For Low-Income Women, Lack of Coverage Leads to Anxiety, Unnecessary Delays in Terminating Pregnancies

Elisabeth Sowecke

Low-income women--even many ostensibly covered by Medicaid--face numerous obstacles to obtaining early, safe abortion services, leading to higher costs and later abortions than need be the case. The DC Abortion Fund is struggling to close the gap.

Regardless of the current state of health care insurance in this country, a woman obtaining abortion care can expect to pay for the surgery on her own.

Perhaps, for example, her insurer claims to cover elective abortion services but there are in reality no in-network providers in her region. Or perhaps her insurer fails to reimburse payment for abortions—jeopardizing a clinic’s ability to afford to provide quality care if they are willing to accept her claim.

Her insurer may not cover elective abortion at all or she may be uninsured, a government employee without coverage for abortion care, or a member of the military or undocumented.

Certainly, she is out of luck if her health care coverage is through Medicaid in one of 32 states or Washington, DC , where Medicaid refuses to cover the fees for abortion services unless her life is imminently threatened or she was raped and has filed a police report.

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For residents of the District of Columbia, the hope of vital changes to Medicaid coverage of abortion services is on the horizon. As reported by Rewire:

Last week, the House of Representatives passed a spending bill, the Financial Services and General Government Appropriations Act, that included a provision for lifting the ban on Washington, D.C.’s use of local funds to pay for abortion services for low-income women. Efforts to lift the ban now move to the Senate.

In theory, if also approved by the DC council, Medicaid would then cover abortion services for recipients in DC.

Currently, a woman seeking abortion care in DC will need anywhere from $250 to $6,000 to cover the cost of a surgical abortion and the longer the delays in obtaining a procedure—the longer it takes her to confirm her pregnancy, choose the most realistic solution for herself and her family and raise the money to personally afford the health care fees–the more expensive the surgery will be.

For a single, uninsured mother of one child to qualify for Medicaid coverage in DC, her annual income cannot exceed $42,000. The average annual income for a single mother of one child who qualifies for financial assistance from the DC Abortion Fund is approximately $7,000—more than 50 percent less than the federal poverty guideline for a two-person household. As a mother in DC, she is inevitably insured by Medicaid, but because she chooses to terminate an unintended pregnancy in order to continue to provide for her family, she may need to raise up to $6,000 within no more than three weeks—if not sooner—in order to afford to secure an abortion and exercise what is her basic right to safe health care. The greater the obstacles to obtaining an early-term procedure the longer the delays and the more expensive and risky it becomes for the woman. It is that simple.

The DC Abortion Fund (DCAF) is the only local fund in the metropolitan area dedicated to pledging financial support to DC residents who cannot afford the full cost of an abortion. We see first-hand when women choose to have an abortion. They face a multitude of state and national restrictions designed to deny their access to this procedure. These restrictions disproportionately affect low-income women.

On average, a DCAF client is a mother of one to three children, employed part-time—if employed at all—and living with family members or friends. She is the primary provider for her children and needs to afford food, clothing, shelter and utilities, possibly childcare, transportation and education—all on a monthly basis.

A majority of the women we serve have scoured every corner to gather payment for an abortion. They borrow money from several family members and friends, sell their children’s things, delay payment of rent and utilities and appeal to several local and national funds—in addition to DCAF—in order to terminate an unintended, unwanted, and unaffordable pregnancy.
As a local fund, working in partnership with local clinics, and women and families desperately seeking clinical services, we dwell in the cracks of the system where crucial details of real lives go ignored and vital necessities are still denied to our most vulnerable neighbors.

Our volunteer case managers connect with women and girls who are eleven or twelve years old, who are homeless, imprisoned, physically or mentally ill, raped and beaten—women unable to access the comprehensive care they need because they live in a community unwilling to acknowledge and empathize with their condition and unwilling or unable to address the root causes of the circumstances with which they are faced.

Due to the modest capacity of the fund, we are often forced to turn women away unless they are completely destitute. We stare head-on at the tremendous and frightening gap in dignified, health care coverage. We sense the weight of needs unmet. We feel the strong force of our clients’ efforts to overcome the barriers imposed on them.

We assertively welcome the possibility of national recognition and local support of this troubling burden to women’s lives and the health of their families. We diligently look forward to the day when Medicaid covers the cost of an abortion in DC and in every deprived state. We dream of a time when accessing reproductive health care services in this country and all over the world is no longer similar to traversing a rough and tumble landmine laced with quagmires and bombs. We believe the time is ripe for turning the hopes and dreams of the families we serve into reality.

