Policy recommendations for the Biden-Harris Administration to enact in its first 100 days.
On October 20, 2020 the Orange County Board of Commissioners unanimously adopted Resolution 65, introduced by Chair Penny Rich. More than 23% of North Carolinians of reproductive age are impacted by coverage bans in the state. Currently, NC Medicaid and insurance plans sold on the Exchange are prohibited from covering abortion with limited exceptions — that along with a host of other restrictions in state and federal law effectively ban the use of insurance to cover the cost of abortion.
Recognizing that no one should be denied access to abortion just because they are struggling financially, the Orange County Board of Commissioners called for the repeal of the Hyde Amendment and urged the governor to support measures that promote access to the full range of reproductive health care for North Carolinians.
How does the Hyde Amendment restrict insurance coverage of abortion care?
Issued September 2020
- The Hyde Amendment is a policy that bans the use of federal funds to pay for abortion care except when a pregnancy endangers the life of the pregnant person, or when it results from rape or incest.1 Since 1976 Congress has inserted the Hyde language in the annual appropriations. 1
- This restriction on federal funding has been expanded to a number of federally funded health insurance programs, including Medicaid, Medicare, the Children’s Health Insurance Program, the Federal Employee’s Health Benefits Program, and the Indian Health. 1
- US states may elect to use state-based funding to pay for the abortion care that the Hyde Amendment prohibits for individuals enrolled in Medicaid; however, as of April 2020 only 16 states do.2
Who is affected by coverage bans on abortion?
- Abortion is a common and safe procedure with very few risks.3 In 2017, 18.4% of all pregnancies in the United States ended in abortion.4 In the same year, the US abortion rate was 13.5 abortions per 1,000 women of reproductive age.4
- In the United States, most women who have an abortion are struggling financially and already face significant barriers to health care. A majority pay out-of-pocket for their care.5
- Among US women aged 15-49, 19% were covered by Medicaid and one percent by Medicare in 2018. Both programs ban abortion coverage and Medicare recipients cannot have their abortion care covered by state funds because it is fully funded by federal dollars.6 Medicaid coverage is disproportionately higher among women living below the Federal Poverty Level (FPL), women of color, single parents, and women with lower educational attainment.7 In 2018, 14% of nonelderly adult women in the United States had incomes at or below the FPL.8
- Sixty-seven percent of all women enrolled in Medicaid were of reproductive age.7 Over half of women of reproductive age who were enrolled in Medicaid in 2018 lived in states that apply the Hyde restrictions to their state funds. 1
- Data on the number of women of reproductive age who rely solely on the Indian Health Service for their sexual and reproductive health care are not available. However, in 2018, there were 700,940 American Indian and Alaska Native women 15-50 years of age in the United States.9
- Most women who obtain abortion care are parents; 29% report that caring for their existing family is a primary reason for obtaining an abortion.10
How do abortion coverage bans impact pregnant people?
- Pregnant people may be unable to find a local abortion provider. The number of abortion-providing facilities in the United States decreased five percent between 2014 and 2017.4 Thirty-eight percent of reproductive-age women in the United States live in a county that lacks an abortion provider.4 A recent analysis of disparities in access to abortion care found that although the median distance to an abortion provider in the United States is 10.79 miles, 20% of US residents may have to travel up to 42.54 miles or farther to reach a provider.11
- Pregnant people may struggle to afford abortion. Pregnant people residing in 33 states and the District of Columbia are unable to use their Medicaid health insurance to cover the cost of abortion care unless their pregnancy results from rape or incest, or is life-endangering.2 Such a time-sensitive and unanticipated out-of-pocket expense can mean forgoing food, rent, or household bills for pregnant people whose insurance will not cover the cost of an abortion.12,13 Over half of the women in one study of abortion patients said such costs amounted to more than one-third of their personal monthly income.13 Individuals seeking abortion after 20 weeks in a pregnancy faced costs nearing two-thirds of their income per month.13
- Pregnant people may be forced to delay care. Even for those who are able to afford care, a lack of available or accessible care may result in additional delays. Many pregnant people are not able to obtain abortion care as early as they would like and attribute delays to the time it took to discover their pregnancy, arrange care, and to decide whether or not to continue the pregnancy.14
What are the impacts of being denied a wanted abortion?
