The repeal of Obamacare, once seen as an imminent threat, has become a dark cloud looming overhead as Republicans remain indecisive about its replacement. But even with no official plan, there’s little doubt that the future of women’s health is at risk. Tom Price’s confirmation as secretary of the U.S. Department of Health and Human Services (HHS) and President Donald Trump’s decision to reinstate the “global gag rule” restricting abortion information overseas just three days after his inauguration are likely just two harbingers of future actions.
While media coverage regarding the fate of women’s health without the Affordable Care Act (ACA) has fixated on the ability to receive and pay for appropriate care—particularly abortion and birth control access—there’s been little to no discussion about the consequences of a repeal on the larger ACA-authorized infrastructures that were created to serve women. But they too are at risk.
Beginning with the establishment of the Public Health Service Task Force on Women’s Health in 1983, there’s been a continuously concerted effort to create a network to magnify the voices of women throughout federal government agencies on national, regional, and local levels. In 1991, the Office on Women’s Health (OWH) was created administratively within HHS and was followed by the formation of separate Offices of Women’s Health within the Agency for Healthcare Research and Quality, the Centers for Disease Control and Prevention, the Food and Drug Administration (FDA), the Health Resources and Services Administration, the National Institutes of Health (NIH), and the Substance Abuse and Mental Health Services Administration (SAMHSA).
“These offices were set up in the first place to prioritize women’s health issues within HHS agencies and offices, and to provide a greater access to women’s health information for women and health professionals related to disease prevention, health promotion, service delivery, and research,” said Dr. Monica P. Mallampalli, vice president of scientific affairs at the Washington, D.C.-based Society for Women’s Health Research. Their creation acknowledges that men and women’s health issues and needs are not one and the same, and that women’s health is not solely tied to their reproductive systems—a fact often ignored or forgotten.
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While the seven offices existed pre-2010, only the offices within NIH and SAMHSA were federally authorized, explains Mallampalli. The other five were codified with the passing of the ACA. Section 3509, titled “Improving Women’s Health,” granted them “new authority, agency location, and protection from termination or reorganization without the direct approval of Congress” and outlined the responsibilities of all seven offices, specifying their obligation to serve women. The ACA also dictated that the head of each OWH reports directly to the leader of their respective agencies.
But even before the OWHs got the stamp of approval, the offices and task forces were making a sizable impact on women. Thanks to the formation of the first women-centric task force within the HHS in 1983, women are now allowed to participate in Phase 1 and early Phase 2 clinical trials. The task force reversed the FDA’s 1977 General Considerations for the Clinical Evaluation of Drugs guidelines, which barred all “premenopausal female[s] capable of becoming pregnant” from inclusion as a means to protect future fetuses, ultimately setting back medical research by ignoring the possibility that biological sex can have an influence on the effectiveness of drugs.
Since the 1980s, these offices have worked to address violence against women at home and on college campuses; created extensive and accessible gender-responsive resources on HIV and AIDS prevention programs; and funded the Healthy Weight in Lesbian and Bisexual Women study to increase exercise, improve diet, reduce alcohol intake, and promote healthy weight loss within lesbian and bisexual communities; among countless other wide-reaching initiatives.
Even though the OWHs aren’t primarily responsible for Title X-funded family planning programs—those are under the purview of the Office of Population Affairs within the HHS—they still play a significant role in educating the public and medical community about sexual violence, reproductive health, and motherhood through training programs, events, publications, ad campaigns, and initiatives on a national and regional level as well as through conducting surveys. If funding were cut, that would restrict the proliferation of unbiased and accurate information for both health and social services providers and U.S. patients in general.
Even if dismantling the ACA takes years, Congress can still reduce funding for any of the women’s health offices by limiting resources or reallocating budget money to programs that don’t offend the conservative values of Price and congressional Republicans. So rather than prioritizing HIV prevention programs or providing help for victims of sexual assault, the offices could be required to focus their efforts on less politicized conditions such as chronic fatigue syndrome, heart disease, or osteoporosis.
Not that OWHs wouldn’t try to push back. In 2005, the FDA clashed with the medical community and its OWH over Plan B, arguing against the proven safety of nonprescription emergency contraception and prolonging the process of getting the drug approved for over-the-counter sales. Dr. Susan F. Wood, then-director of the FDA Office of Women’s Health, resigned in protest against the agency’s refusal to vote with science. It wasn’t until August 2006 that the FDA settled on a compromise that allowed women 18 and older to purchase Plan B without a prescription. Only in March 2007 did OWH receive assurance from the FDA that its funding would not be cut.
Of course, OWH budgets could be threatened again. “I think this a risk that all the domestic agencies are going to face with the president’s budget,” said Wood, now associate professor of health policy at George Washington University and director of the Jacobs Institute of Women’s Health Services. “Any agency could be substantially reduced in their annual budgeting and that would of course have to be done by Congress. But we’ll see the blueprint for it in a couple of months. I imagine the Office of Women’s Health will not survive very well, but until we see it we don’t know.”
What’s more, because the OWHs support and coordinate actions among agencies and other parts of the federal government, “nobody can pick up the slack,” explains Dr. Wood. “The whole function is to make the government work better and to work on behalf of women’s health. If we cut these offices back, this is saying that the government doesn’t make this a priority.”
Aside from budgetary concerns, there are two other major roadblocks for the OWHs. The first is that there’s no director for the Health and Human Services OWH, which communicates with that department’s secretary. Since Trump’s hiring freeze on all federal civilian employees took effect on January 23, OWH hasn’t been able to fill the position. While this gap doesn’t prevent the office from functioning, it does mean that there’s no leader to advocate on its behalf and for the priorities of U.S. women.
There’s also the potential for website scrubbing and social media censoring similar to that faced by the Environmental Protection Agency and the National Park Service. The OWHs provide health content at a sixth- to eighth-grade reading level through two websites, social media sites such Facebook and Twitter, publicly available reports, and a women’s health helpline as well as the only national breastfeeding helpline (both of which have Spanish-speaking options). As of now, the @womenshealth Twitter account has 979,000 followers, and its sister site @girlshealth has 588,000. While there do not appear to be any drastic changes to their content strategy yet, it’s a legitimate fear.
Unfortunately, all we can do at this point is “wait to see what they do,” says Dr. Wood. Then “we object. Will that have an impact? I don’t think so. But we have to keep objecting. We have to keep saying no. But will that work? I don’t know, but I’m not optimistic …. Let’s do what we can, whether it’s in advocating and getting people who are supporters of this administration to object or whether it’s waiting for the next election cycle.”