One year into the pandemic, ensuring access to abortion is more critical than ever. Being able to decide whether and when to give birth has always been central to women’s economic security, and is of particular importance now: women—especially women of color—are bearing the brunt of the job loss caused by the COVID-19 pandemic. Furthermore, because of restrictions on insurance coverage of abortion, abortion services are already inaccessible for many low-income women, including many women insured by Medicaid. The Equal Access to Abortion Coverage in Health Insurance (EACH) Act, reintroduced in Congress March 25 by Representative Barbara Lee (D-CA) and Senator Tammy Duckworth (D-IL), would take a crucial step in making affordable abortion care a reality for these women.
The EACH Act would ensure coverage of abortion for individuals insured by plans impacted by the Hyde Amendment and other restrictions on abortion coverage. The act would ensure access for not only people insured through Medicaid and Medicare, but also other pregnant individuals reliant on the federal government for their health insurance or health care, including Peace Corps volunteers, military service members and veterans, people receiving care from the Indian Health Services, and individuals incarcerated in federal prisons.
The EACH Act would go even further by also prohibiting the government from restricting payments for abortion service in the private insurance market, including plans under the marketplaces established by the Affordable Care Act.
There has long been a need to ensure equitable and affordable access to abortion, and this gap in health care access has been underscored by a pandemic that has threatened the health and livelihood of so many people in need of abortion care. This commentary will discuss the necessity of the EACH Act during this public health emergency and beyond, how access has been alternately both restricted and (temporarily) expanded over the course of the pandemic, and how the increased focus on mutual aid relates to abortion patients—where communities have already had to step up because of longstanding funding restrictions.
Importance of the EACH Act
Removing restrictions on abortion funding would have a substantial impact on the lives of the people hit hardest by the economic and health effects of the COVID-19 pandemic. Women with low incomes have been disproportionately affected by lost or reduced income as a result of the pandemic. Since three-quarters of abortion patients in the United States are low-income, restrictions on payments for abortion services further exacerbates the financial insecurity these women have experienced, especially during the pandemic.
The Hyde Amendment in particular compounds the effects of systematic racial oppression and inequality that mark the U.S. economy and health care system. Women of color are more likely to be insured by Medicaid and are overrepresented among abortion patients—due to a legacy of complex and interrelated factors including reproductive coercion, discrimination within the health care system, and lack of access to health services.
Other existing abortion restrictions, such as two-visit requirements, already burden patients with additional costs for travel, child care, and time off of work. Financial concerns are among the most common reasons cited for seeking abortion, and coverage restrictions force women to pay out-of-pocket for procedures—which generally cost around $500.
Notably, parents have faced the unique effects of a pandemic without universal child care and sufficient government assistance. The simple fact is, a woman raising a child during the pandemic is frequently faced with having to leave her job: women have dropped out of the labor force at much higher numbers than men, often because of a lack of child care. Since 59 percent of abortion patients already have at least one child, barriers to affordable abortion access cannot be viewed in isolation from the burdens facing parenting individuals during the pandemic. Many women seeking abortion cite their ability to care for existing dependents as an important factor in their decision.
Changes in Abortion Access During the Pandemic
From the start of this public health emergency, anti-abortion politicians attempted to use the pandemic as an excuse to further restrict access to abortion in states such as Texas, Oklahoma, and Ohio by declaring abortion care as “non-essential”—despite the fact that it is vital and time-sensitive health care. Some governors made the disingenuous argument that abortion care would take away personal protective equipment (PPE) from medical workers treating COVID-19 patients to further their agenda to limit abortion access.