- Women who do not obtain a wanted abortion are more likely to subsequently live in poverty.15Women unable to obtain a wanted abortion may be more likely to be unemployed and less likely to have the financial resources to afford household essentials such as food and the cost of housing.15 The negative financial impacts of abortion denial have been found to persist for up to several years.16
- Pregnant people can face risk of violence. Carrying an unwanted pregnancy to term can slow a woman’s separation from the man involved in the pregnancy.18 For women experiencing intimate partner violence, this can mean they and their children are at continued risk of violence from that partner.19
- Salganicoff A, Sobel L, Ramaswamy The Hyde Amendment and coverage for abortion services: Kaiser Family Foundation; 2020.
- Guttmacher State funding of abortion under Medicaid. 2020; https://www.guttmacher.org/state-
policy/explore/state-funding-abortion-under-medicaid. Accessed April 29, 2020.
- National Academies of Sciences Engineering and The safety and quality of abortion care in the United States: National Academies Press;2018.
- Jones R, Witwer E, Jerman Abortion incidence and service availability in the United States, 2017. New York: Guttmacher Institute;2019.
- Jerman J, Jones R, Onda Characteristics of US abortion patients in 2014 and changes since 2008. New York: Guttmacher Institute;2016.
- Kaiser Family Foundation. Health insurance coverage of women ages 15-49, 2018. https://wkff.org/other/state-indicator/health-insurance-coverage-of-women-ages-15-49/? currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D. Accessed April 30, 2020.
- Kaiser Family Medicaid’s role for women. 2019; https://www.kff.org/womens-health-policy/ fact-sheet/medicaids-role-for-women/.
- Kaiser Family Nonelderly adult poverty rate by gender estimates based on the Census Bureau’s American Community Survey, 2009-2018.
- United States Census Bureau. American Community Survey 1-Year Estimates Selected Population Profiles: American Indian and Alaska Native.
- Biggs M, Gould H, Foster Understanding why women seek abortions in the US. BMC women’s health. 2013;13(1):29.
- Bearak J, Burke K, Jones Disparities and change over time in distance women would need to travel to have an abortion in the USA: a spatial analysis. The Lancet Public Health. 2017;2(11):e493-500.
- All* Above All and Ibis Reproductive Health. Research brief: The impact of out-of-pocket costs on abortion care access. 2016; https://wibisreproductivehealth.org/publications/research-brief-impact- out-pocket-costs-abortion-care-access.
- Roberts S, Gould H, Kimport K, Weitz T, Foster Out-of-pocket costs and insurance coverage for abortion in the United States. Women’s Health Issues. 2014;24(2):e211-218.
- Finer L, Frohwirth L, Dauphinee L, Singh S, Moore Timing of steps and reasons for delays in obtaining abortions in the United States. Contraception. 2006;74(4):334-344.
- Foster DG, Biggs MA, Ralph L, Gerdts C, Roberts S, Glymour Socioeconomic outcomes of women who receive and women who are denied wanted abortions in the United States. American journal of public health. Mar 2018;108(3):407-413.
- Miller S, Wherry L, Foster The economic consequences of being denied an abortion: National Bureau of Economic Research; January 2020.
- Foster DG, Raifman SE, Gipson JD, Rocca CH, Biggs Effects of carrying an unwanted pregnancy to term on women’s existing children. J Pediatr. Feb 2019;205:183-189 e181.
- Mauldon J, Foster D, Roberts Effect of abortion vs. carrying to term on a woman’s relationship with the man involved in the pregnancy. Perspectives on Sexual and Reproductive Health. 2015;47(1):11-18.
- Roberts S, Biggs M, Chibber K, Gould H, Rocca C, Foster Risk of violence from the man involved in the pregnancy after receiving or being denied an abortion. BMC Medicine. 2014(12):144.
