Analysis Health Systems

What the Attack on Medicaid Means for Reproductive Health Care

Davida Silverman

Any cut to Medicaid is a threat to reproductive healthcare.  During this political War on Women, it is not unreasonable to assume that the first thing on the chopping block will be reproductive health services and women’s health care.

Brace yourself: there are new attacks on public health, and this time the target is Medicaid. Earlier this month, the House of Representatives passed a budget proposal designed by Rep. Paul Ryan (R-WI) that would convert Medicaid to a block grant. Prior to that, Sen. McCaskill (D-MO) and Sen. Corker (R-TN) proposed a bill that would cap all federal spending, including for key public health programs, such as Medicaid.  Meanwhile, we are about to hit our national debt ceiling, which has prompted further to demands to drastically reduce federal spending.  So why do these proposals matter, and what do they have to do with reproductive health? 

Medicaid is currently the largest provider of reproductive health care for low-income people. The program provides medical coverage for 54 percent of non-elderly women and it is has been credited for financing over 40 percent of births across the country.  In addition, Medicaid is required to cover a wide range of reproductive health services, including: pregnancy-related services, prenatal care, delivery services, screening and treatment of sexually transmitted infections and family planning.  The federal ban on abortion funding has three exceptions: when continuing the pregnancy would endanger the life of the woman or when the pregnancy resulted from rape or incest. For low-income individuals, Medicaid is the primary (sometimes only) source for reproductive health services. 

All of the proposals mentioned above drastically reduce federal funding for Medicaid, which would result in serious cuts to who can get Medicaid health coverage and what services they can get.  Currently, Medicaid utilizes a matching structure in which the federal government funds a certain percentage of a state Medicaid program’s expenditures.  The federal government matching rate differs state to state, but it typically covers 50 to 75 percent of each state’s Medicaid costs.  This structure allows states to accommodate increases in health care needs, enrolling more people in Medicaid, providing more services in their program, and meeting increased costs of services.  For example, during the recession when so many people lost their jobs and their health insurance, an additional 6 million people enrolled in Medicaid.  The federal government’s matching rate helped off-set states’ health care costs and ensured that all those who became eligible for Medicaid could enroll.

If the House has its way, however, Medicaid would be converted into a block grant.  Instead of continuing the matching structure, each state would receive a set, finite amount of federal funding for its Medicaid program.  And to make it even worse, the House budget sets the block grant at a rate that is significantly lower than current federal expenditures and then incrementally decreases the funding every year.  According to Congressional Budget Office (CBO) estimates, under the House budget proposal, federal Medicaid spending would be 35 percent lower in 2022 and 49 percent lower in 2030. The cap would stay in place regardless if there was an increased need for Medicaid services.

Like This Story?

Your $10 tax-deductible contribution helps support our research, reporting, and analysis.

Donate Now

Meanwhile, on the Senate side, the McCaskill-Corker bill (S.245) aims to cap total federal spending, and includes a “sequestration” process that would automatically make cuts if the cap was exceeded.  While couched as a neutral proposal to address the deficit, this bill is nothing more than the House budget proposal dressed up in better rhetoric.  Under the McCaskill-Corker bill, the federal cap is set at a low rate, and like a block grant, it will prohibit the federal government from spending more than the cap, regardless of an increased need for Medicaid services.  The process will disproportionately affect entitlement and mandatory programs, like Medicaid.  As such, the bill that pretends to simply reign in federal spending actually creates devastating funding cuts for Medicaid.

In the background of these two proposals looms another possible threat to Medicaid: across the board federal spending cuts.  The nation is expected to reach the debt ceiling in early May, and legislation must be passed to raise it.  President Obama has requested a debt ceiling bill that does not contain any policy riders, but Republicans have pounced on the opportunity to use the bill as leverage for spending cuts.  To be fair, Republicans have not yet stated which programs they would want to cut; however, the House budget proposal and the McCaskill-Corker bill showcase Medicaid as a likely target.

Arbitrary federal caps or spending cuts – with or without a block grant – will drastically reduce federal funding for Medicaid.  Inadequate federal funding leaves states with two possibilities: shouldering the costs so that they can operate their Medicaid programs at the pre-cut level, or cutting services to fit within the reduced federal funding limit.  Given today’s economic and political climate, it is more likely than not that states will cut services.