As a grassroots fund, we exist because we understand that neither national nor local health care systems currently fulfill every individual’s unalienable rights. We also provide assistance to women who live in the state of Maryland where Medicaid voluntarily claims to cover abortion services. However, not one DCAF partner clinic in MD currently accepts Medicaid due to a dismal history of reimbursement failures. We consider Maryland Medicaid recipients our most underserved clientele due to the grave misconception that there are policies in place to cover their health care needs.

Because of similar obstacles, Women’s Choice of Oakland, California closed this spring due to California’s chronic low and slow reimbursements for MediCal services. In theory, California also voluntarily claims to cover abortion services for Medicaid recipients but in practice there are many roadblocks to accessing services.

If DC Medicaid does eventually cover abortion services for low-income women in the district, we must be vigilant to ensure accountability and that the local government complies with the law and genuinely fulfills its obligations.

We see the availability of quality abortion care services and family planning resources for every human being as the baseline for a healthy and progressive society and we will continue to subsidize the cost of abortion care until we have no more cases to address.
Our hope for a brighter day is unwavering and our dedication to our neighbors is steadfast.

In direct support of the women we serve and our local abortion providers, we will know when to stop relentlessly pleading for your donation because we will truly see that a woman’s right to safe health care no longer depends on what’s in her wallet.

Donations to the DC Abortion Fund can be made through this link.

News Health Systems

Complaint: Citing Catholic Rules, Doctor Turns Away Bleeding Woman With Dislodged IUD

Amy Littlefield

“It felt heartbreaking,” said Melanie Jones. “It felt like they were telling me that I had done something wrong, that I had made a mistake and therefore they were not going to help me; that they stigmatized me, saying that I was doing something wrong, when I’m not doing anything wrong. I’m doing something that’s well within my legal rights.”

Melanie Jones arrived for her doctor’s appointment bleeding and in pain. Jones, 28, who lives in the Chicago area, had slipped in her bathroom, and suspected the fall had dislodged her copper intrauterine device (IUD).

Her doctor confirmed the IUD was dislodged and had to be removed. But the doctor said she would be unable to remove the IUD, citing Catholic restrictions followed by Mercy Hospital and Medical Center and providers within its system.

“I think my first feeling was shock,” Jones told Rewire in an interview. “I thought that eventually they were going to recognize that my health was the top priority.”

The doctor left Jones to confer with colleagues, before returning to confirm that her “hands [were] tied,” according to two complaints filed by the ACLU of Illinois. Not only could she not help her, the doctor said, but no one in Jones’ health insurance network could remove the IUD, because all of them followed similar restrictions. Mercy, like many Catholic providers, follows directives issued by the U.S. Conference of Catholic Bishops that restrict access to an array of services, including abortion care, tubal ligations, and contraception.

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Some Catholic providers may get around the rules by purporting to prescribe hormonal contraception for acne or heavy periods, rather than for birth control, but in the case of copper IUDs, there is no such pretext available.

“She told Ms. Jones that that process [of switching networks] would take her a month, and that she should feel fortunate because sometimes switching networks takes up to six months or even a year,” the ACLU of Illinois wrote in a pair of complaints filed in late June.

Jones hadn’t even realized her health-care network was Catholic.

Mercy has about nine off-site locations in the Chicago area, including the Dearborn Station office Jones visited, said Eric Rhodes, senior vice president of administrative and professional services. It is part of Trinity Health, one of the largest Catholic health systems in the country.

The ACLU and ACLU of Michigan sued Trinity last year for its “repeated and systematic failure to provide women suffering pregnancy complications with appropriate emergency abortions as required by federal law.” The lawsuit was dismissed but the ACLU has asked for reconsideration.

In a written statement to Rewire, Mercy said, “Generally, our protocol in caring for a woman with a dislodged or troublesome IUD is to offer to remove it.”

Rhodes said Mercy was reviewing its education process on Catholic directives for physicians and residents.

“That act [of removing an IUD] in itself does not violate the directives,” Marty Folan, Mercy’s director of mission integration, told Rewire.

The number of acute care hospitals that are Catholic owned or affiliated has grown by 22 percent over the past 15 years, according to MergerWatch, with one in every six acute care hospital beds now in a Catholic owned or affiliated facility. Women in such hospitals have been turned away while miscarrying and denied tubal ligations.

“We think that people should be aware that they may face limitations on the kind of care they can receive when they go to the doctor based on religious restrictions,” said Lorie Chaiten, director of the women’s and reproductive rights project of the ACLU of Illinois, in a phone interview with Rewire. “It’s really important that the public understand that this is going on and it is going on in a widespread fashion so that people can take whatever steps they need to do to protect themselves.”

Jones left her doctor’s office, still in pain and bleeding. Her options were limited. She couldn’t afford a $1,000 trip to the emergency room, and an urgent care facility was out of the question since her Blue Cross Blue Shield of Illinois insurance policy would only cover treatment within her network—and she had just been told that her entire network followed Catholic restrictions.