THE EQUAL ACCESS TO ABORTION COVERAGE
IN HEALTH INSURANCE (EACH Woman) ACT:
Groundbreaking Legislation for Reproductive Justice
The EACH Woman Act is bold legislation to reverse the Hyde Amendment and related abortion funding restrictions. Initially introduced in the House in July 2015, this legislation (HR 1692 and S 758) was reintroduced on March 12, 2019, by Representatives Barbara Lee (D-CA), Jan Schakowsky (D-IL), and Diana DeGette (D-CO). The legislation was also introduced in the Senate for the first time ever by Senators Tammy Duckworth (D-IL), Kamala Harris (D-CA), Mazie Hirono (D-HI), and Patty Murray (D-WA).
The EACH Woman Act makes a meaningful policy change for women and their families, creating two important standards for reproductive health:
First, it sets up the federal government as a standard-bearer, ensuring that every woman who receives care or insurance through the federal government will have coverage for abortion services. The EACH Woman Act restores abortion coverage to those:
- enrolled in a government health insurance plan (i.e., Medicaid, Medicare), including those who live in the District of Columbia;
- enrolled in a government-managed health insurance program (i.e., FEHBP, TRICARE) due to an employment relationship; or
- receiving health care from a government provider or program (i.e., Indian Health Services, the Federal Bureau of Prisons, the Veterans Administration).
Second, it prohibits political interference with decisions by private health insurance companies to offer coverage for abortion care. Federal, state and local legislators will not be able to interfere with the private insurance market, including the insurance marketplaces established by the Affordable Care Act, to prevent insurance companies from providing abortion coverage.
Since the Hyde Amendment was passed in 1976, anti-choice federal politicians have added abortion coverage and funding bans to programs affecting:
- Medicaid, Medicare and Children’s Health Insurance Program enrollees;
- Federal employees and their dependents;
- Peace Corps volunteers;
- Native Americans;
- Women in federal prisons and detention centers, including those detained for immigration purposes;
- Military servicewomen, veterans and their dependents; and
- Low-income women in the District of Columbia.
Currently, 35 states and the District of Columbia do not cover abortion within their state Medicaid programs, except for limited exceptions. Additionally, anti-abortion politicians in 26 states have enacted restrictions that interfere with abortion as a covered health service in health plans offered by health insurance exchanges, 22 states restrict abortion coverage in insurance plans available for public employees, and 11 states have laws restricting insurance coverage of abortion in all private insurance plans written in the state.
THE IMPACT OF ABORTION COVERAGE BANS
When policymakers deny women insurance coverage for abortion, they either are forced to carry the pregnancy to term or pay for care out of their own pockets. Consequently, cutting off access to or placing strict limitations on abortion can have profoundly harmful effects on public health, particularly for those who already face significant barriers to receiving high-quality care, such as low-income women, immigrant women, young women, and women of color.
- Fifty-eight (58%) of reproductive-age women enrolled in Medicaid live in states that withhold insurance coverage for abortion except in limited circumstances.
- Fifty-one percent (51%) of reproductive-age women enrolled in Medicaid and subject to abortion coverage restrictions are women of color.
- Studies show that when policymakers place severe restrictions on Medicaid coverage of abortion, it forces one in four poor women seeking an abortion to carry an unwanted pregnancy to term.
- When a woman is living paycheck to paycheck, denying coverage for an abortion can push her deeper into poverty. Indeed, studies show that a woman who seeks an abortion but is denied is more likely to fall into poverty than one who is able to get an abortion.
- Women with lower socioeconomic status – specifically those who are least able to afford out-of-pocket medical expenses – already experience disproportionately high rates of adverse health conditions. Denying access to abortion care only exacerbates existing health disparities.
- Due to a number of underlying reasons connected to inequity, women of color are more likely to qualify for government insurance programs that restrict abortion coverage and are more likely to experience higher rates of unintended pregnancy.
- In summary, when it comes to the most important decisions in life, such as whether to become a parent, it is vital that a woman is able to consider all the options available to her, however little money she makes or however she is insured. The EACH Woman Act creates a more even playing field, so that a lack of health coverage will not stand in the way of a woman making the best decision for her and her family.
State funding of abortion under Medicaid. Guttmacher Institute. December 2018. https://www.guttmacher.org/state-policy/explore/state-funding-abortion-under-medicaid.