Any cut to Medicaid is a threat to reproductive health care.  During this political War on Women, it is not unreasonable to assume that the first thing on the chopping block will be reproductive health services and women’s health care.  After all, it was just two weeks ago that the federal government came within an hour of shutting down because ideologues in the House wanted to prohibit Planned Parenthood from receiving Title X funding.  While they lost that fight, they were able to reinstate the D.C. abortion funding ban.  Even less “controversial” programs like maternity health services have experienced cuts, and hospitals across the nation are closing their maternity wards, in part, because of the lack of public funding to support operations. 

Make no mistake: attacks on Medicaid are simply proxies for attacks on reproductive health services.  As advocates for reproductive rights and health, it is imperative that we make sure Medicaid remains fully funded and that we work to defeat any proposal that would block grant, cap or cut funding for Medicaid.

Analysis Law and Policy

The Hyde Amendment and Beyond: The Conservative Attack on Reproductive Health Care That Just Won’t Quit

Jessica Mason Pieklo

Almost 40 years since the Hyde Amendment was first passed, another Supreme Court fight over reproductive health-care access and income inequality is shaping up.

This week marks the 39th anniversary of the Hyde Amendment, the federal appropriations ban on Medicaid reimbursement for most abortions. This summer will also mark the 35th anniversary of Harris v. McRae, the Supreme Court decision that ruled the Hyde Amendment’s restrictions constitutional, enshrining into law the idea that it is completely permissible for Congress to discriminate against poor people when it comes to reproductive health-care access.

The Hyde Amendment singles out low-income people for unequal treatment under the law. In order to come to the conclusion that it is constitutional, conservatives on the Supreme Court in 1980 advanced what has become a familiar mantra in opposition to reproductive rights: Just because a federal right to abortion exists doesn’t mean the government is obligated to pay for it. It’s a catchy quip, and one that persists today. But it is also an inherently dishonest way to think of how our fundamental rights work—one that depends on ignoring the realities of structural inequality.

“The Hyde Amendment,” wrote the Court in Harris v. McRae, “places no governmental obstacle in the path of a woman who chooses to terminate her pregnancy, but rather, by means of unequal subsidization of abortion and other medical services, encourages alternative activity deemed in the public interest.”

Under the Medicaid program, which currently provides coverage for approximately 60 million individuals, federal and state governments jointly pay for the health-care services of eligible low-income individuals and their families. Medicaid funding provides coverage for the “categorically needy” with respect to five general areas of medical treatment, including “skilled nursing facilities services, periodic screening and diagnosis of children, and family planning services.”

Like This Story?

Your $10 tax-deductible contribution helps support our research, reporting, and analysis.

Donate Now

In theory, that “family planning services” coverage should extend to abortion care. But it doesn’t, thanks to congressional Republicans. First passed in 1976—just three years after Roe v. Wade said the right to an abortion is fundamental—the Hyde Amendment, named after Rep. Henry Hyde (R-IL), places various limits on Medicaid funding for abortions. Currently, it only provides funding for abortions in cases of rape, incest, or life endangerment of the pregnant person. The Hyde Amendment is not permanent law. Rather, it is a funding limitation created by Congress, one legislators must renew every year.

Today approximately one in ten women are Medicaid enrollees, with women comprising more than two-thirds of adult rolls. According to a 2009 Kaiser Family Foundation report, Medicaid pays for more than four in ten births nationwide; in some states, it pays for more than half of the total births. With no Medicaid assistance for abortions, poor patients often have to reschedule appointments while they try and save money to pay for them, which pushes them into later, more expensive and potentially riskier abortions. Or worse, it forces them to carry to term pregnancies they otherwise would not.

Yet according to the Supreme Court in Harris v. McRae, the Hyde Amendment is not a government-created obstacle designed to limit access to the fundamental right to an abortion. It is rather just an exercise of state power, one that encourages childbirth over abortion.

No, I can’t explain the legal difference between those two positions, because there is none. Harris v. McRae is a case study in conservative morality policing, a truth borne out later in the opinion. Let’s walk through it.

“[A]lthough government may not place obstacles in the path of a woman’s exercise of her freedom of choice, it need not remove those not of its own creation,” the Court in Harris wrote. “Indigency falls in the latter category. The financial constraints that restrict an indigent woman’s ability to enjoy the full range of constitutionally protected freedom of choice are the product not of governmental restrictions on access to abortions, but rather of her indigency.”

