNs and 2 million nursing aides and assistants—most of whom are women. Further, these IFRs ignore Congress' explicit intent that the ACA require coverage of contraception. The Academy strongly urged rescission of these rules.
      • As national nursing organizations deeply committed to ensuring that all people have access to affordable health care, including contraceptive coverage as intended by the ACA (

        Affordable Care Act. (n.d.). Pub. L. No. 111–148, 124 Stat. 119, amended by Pub. L. No. 111–152, 124 Stat. 1029 §.

        ), the ANA and the Academy have a particular interest in these IFRs because nurses know and understand the importance of women having seamless contraception coverage to protect their health and ability to work, both of which are essential for the economic security of families across America.
      • Both ANA (
        • Weston M.
        American Nurses Association Statement on Certain Preventive Services Under the Affordable Care Act CMS-9968-ANPRM; RIN 0938-AR42 Fed.Reg March 21, 2012.
        ) and the Academy comment on how these IFRs are at odds with science and research, have serious implications for women's health, and disregard the compelling interests furthered by the contraception coverage requirement and regulations included in the Affordable Care Act; as well as jeopardizing vital services to which some may object. The ANA and the Academy have urged HHS to remain religiously and morally neutral in its funding, policies, and activities to ensure that individuals do not feel proselytized by providers or receive a limited scope of services due to the moral or religious nature of an organization (
        • American Academy of Nursing
        Statement on DHHS Request for Information (RFI) on “Removing barriers to religious and faith-based organizations to participate in HHS programs and receive public funding” Fed Reg Volume 82, Issue 205.
        ).
      • 7.
        2018, Position statement (March 23, 2018): DHHS/Office for Civil Rights new division and regulations (opposes the expansion of conscience rules and health care refusals by healthcare providers) (
        • American Academy of Nursing
        Statement on DHHS Request for Information (RFI) on “Removing barriers to religious and faith-based organizations to participate in HHS programs and receive public funding” Fed Reg Volume 82, Issue 205.
        ).
      • The ANA and the Academy submitted comments (March 23, 2018) in response to the U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR) Proposed Rule: Protecting Statutory Conscience Rights in Health Care; Delegations of Authority, Conscience Notice of Proposed Rule Making (NPRM), RIN 0945-ZA03. ANA and the Academy urged HHS to rescind this proposed rule and instead, through the OCR, create a standard for health systems and individual practices to ensure prompt, easy access to critical health care services if an individual provider has a moral or ethical objection to certain health care services; such a standard should build on evidence-based and effective mechanisms to accommodate conscientious objections to services including abortion, sterilization, or assisted suicide as cited in the proposed rule. ANA and the Academy also stand firm that in no instance should a nurse—or any health care provider—refuse to treat a patient based on that patient's individual attributes; such treatment violates one of the central tenets of the professional Code of Ethics for Nurses. No patient should ever be deprived of necessary health care services or of compassionate health care; it is incumbent upon HHS to work to create accommodations to that end.
      • Discrimination in health care settings remains a grave and widespread problem for many vulnerable populations and contributes to a wide range of health disparities. Existing religion-based exemptions already create hardships for many individuals.
        Sonfield A (2018). In bad faith: How conservatives are weaponizing “religious liberty” to allow religious institutions to discriminate. Guttmacher Institute, vol 21. Available at https://www.guttmacher.org/gpr/2018/05/bad-faith-how-conservatives-are-weaponizing-religious-liberty-allow-institutions?org=801&lvl=100&ite=388&lea=330&ctr=0&par=1&trk=
        The mission of DHHS is to enhance the health and well-being of all Americans, by providing for effective health and human services and by fostering sound, sustained advances in the sciences underlying medicine, patient care, public health, and social services. This proposed rule fails to ensure that all people have equal access to comprehensive and nondiscriminatory services, and dangerously expands the ability of institutions and entities, including hospitals, pharmacies, doctors, nurses, even receptionists, to use their religious or moral beliefs to discriminate and deny patients health care. All patients deserve universal access to high quality care and we as health care providers must guard against any erosion of civil rights protections in health care that would lead to denied or delayed care.
        16Sonfield A (2018). In bad faith: How conservatives are weaponizing “religious liberty” to allow religious institutions to discriminate. Guttmacher Institute, vol 21. Available at https://www.guttmacher.org/gpr/2018/05/bad-faith-how-conservatives-are-weaponizing-religious-liberty-allow-institutions?org=801&lvl=100&ite=388&lea=330&ctr=0&par=1&trk=
      • 8.
        2018, Position Statement (April 18, 2018): DHHS/DOL/IRS rule expanding short-term health plan (oppose due to multiple discriminatory elements that impact all populations;
        • American Academy of Nursing
        Statement on Short-Term, Limited-Duration Insurance Proposed Rule (CMS-9924-Statement on Short-Term, Limited-Duration Insurance Proposed Rule (CMS-9924-P; RIN 0938-AT48)P; RIN 0938-AT48.
        ).
      • The Academy provided official comments on a proposed rule of the DHHS, Department of Labor (DOL), and Internal Revenue Service (IRS) that would expand short-term limited-duration insurance plans (April 18, 2018). The Academy urged that the rule not be finalized because many individuals who rely on comprehensive coverage—including women, older adults, and people with chronic conditions—would be left without affordable, comprehensive options. The proposed rule rescinds restrictions on short-term plans, allowing insurers to offer inadequate policies to millions of consumers. These plans exclude coverage for important health care services and pre-existing conditions; vary premium rates by gender, health status, and age; and put individuals and families at significant financial risk. In addition to being able to exclude coverage for pre-existing conditions, these plans are also allowed to categorically exclude certain benefits, such as routine maternity and newborn care, prescription drugs, mental health care, substance use services, and preventive services like birth control and tobacco cessation. Without these essential benefits consumers will lack adequate coverage.
