October 1, 2012 — Summary of "Pre-existing Conditions: How Restrictions on Abortion Coverage and Marginalization of Care Paved the Way for Discriminatory Treatment of Abortion in Health Reform and Beyond," Allina et al., Center for Women Policy Studies, August 2012.
Although the passage of the Affordable Care Act (PL 111-148) was a "historic achievement" for women's health in many ways, it "significantly expanded the pool of women who are not able to obtain coverage" for abortion services, write Amy Allina of the National Women's Health Network, Jessica Arons of the Center for American Progress and Elizabeth Barajas-Román of the National Latina Institute for Reproductive Health.
Although obtaining health services that are not covered by insurance "will always be hardest for women without financial resources," the enshrinement of new restrictions on abortion coverage in the ACA expanded these barriers to "women across the economic spectrum," the authors write.
The paper describes how two tactics -- restrictions on abortion coverage and marginalization of abortion services -- laid the foundation for the ACA's restrictions on abortion. It also describes the state and federal response to passage of the law and outlines recommendations for advocates going forward.
Paving the Way for the ACA's Abortion Restrictions
Allina, Arons and Barajas-Román argue that abortion coverage restrictions in the ACA are the culmination of two tactics: "the slow accretion of legal restrictions banning coverage of abortion care for women who rely on government health care programs and the gradually increasing marginalization of abortion services within the health care field."
The ACA "enshrined in statute the logical consequence of the two tactics that had been steadily eroding women's reproductive rights for 35 years," they write. They review the history of the Hyde Amendment -- which bars abortion coverage through Medicaid except in cases of rape, incest or threats to the woman's life -- and related provisions that continue to fuel a huge unmet need for abortion coverage among low-income women.
The authors note that while the ACA's Medicaid expansion is a "boon" for health care access generally, "it means millions more women will come under the purview of the Hyde Amendment." Further, restrictions on abortion coverage in health plans in the exchanges "are likely to diminish abortion coverage in the private market as well," they add.
Meanwhile, just as abortion coverage has become increasingly restricted, the procedure itself has become more "marginalized within health care, through routine harassment and violence directed at abortion providers by anti-choice activists, ostracization of abortion providers by other members of the medical community, and the imposition of regulations on abortion care that do not apply to any other medical field," Allina, Arons and Barajas -Román continue. They highlight numerous examples of violence against providers, practices within the medical field that segregate abortion care from other medical services, and state laws and regulations that impose more obstacles on abortion providers and women.
Consequences for ACA
"[W]hen the Congressional battle broke out over how to address abortion in the ACA, it laid bare the consequences of these accumulated changes," the authors write.
After much haranguing, the end result was the inclusion of language offered by Sen. Ben Nelson (D-Neb.) that requires insurance companies to collect two separate payments from each policyholder who purchases a plan that includes abortion coverage through the exchanges -- one for the abortion coverage and one for the rest of the premium. The law also allows states to ban abortion coverage in state insurance exchanges and bans discrimination against individuals or entities that refuse to provide abortion coverage, services or referrals.
Aftermath of ACA
The provision allowing states to ban abortion coverage in their exchanges has "already led to women being denied the opportunity to purchase health plans that include abortion coverage in more than a quarter of the country," according to the authors.
To date, 14 states have passed laws banning insurers from providing abortion coverage in state exchanges, a move that gives conservative lawmakers "the perfect vehicle to express their animosity to both abortion and the ACA," the authors write.
The consequences of concessions on abortion in the health reform debate spilled over into other areas of women's health, they add. "[H]aving tasted victory, anti-choice legislators came back in full force," introducing multiple measures to further restrict access to abortion and even to defund family planning programs. At the state level, 470 antiabortion bills were introduced in the first six months of 2011, compared with 175 in all of 2010.
Although it is "accurate" to describe the ACA as a defeat because it includes abortion restrictions, it also is largely "ahistorical" to do so, as the description "fail[s] to recognize how trends in policy, law and clinical practice created conditions in which such restrictions would be an inevitable part of any legislative debate over health reform," the authors argue.
Nonetheless, understanding the factors that contributed to the ACA's abortion restrictions "points us toward the policy changes we must pursue to level that playing field and create the conditions in which the health care experience of a woman who discovers she is pregnant is not so radically different depending on the decision she makes about whether to continue her pregnancy," the authors continue.
They list several recommendations for policy changes, including integrating abortion care into medical education and practice; prosecution of those who harass abortion providers and the businesses they work with; elimination of abortion coverage bans and exclusions; and "explicit political support of abortion rights."
The disappointment with the ACA "has helped create a strong impetus for advocacy to improve public and private insurance coverage of abortion," the authors continue, adding that "advocates must commit to, and invest in, robust movement-building to build greater power that can back up the advocacy that seeks to advance this agenda."
Debra Ness, publisher & president, National Partnership
Andrea Friedman, associate editor & director of reproductive health programs, National Partnership
Marya Torrez, associate editor & senior reproductive health policy counsel, National Partnership
Melissa Safford, associate editor & policy advocate for reproductive health, National Partnership
Perry Sacks, assistant editor & health program associate, National Partnership
Cindy Romero, assistant editor & communications assistant, National Partnership
Justyn Ware, editor
Amanda Wolfe, editor-in-chief
Heather Drost, Hanna Jaquith, Marcelle Maginnis, Ashley Marchand and Michelle Stuckey, staff writers
Tucker Ball, director of new media, National Partnership