Jones, on the advice of a friend, contacted the ACLU of Illinois. Attorneys there advised Jones to call her insurance company and demand they expedite her network change. After five hours of phone calls, Jones was able to see a doctor who removed her IUD, five days after her initial appointment and almost two weeks after she fell in the bathroom.

Before the IUD was removed, Jones suffered from cramps she compared to those she felt after the IUD was first placed, severe enough that she medicated herself to cope with the pain.

She experienced another feeling after being turned away: stigma.

“It felt heartbreaking,” Jones told Rewire. “It felt like they were telling me that I had done something wrong, that I had made a mistake and therefore they were not going to help me; that they stigmatized me, saying that I was doing something wrong, when I’m not doing anything wrong. I’m doing something that’s well within my legal rights.”

The ACLU of Illinois has filed two complaints in Jones’ case: one before the Illinois Department of Human Rights and another with the U.S. Department of Health and Human Services Office for Civil Rights under the anti-discrimination provision of the Affordable Care Act. Chaiten said it’s clear Jones was discriminated against because of her gender.

“We don’t know what Mercy’s policies are, but I would find it hard to believe that if there were a man who was suffering complications from a vasectomy and came to the emergency room, that they would turn him away,” Chaiten said. “This the equivalent of that, right, this is a woman who had an IUD, and because they couldn’t pretend the purpose of the IUD was something other than pregnancy prevention, they told her, ‘We can’t help you.’”

Commentary Human Rights

When It Comes to Zika and Abortion, Disabled People Are Too Often Used as a Rhetorical Device

s.e. smith

Anti-choicers shame parents facing a prenatal diagnosis and considering abortion, even though they don't back up their advocacy up with support. The pro-choice movement, on the other hand, often finds itself caught between defending abortion as an absolute personal right and suggesting that some lived potentials are worth more than others.

There’s only one reason anyone should ever get an abortion: Because that person is pregnant and does not want to be. As soon as anyone—whether they are pro- or anti-choice—starts bringing up qualifiers, exceptions, and scary monsters under the bed, things get problematic. They establish the seeds of a good abortion/bad abortion dichotomy, in which some abortions are deemed “worthier” than others.

And with the Zika virus reaching the United States and the stakes getting more tangible for many Americans, that arbitrary designation is on a lot of minds—especially where the possibility of developmentally impaired fetuses is concerned. As a result, people with disabilities are more often being used as a rhetorical device for or against abortion rights rather than viewed as actualized human beings.

Here’s what we know about Zika and pregnancy: The virus has been linked to microcephaly, hearing loss, impaired growth, vision problems, and some anomalies of brain development when a fetus is exposed during pregnancy, according to the Centers for Disease Control and Prevention. Sometimes these anomalies are fatal, and patients miscarry their pregnancies. Sometimes they are not. Being infected with Zika is not a guarantee that a fetus will develop developmental impairments.

We need to know much, much more about Zika and pregnancy. At this stage, commonsense precautions when necessary like sleeping under a mosquito net, using insect repellant, and having protected sex to prevent Zika infection in pregnancy are reasonable, given the established link between Zika and developmental anomalies. But the panicked tenor of the conversation about Zika and pregnancy has become troubling.

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In Latin America, where Zika has rampantly spread in the last few years, extremely tough abortion restrictions often deprive patients of reproductive autonomy, to the point where many face the possibility of criminal charges for seeking abortion. Currently, requests for abortions are spiking. Some patients have turned to services like Women on Web, which provides assistance with accessing medical abortion services in nations where they are difficult or impossible to find.

For pro-choice advocates in the United States, the situation in Latin America is further evidence of the need to protect abortion access in our own country. Many have specifically using Zika to advocate against 20-week limits on abortion—which are already unconstitutional, and should be condemned as such. Less than 2 percent of abortions take place after 20 weeks, according to the Guttmacher Institute. The pro-choice community is often quick to defend these abortions, arguing that the vast majority take place in cases where the life of the patient is threatened, the fetus has anomalies incompatible with life, or the fetus has severe developmental impairments. Microcephaly, though rare, is an example of an impairment that isn’t diagnosable until late in the second trimester or early in the third, so when patients opt for termination, they run smack up against 20-week bans.

Thanks to the high profile of Zika in the news, fetal anomalies are becoming a talking point on both sides of the abortion divide: Hence the dire headlines sensationalizing the idea that politicians want to force patients to give birth to disabled children. The implication of leaning on these emotional angles, rather than ones based on the law or on human rights, is that Zika causes disabilities, and no one would want to have a disabled child. Some of this rhetoric is likely entirely subconscious, but it reflects internalized attitudes about disabled people, and it’s a dogwhistle to many in the disability community.