In other words, it is not the Hyde Amendment preventing poor patients from accessing abortion care; it’s the fact that they are poor to begin with.

“Whether freedom of choice that is constitutionally protected warrants federal subsidization is a question for Congress to answer,” wrote the Harris Court. “[I]t simply does not follow that a woman’s freedom of choice carries with it a constitutional entitlement to the financial resources to avail herself of the full range of protected choices.”

So. The Supreme Court in Harris v. McRae said that the congressionally created Hyde Amendment was not a government-created obstacle designed to limit poor patients’ reproductive health-care choices. Those choices, the Court reasoned, are already limited by the fact that the patient is poor and all the Hyde Amendment does is express the government’s general preference for childbirth over abortion. Somehow, it does not place another obstacle on the indigent person’s path to try and terminate a pregnancy.

OK then.

Almost 40 years and as many renewals of the Hyde Amendment later, conservative gamesplaying with Medicaid family provisions have only amplified. As their party heads to the 2016 presidential elections, Republicans are now calling for Benghazi-like investigations into Planned Parenthood and to exclude the reproductive health-care provider from the Medicaid program.

It’s important to note that conservatives in states like Indiana and Tennessee quietly widened Medicaid eligibility while continuing to pursue ways to strip comprehensive reproductive health-care services from its list of covered items. These states expanded their Medicaid programs because, frankly, they work. Medicaid as a venture of cooperative federalism has been a smashing success in reducing barriers to health care. Which is what makes the injustice of singling out abortion as the only medical procedure excluded for Medicaid funding all the more apparent.

“When viewed in the context of the Medicaid program to which it is appended, it is obvious that the Hyde Amendment is nothing less than an attempt by Congress to circumvent the dictates of the Constitution and achieve indirectly what Roe v. Wade said it could not do directly,” Justice William J. Brennan, Jr. wrote in his dissent in Harris.

And as we’ve seen in the last five years with the unprecedented explosion of reproductive rights restrictions at the state level, conservatives never planned to end their campaign with undoing abortion rights. Upending contraception access, a cornerstone of science- and evidence-based family planning services, is also part of the right’s political play—especially where low-income people are concerned.

HR 3495, which the House votes on this week, would allow states to exclude providers from Medicaid based on ideology like a moral or religious objection to contraception and abortion, or a declaration that a fertilized egg is a person. HR 3495 builds off conservatives’ win in Hobby Lobby, the case last summer that allowed for-profit secular employers to raise religious objections to providing employee health insurance plans that covered contraception as required under the Affordable Care Act. So those who “consciously object” to providers who perform abortions are perfectly poised for support among the conservatives on the Roberts Court—most notably Justice Kennedy, who has yet to vote to support reproductive rights since 1992’s Planned Parenthood v. Casey.

If enacted and supported, HR 3495 could mean the end of reproductive health care grounded in science. But only for poor women.

So far, thanks to the Roberts Court, conservatives have successfully rolled back insurance coverage for contraception under the Affordable Care Act. HR 3495, by granting states the power to discriminate against health-care providers based on ideology, could do to contraceptive services under Medicaid what Hobby Lobby did for contraception coverage in the private sector: subject the right to access it to conservative veto. And with the holding and reasoning from Harris to guide them, there’s every reason to think the Roberts Court would find that restriction constitutional.

In addition, it’s very likely the Roberts Court will hear an abortion case and a contraception case this term. These cases, to varying degrees, address issues of reproductive health-care access and income inequality. That means the themes of state power, individual rights, and just how far the government can go to obstruct a patient from terminating a pregnancy—or accessing reproductive health care generally—will again be at the forefront of our legal conversations. And it will happen against the backdrop of the 2016 presidential elections and the Planned Parenthood smear campaign. It’s hard to see these converging events as a good thing.

All this means we shouldn’t just be outraged at the injustice of the Hyde Amendment on its anniversary; we should be scared of what follows.

News Abortion

Oregon Bill Would Ensure Coverage for Reproductive Health Care, Abortions

Nina Liss-Schultz

Four Oregon lawmakers Thursday introduced the Comprehensive Women’s Health Bill, intended to ensure access to affordable, full-spectrum reproductive health care for every woman and transgender man in the state.