      • 9.
        2018, Amicus Brief: State of California v 9th Circuit Court of US Court of Appeals case on ACA contraceptive benefit with ANA/Academy (lead amici) for health professional organizations (May 29, 2018;
        • American Academy of Nursing
        Statement on Short-Term, Limited-Duration Insurance Proposed Rule (CMS-9924-Statement on Short-Term, Limited-Duration Insurance Proposed Rule (CMS-9924-P; RIN 0938-AT48)P; RIN 0938-AT48.
        ,
        • Amicus Brief
        Brief of the Amici Curiae (American Nurses Association, American College of Obstetricians, American Academy of Nursing, American Academy of Pediatrics, Physicians for Reproductive Health, California Medical Association) in support of Appellees and Affirmance for State of California v Alex Azar. US 9th Circuit Court of Appeals Court Case Nos. 18–15144, 18–15166, and 18–15255.
        ).
      • Dozens of reproductive rights, civil liberties, gender equality, religious and health groups (including the ANA/Academy, Center for Reproductive Rights, Interfaith Alliance Foundation, U.S. Women's Chamber of Commerce, Planned Parenthood Federation of America and American Civil Liberties Union) filed amicus briefs supporting California, Delaware, Maryland, New York and Virginia in urging the Ninth Circuit to uphold a nationwide block on Trump administration rules permitting employers to claim religious or moral exemptions to the ACA's contraception mandate.
      • In the amicus brief for health professional groups led by the ANA/Academy, the nation's front-line health care providers support access to a full-range of FDA-approved prescription contraceptives as an essential part of health care for women and their families: “without affirmance of the district court's ruling, access to a critical component of women's preventive healthcare will be compromised for countless American women—and all without affording parties such as amici notice and an opportunity required by the Administrative Procedure Act to air the substantial public health issues raised here.”
      • 10.
        2018, Academy/ANA join coalition letter opposing Domestic “gag” rule and issue a press release on the latest in a continuing attack on Planned Parenthood and SRH services (May 23, 2018; ).
      • On May 23, 2018, the Academy issued a statement urging the Trump-Pence Administration to remove the “gag” rule on Title X—one of the nation's primary birth control and reproductive health care programs. The gag rule removes the guarantee that a Title X patient receives full and accurate information about their health care from their providers.
        See Guttmacher Institute statement Why this matters to patients/providers
        18See Guttmacher Institute statement Why this matters to patients/providers
      • As expected, following the administration's notice of proposed rulemaking (NPRM),
        Notice of proposed rulemaking posted to Federal Register, June 1, 2018.
        the Title X domestic gag rule was posted to the Federal Register on June 1, 2018 with comments due by July 31. This rule is designed to block access to health care under Title X, deny women information about their full reproductive health care options, and creates new rules designed to dismantle the Title X program.
        Details of the Trump/Pence gag rule goes far beyond the first domestic gag rule imposed by President Reagan by:
        • Imposing new rules that are designed to make it impossible for millions of patients to get birth control or preventive care from reproductive health care providers like Planned Parenthood.
        • Restricting doctors, nurses, hospitals, and community health centers who could no longer refer their patients for safe, legal abortion.
        • Removing the guarantee that people get full and accurate information about health care from their health care providers.
        • Creating a new policy stipulating that Title X projects do not have to provide every effective and acceptable method of birth control. This is a sharp departure from the way the program has been operating, where HHS put an emphasis on ensuring women have access to all 18 FDA-approved contraceptive methods.
        • Redefining what “low-income” means – expanding it to now include women whose employers no longer allow them to have their birth control covered by health insurance but does not provide for any additional resources or financing to help the program or providers meet this increased need.
        19Notice of proposed rulemaking posted to Federal Register, June 1, 2018.
        20Details of the Trump/Pence gag rule goes far beyond the first domestic gag rule imposed by President Reagan by:• Imposing new rules that are designed to make it impossible for millions of patients to get birth control or preventive care from reproductive health care providers like Planned Parenthood.• Restricting doctors, nurses, hospitals, and community health centers who could no longer refer their patients for safe, legal abortion.• Removing the guarantee that people get full and accurate information about health care from their health care providers.• Creating a new policy stipulating that Title X projects do not have to provide every effective and acceptable method of birth control. This is a sharp departure from the way the program has been operating, where HHS put an emphasis on ensuring women have access to all 18 FDA-approved contraceptive methods.• Redefining what “low-income” means – expanding it to now include women whose employers no longer allow them to have their birth control covered by health insurance but does not provide for any additional resources or financing to help the program or providers meet this increased need.
      • This is just another “Resist and Respond” action for nursing (in collaboration with our partners); as you read this policy brief, we will have submitted yet another position statement on protecting reproductive rights and essential health services.