Anti-choicers, meanwhile, are leveraging that argument in the other direction, suggesting that patients with Zika will want to kill their precious babies because they aren’t perfect, and that therefore it’s necessary to clamp down on abortion restrictions to protect the “unborn.” Last weekend, for instance, failed presidential candidate Sen. Marco Rubio (R-FL) announced that he doesn’t support access to abortion for pregnant patients with the Zika virus who might, as a consequence, run the risk of having babies with microcephaly. Hardline anti-choicers, unsurprisingly, applauded him for taking a stand to protect life.

Both sides are using the wrong leverage in their arguments. An uptick in unmet abortion need is disturbing, yes—because it means that patients are not getting necessary health care. While it may be Zika exposing the issue of late, it’s a symptom, not the problem. Patients should be able to choose to get an abortion for whatever reason and at whatever time, and that right shouldn’t be defended with disingenuous arguments that use disability for cover. The issue with not being able to access abortions after 20 weeks, for example, isn’t that patients cannot access therapeutic abortions for fetuses with anomalies, but that patients cannot access abortions after 20 weeks.

The insistence from pro-choice advocates on justifying abortions after 20 weeks around specific, seemingly involuntary instances, suggests that so-called “late term abortions” need to be circumstantially defended, which retrenches abortion stigma. Few advocates seem to be willing to venture into the troubled waters of fighting for the right to abortions for any reason after 20 weeks. In part, that reflects an incremental approach to securing rights, but it may also betray some squeamishness. Patients don’t need to excuse their abortions, and the continual haste to do so by many pro-choice advocates makes it seem like a 20-week or later abortion is something wrong, something that might make patients feel ashamed depending on their reasons. There’s nothing shameful about needing abortion care after 20 weeks.

And, as it follows, nor is there ever a “bad” reason for termination. Conservatives are fond of using gruesome language targeted at patients who choose to abort for apparent fetal disability diagnoses in an attempt to shame them into believing that they are bad people for choosing to terminate their pregnancies. They use the specter of murdering disabled babies to advance not just social attitudes, but actual policy. Republican Gov. Mike Pence, for example, signed an Indiana law banning abortion on the basis of disability into law, though it was just blocked by a judge. Ohio considered a similar bill, while North Dakota tried to ban disability-related abortions only to be stymied in court. Other states require mandatory counseling when patients are diagnosed with fetal anomalies, with information about “perinatal hospice,” implying that patients have a moral responsibility to carry a pregnancy to term even if the fetus has impairments so significant that survival is questionable and that measures must be taken to “protect” fetuses against “hasty” abortions.

Conservative rhetoric tends to exceptionalize disability, with terms like “special needs child” and implications that disabled people are angelic, inspirational, and sometimes educational by nature of being disabled. A child with Down syndrome isn’t just a disabled child under this framework, for example, but a valuable lesson to the people around her. Terminating a pregnancy for disability is sometimes treated as even worse than terminating an apparently healthy pregnancy by those attempting to demonize abortion. This approach to abortion for disability uses disabled people as pawns to advance abortion restrictions, playing upon base emotions in the ultimate quest to make it functionally impossible to access abortion services. And conservatives can tar opponents of such laws with claims that they hate disabled people—even though many disabled people themselves oppose these patronizing policies, created to address a false epidemic of abortions for disability.

When those on either side of the abortion debate suggest that the default response to a given diagnosis is abortion, people living with that diagnosis hear that their lives are not valued. This argument implies that life with a disability is not worth living, and that it is a natural response for many to wish to terminate in cases of fetal anomalies. This rhetoric often collapses radically different diagnoses under the same roof; some impairments are lethal, others can pose significant challenges, and in other cases, people can enjoy excellent quality of life if they are provided with access to the services they need.

Many parents facing a prenatal diagnosis have never interacted with disabled people, don’t know very much about the disability in question, and are feeling overwhelmed. Anti-choicers want to force them to listen to lectures at the least and claim this is for everyone’s good, which is a gross violation of personal privacy, especially since they don’t back their advocacy up with support for disability programs that would make a comfortable, happy life with a complex impairment possible. The pro-choice movement, on the other hand, often finds itself caught between the imperative to defend abortion as an absolute personal right and suggesting that some lived potentials are worth more than others. It’s a disturbing line of argument to take, alienating people who might otherwise be very supportive of abortion rights.

It’s clearly tempting to use Zika as a political football in the abortion debate, and for conservatives, doing so is taking advantage of a well-established playbook. Pro-choicers, however, would do better to walk off the field, because defending abortion access on the sole grounds that a fetus might have a disability rings very familiar and uncomfortable alarm bells for many in the disability community.

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