In their attempts to push abortion care further out of reach, though, these politicians threatened to add hurdles such as increased travel and clinic wait times. Delaying abortion further into pregnancy, however, only makes care more expensive and difficult to obtain; if delayed late enough, the procedure may be more invasive and require multiple visits—and more PPE. The service delivery problems introduced by these efforts to throttle abortion care may even push abortion out of reach for some women; the negative effects of denial of abortion are well documented, including increased likelihood of financial insecurity and greater risk of women staying in contact with abusive partners. Fortunately for pregnant people in such states, these pandemic-specific restrictions to access have been lifted or blocked by court orders. Still, existing restrictions, such as those that require multiple visits to clinics for counseling appointments, are still in effect, unnecessarily increasing patients’ potential exposure to COVID-19.
The pandemic has also sparked a renewed fight over the provision of medication abortion outside of the clinic setting. In 2017, medication abortion (a combination of two pills, misoprostol and mifepristone) made up 39 percent of all abortions in the United States. An overwhelming body of evidence has demonstrated that medication abortion can be administered safely and effectively outside of the clinic setting.
Last year, the ACLU filed a lawsuit on behalf of a number of medical organizations, including the American College of Obstetricians and Gynecologists, to temporarily suspend restrictions that force providers to dispense medication abortion in person. The United States District Court of Maryland ruled in favor, permitting providers to dispense mifepristone via mail, allowing patients to avoid unnecessary travel during the pandemic—reducing potential exposure to COVID-19 and the additional burdens associated with travel to an abortion clinic. In January of this year, however, the Supreme Court overturned this ruling and once again instituted restrictions on medication abortion provision. Notably, the FDA itself has the opportunity to suspend the in-person provision requirements, a move that would be supported by research and allow pregnant people to avoid unnecessary pandemic travel.
Mutual Aid and Abortion Funds
The COVID-19 pandemic has done more than throw existing inequities into sharp relief—it has also drawn attention to the ways in which communities come together to meet needs that are not being met by their government. The lack of adequate institutional support throughout the past year has thrown a particular spotlight on mutual aid. Mutual aid networks have long been used by underserved groups, including people living under-resourced neighborhoods and other marginalized communities. They operate by uniting communities and building solidarity through mutual support, which can look different depending on the organization.
In large part because of harms like those the EACH Act seeks to undo, communities have established organizations—called abortion funds—to help pregnant people seeking abortion pay for their procedures. Abortion funds (many of which are members of a national network) are a form of mutual aid that attempt to make up for the shortfall in health care coverage created by the network of state and federal funding restrictions on abortion in the United States. Often entirely volunteer-run, abortion funds provide assistance to patients in the form of funding for appointments and related costs, such as transportation and hotel stays for patients who need to travel for care. These abortion funds do critical work, particularly in states where state Medicaid and private health plans are limited in their coverage of abortion.
Although these abortion funds play an incredibly important role in the lives of patients who otherwise could not afford care, they cannot meet the need of every patient seeking abortion—nor should they need to. These organizations only exist because of laws that limit payment for abortion by placing it in a separate category from all other health care. Abortion is health care: the EACH Act would relieve this pressure on cash-strapped abortion funds by allowing more patients to use their health insurance to pay for their abortion care as they would for other health services.
The COVID-19 pandemic has highlighted the lack of support available to pregnant and parenting individuals—and people of color in particular. The EACH Act is critical in making abortion access a reality rather than a right in name only. It is only one piece, however, in a larger effort to ensure reproductive autonomy for all people who can become pregnant. Legislation is needed to ensure not only that abortion care is accessible, but also that those who wish to have children can do so safely and with adequate support.
The recently reintroduced Momnibus is crucial to improving maternal health, especially for Black women, who face unacceptably high rates of mortality and morbidity regardless of education level and income. The American Rescue Plan took important first steps to mitigate the inequity exposed by the pandemic, including an option for states to extend postpartum Medicaid coverage to twelve months after birth. This is the floor and not the ceiling, however, and should be viewed as a starting point for achieving the pillars of reproductive justice—the right to bodily autonomy, the ability to decide whether to have children or not have children, and the ability to raise children in a safe and healthy environment. The EACH Act is necessary progress toward this goal, and is more vital than ever during the COVID-19 pandemic.