      Summary/Conclusion

      The recent and ongoing political attacks on women's health, specifically focused on sexual and reproductive health (SRH) rights and access, continue to strike a strong alarm for the health of the public. Although some government officials at the federal and state levels are pursuing an aggressive agenda to broadly undermine essential health services, nursing is working with partners to resist and respond. In this paper, we summarize the commitment by the WHEP of the Academy, in collaboration with our partners, to take strong positions against discriminatory regulations and actions based on ideology over evidence. In the ten actions taken by nursing since 2016, we have established policy recommendations that 1) support women's access to safe, quality SRH care and reproductive health care providers; 2) protect Title X family planning funding and access to a full range of FDA-approved prescription contraceptives; 3) oppose restrictive and discriminatory regulations in the DHHS Strategic Plan and programs; 4) oppose changes in health insurance plans that allow inadequate policies and put women and families at significant financial risk; 5) oppose political interference in SRH research and health professional education; and 6) support legal actions to protect the patient-provider relationship, overturn abortion facility restrictions, and to block the administration rules permitting employers to claim religious or moral exemptions to the ACA's contraception mandate. We will continue to be vigilant in our resisting and responding and we are proud to be part of a professional group that has a commitment to maintaining a strong and powerful voice on behalf of our patients and evidence-based SRH policies and care.
      We wish to acknowledge the strong support of Academy staff and leadership: President Karen Cox, Jocelyn Cunic, Kim Czubaruk, Barry Eisenberg, Mary Dee Hacker, and Cheryl Sullivan.

      References

      1. Affordable Care Act. (n.d.). Pub. L. No. 111–148, 124 Stat. 119, amended by Pub. L. No. 111–152, 124 Stat. 1029 §.

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