Four Oregon lawmakers Thursday introduced the Comprehensive Women’s Health Bill, intended to ensure access to affordable, full-spectrum reproductive health care for every woman and transgender man in the state. The bill, if passed, would make Oregon the first state in the nation to ensure every state resident is covered for every type of reproductive health care, including abortion, under all forms of insurance.

Backed by a handful of local groups, the bill is part of a larger progressive legislative effort announced Thursday that will also tackle sexual assault and domestic violence issues.

“I’m proud to be working with such a wide range of legislators and advocates on this issue,” state Sen. Elizabeth Steiner Hayward, one of the bill’s sponsors, told Rewire. “We’ve got Republicans and Democrats, men and women, and advocates from across the spectrum who care deeply about this bill.”

Oregon is often considered a bastion of progressivism in a country battling over abortion and reproductive rights on both the federal and state level.

Like This Story?

Your $10 tax-deductible contribution helps support our research, reporting, and analysis.

Donate Now

The Oregon Health Plan (OHP) provides extensive Medicaid coverage of health care for low-income residents, including abortion, though that coverage is currently added as a line item in the governor’s budget each year. And there is only one anti-choice law on the books to date. Both of the Oregon’s legislative chambers are controlled by Democrats, and the state’s new Democratic Gov. Kate Brown, who was sworn in last week following the resignation of John Kitzhaber, is widely seen as more progressive than her predecessor.

Still, even under a progressive government, efforts are needed to ensure that the funding and systems are in place for everyone to get the care they need. Even in Oregon, the high cost of family planning, abortion, prenatal, and childbirth care, among other reproductive-related services, can force people, particularly those with low incomes, to carry unwanted pregnancies to term or forgo important services during and after pregnancy.

“Currently, because of gaps in coverage, our clients have issues regarding lack of access to prenatal care and high teen pregnancy rates,” said Levi Herrera, executive director of the Mano a Mano Family Center in Salem, Oregon, which annually serves 2,000 families, most of whom identify as Latino immigrants. “Two-thirds of our clients are female. These women are part of the community, and having access to the full spectrum of health care will improve quality of life for everybody.”

Safety net health centers in 2012 alone provided contraceptive care to more than 123,300 women. In 2010, 46 percent of pregnancies in Oregon were unintended, and 32 percent of those pregnancies resulted in abortion, according to the Guttmacher Institute.

That same year, publicly funded family planning services helped women avoid 30,200 unintended pregnancies.

The Comprehensive Women’s Health Bill seeks to close those gaps in access. The bill would require that all health insurancewhether private, employer sponsored, or public plans—cover contraception, abortion, prenatal care, childbirth, and postpartum care, including breast-feeding support and folic acid without prescription. Insurers would be barred from imposing cost-sharing for abortions at more than 10 percent of the cost of the procedure, and deductibles for abortions would be barred altogether. And, critically, the bill strengthens and protects existing abortion coverage under OHP by removing it from the annual budget and codifying such coverage.

The bill also ensures coverage for a 12-month supply of birth control, without cost, to be dispensed at one time, removing time and cost constraints faced by those who seek to prevent an unwanted pregnancy.

Insurance plans would also be required to cover the cost of out-of-network provider care for these services under certain circumstances.

Access to preventive reproductive health services has increased significantly under the Affordable Care Act. As part of the law, insurers are required to cover a range of reproductive health services, including sexually transmitted infection counseling, contraceptive methods and counseling, and breastfeeding support, without cost-sharing.

But advocates in Oregon say the bill introduced today is significant, as both a proactive measure and a solution to holes in coverage.

“There are parts of the state statute that don’t align with the ACA, so it’s important to make sure state law aligns with federal,” Hayward said. “This bill standardizes across the board what we mean by access to full-spectrum reproductive health from pre-conception to postpartum.”

Reproductive rights advocates said the Oregon bill could prove critical, as the U.S. Supreme Court could soon gut the ACA’s federal exchanges and many Republican governors and GOP-dominated state legislatures refuse to expand health-care coverage.

“As the ACA is being eroded in states across the country, we’re trying to make sure that in this state there’s an assurance of care across all populations and for all Oregonians,” Aimee Santos-Lyons, director of programs for Western States Center, told Rewire. “Plus, there are still communities of women that don’t have access to coverage right now, so we want to start that process. And as we’ve recently seen, governors can change on a dime, so we want to make sure this kind of health care is is codified law in our state.”