 Restricting Insurance Coverage of Abortion. Guttmacher Institute. December 2018. Available at https://www.guttmacher.org/state-policy/explore/restricting-insurance-coverage-abortion.
 Donovan M. In Real Life: Federal Restrictions on Abortion Coverage and the Women They Impact. Guttmacher Institute. January 2017. Available at https://www.guttmacher.org/gpr/2017/01/real-life-federal-restrictions-abortion-coverage-and-women-they-impact
 Henshaw SK et al., Restrictions on Medicaid Funding for Abortions: A Literature Review, Guttmacher Institute, 2009. Available at http://www.guttmacher.org/pubs/MedicaidLitReview.pdf
 Foster DG et al, Socioeconomic consequences of abortion compared to unwanted birth, abstract presented at the American Public Health Association annual meeting, San Francisco, Oct. 27–31, 2012. Available at https://apha.confex.com/apha/140am/webprogram/Paper263858.html
 Arons, J et al. How the Hyde Amendment Discriminates Against Poor Women and Women of Color. Center for American Progress, May 2013. Available at http://www.americanprogress.org/issues/women/news/2013/05/10/62875/how-the-hyde-amendment-discriminates-against-poor-women-and-women-of-color/
The Hyde Amendment is language in the yearly Labor, Health and Human Services, Education and Related Agencies (often shortened to Labor-H or LHHS) appropriations legislation that bars programs in these agencies from covering abortion. This restriction primarily withholds abortion coverage from those qualified and enrolled in the Medicaid health insurance program for low-income people, except in the limited cases of rape, incest, and life endangerment.
The Hyde Amendment is designed to deprive poor and minority women of the constitutional right to choose abortion.”
-Supreme Court Justice Thurgood Marshall (1980)
THE HYDE AMENDMENT PAVED THE WAY FOR OTHER FEDERAL ABORTION COVERAGE RESTRICTIONS
Since the Hyde Amendment passed in 1976, anti-choice politicians have added abortion coverage and funding bans to appropriations language that restricts: Medicaid, Medicare and Children’s Health Insurance Program enrollees; Federal employees and their dependents; Peace Corps volunteers; Native Americans; women in federal prisons and detention centers, including those detained for immigration purposes; women who receive health care from community health centers; survivors of human trafficking; and low-income women in the District of Columbia.
REAL WORLD IMPACT OF THE HYDE AMENDMENT
- Medicaid coverage can mean the difference between getting abortion care or being denied. Studies show that when policymakers place severe restrictions on Medicaid coverage of abortion, it forces one in four poor women seeking an abortion to carry an unwanted pregnancy to term.1
- When a woman is living paycheck to paycheck, denying coverage for an abortion can push her deeper into poverty. Indeed, studies show that a woman who seeks an abortion but is denied is more likely to fall into poverty than one who is able to get an abortion.2
- According to the most recent data, 58% of women of reproductive age enrolled in Medicaid or CHIP live in states that ban Medicaid coverage for abortion except in limited circumstances. 51% of these enrollees are women of color.3
- The Hyde Amendment creates an often insurmountable barrier to abortion for women across the country already struggling to get affordable health care, and disproportionately affects those who are low-income, people of color, young, immigrants, or live in rural communities.
The Hyde Amendment is not permanent law. Congress has the opportunity to lift the Hyde Amendment each year. Tell them to take action now.
1 Henshaw SK et al., Restrictions on Medicaid Funding for Abortions: A Literature Review, Guttmacher Institute, 2009. Available at http://bit.ly/1IK5XcF.
2 Foster DG, Roberts SCM and Mauldon J, Socioeconomic consequences of abortion compared to unwanted birth, abstract presented at the annual meeting of the American Public Health
Association, San Francisco, Oct. 27–31, 2012. Available at http://bit.ly/1PvNd4w.
3 Donovan, M., In Real life: Federal Restrictions on Abortion Coverage and the Women They Impact, Guttmacher Institute. Guttmacher Policy Review. Vol. 20. 2017. Available. At http://bit.ly/2j6Ec3W.
A resolution supporting the ROE Act and full access to abortion.