September 30 marks the forty-third anniversary of the Hyde Amendment’s initial passage. A measure renewed annually through the Labor, Health and Human Services, Education, and Related Agencies (LHHS) federal appropriations process, it has stood for over four decades as one of the nation’s worst obstacles to accessing abortion care. In particular, it prohibits the nearly one in seven women of reproductive age who are enrolled in Medicaid from using their insurance to access abortion care. But its restrictions extend beyond even that. As policymakers and advocates bring ever more attention to bear on health care reform and how to go about it, they must not leave out, once again, this predatory provision that has now affected people for two generations.
A Pervasive, Pernicious Impact
As mentioned, the Hyde Amendment outlaws the use of federal Medicaid resources to access abortion care. But Medicaid enrollees are not the only group subjected to prohibitions on abortion coverage due to their public source of health insurance. Incarcerated women, federal employees, residents of the District of Columbia, veterans, Peace Corps volunteers, people on Medicare, Children’s Health Insurance Program (CHIP) enrollees, and a host of others are also prohibited from using their public health insurance to attain abortion care. People insured by these health programs must use their own, private funds to pay for an abortion. However, fifteen states have opted to use state Medicaid funds to cover abortion care without exception in spite of the longstanding restrictions on federal funding. In all, approximately 7.4 million women aged 15 to 49 who are enrolled in the Medicaid program and may want or need abortion care are denied insurance coverage of abortion. Narrow exceptions for coverage are permitted only in the cases of rape, incest, and endangerment of the life of the pregnant person.
The Affordable Care Act (ACA) helped to greatly expand affordable access to essential women’s health care services. Unfortuntately, abortion was not included in the suite of services offered as essential health benefits (EHBs) through the law. The ACA applies the Hyde Amendment to marketplace plans. Therefore, federal subsidies used for premiums or cost-sharing may be used to pay for abortions only in the aforementioned exceptions. Private and employer-based health insurance plans offered under the ACA maketplaces are also subject to state-imposed abortion restrictions. According to the Kaiser Family Foundation, twenty-six states have enacted laws that prohibit all marketplace plans from covering abortion. It is estimated that these laws keep insurance coverage of abortion out of reach for 2.9 million women. Thirty-four states do not offer any marketplace plans that include abortion coverage. For people with marketplace plans that do offer abortion coverage, they must go through the onerous process of making two separate premium payments to ensure the segregation of funds. Abortion coverage through these plans may not be paid for with federal dollars.
Today’s Policy Responses to Abortion Coverage
The issue of abortion coverage has been front and center in recent discussions around health care reform. 2020 presidential candidates Joe Biden, Bernie Sanders, Elizabeth Warren, Beto O’Rourke, Cory Booker, Pete Buttigeig, Julian Castro, and Kamala Harris have all called for repealing the Hyde Amendment and finally treating abortion as health care. Additionally, key federal health care reform legislation introduced in both the House of Representatives and the Senate would allow insurance coverage of abortion. These bills include Medicare for America, Medicare For All, and the Consumer Health Options and Insurance Competition Enhancement (CHOICE) Act. The Equal Access to Aborton Coverage in Health Insurance (EACH Woman) Act is proactive legislation developed by reproductive rights and justice advocates alongside key pro-choice congressional leaders. The bill would ensure affordable abortion coverage for all people, regardless of the source of health insurance. And in a bold move, Representative Ayanna Pressley tried, albeit unsuccessfully, to advance an amendment to strike the Hyde Amendment from the fiscal year 2020 Labor, Health, and Human Services, Education, and Related Agencies appropriations bill this summer.
These are promising developments; however, it remains to be seen whether or not any of these bills or plans will stick, particularly as we head into the 2020 congressional election season, as well as the U.S. presidential election. And opposing political forces have been equally as active, if not more so, in their efforts.
In particular, while progressive politicians have worked to protect abortion access and expand insurance coverage of abortion, President Trump has used a whole battery of executive prerogatives to deny people access to abortion. He has appointed anti-choice judges to the U.S. Supreme Court and lower courts, expanded abortion-related restrictions on the Title X Family Planning program, proposed regulations that would make it harder for people with private insurance to access abortion, and issued regulations that permit some health care providers to discriminate on the basis of religious or moral objection against people in need of contraception and abortion care. Anti-choice members of Congress have worked in lockstep with the president by introducing countless pieces of legislation aimed at banning abortion care and coverage and attempting to withhold Medicaid enrollees from using their insurance to access health care at Planned Parenthood facilities, to name but some of many such efforts.
The Cost Is Only Growing
The Hyde Amendment impacts everyone with the ability to reproduce, but it has an especially profound impact on low-income women, young women, and women of color. These demographic groups are more likely to be enrolled in Medicaid and other public health insurance programs. They are disproportionately affected by individual and community-level factors that can compound the obstacles to their ability to lead healthy reproductive lives. These factors can include lack of access to a trusted provider within a given community, lack of access to reliable and safe housing, grappling with systemic barriers like discrimination in the health care system, or being economically disadvantaged. Taken together, these circumstances also make low-income women, young women, and women of color most likely to experience unintended pregnancy.
Not only is accessing abortion essential in the continuum of reproductive health care: so is accessing contraception, treatment of sexually transmitted infections, screening for reproductive cancers, and access quality maternity care. And when abortion coverage is lacking, the groups of people mentioned above are least likely to have the financial resources to pay for an abortion out of pocket. The average cost of an abortion in the first trimester is roughly $500—already a steep fee for so many people in this country. And this cost can greatly increase if a person has to wait longer to attain an abortion, due to barriers related to access and/or efforts to attain the needed funding. An unexpected cost of this magnitude can set someone and their family back considerably.
Nikki had worked to save the funding she needed for the abortion, yet due to the cost of gas, she arrived $15 short of what she needed.
In a story shared with the National Network of Abortion Funds, a national reproductive justice organization led by women of color working to remove financial and logistical barriers to abortion access, an advocate recounts the experience of a woman without abortion coverage who had to drive for a total of four hours to attain an abortion. Referred to as Nikki in the clip, the advocate shares that due to a twenty-four-hour waiting period in her state, Nikki had to make two two-hour trips by car, miss two days of work, and pay for two days of child care. Nikki had worked to save the funding she needed for the abortion, yet due to the cost of gas, she arrived $15 short of what she needed. Nikki’s story is not uncommon, particularly for mothers in need of abortion care. Roughly 59 percent of women who have abortions are already mothers.
It’s Time to Lay Hyde to Rest
No one should ever have to go through desperate measures in order to attain the health care they need. But with the Hyde Amendment as an impediment, the likelihood of such crises will remain high. One in four women will have an abortion by the age of 45; and every one of them should have insurance coverage of abortion, regardless of the source. Policies like the Hyde Amendment promote a system of inequality in health care, where coverage of abortion and access to this vital health care service depends on the source of health insurance and whether or not a person has the ability to pay for it out of pocket. This means that people with significant financial means will always have access to the abortions they need, while those without financial means will continue to face barriers to care.
At this pivotal moment in which we find ourselves, mulling over health care reform and the direction in which to go next, policymakers and health care advocates have been presented with the opportunity to get it right on insurance coverage of abortion. And getting it right means treating abortion as health care within insurance and the health care system, and covering this vital care once and for all.