Commentary Health Systems

By Withholding the Medicaid Expansion, Republicans Will Keep the Unintended Pregnancy Rate High

Amanda Marcotte

With the Affordable Care Act, the United States has a good chance of drastically lowering its unintended pregnancy rates. Unfortunately, political posturing from Republicans is stalling the implementation of a key part of the law necessary to achieve that result.

Getting the unintended pregnancy and teen pregnancy rates as low as possible: What once seemed a far away, nearly impossible goal for the reproductive rights movement has, in recent decades, slowly started to become a lived reality for much of Western Europe and Canada. While unintended and teen pregnancy rates—and therefore abortion rates—are declining around the world, the United States notoriously falls behind countries that have similar levels of wealth and industrialization. Within our own country, there’s wide disparity, too, with the poorest cohort of women having five times the unintended pregnancy rate as the wealthiest. Indeed, for lower-income women in the country, the unintended pregnancy rate is actually rising, bucking the worldwide trend.

None of this has to happen. What makes all this particularly frustrating is that the United States has the capability right now to reverse the trend for lower-income women and get our unintended pregnancy rates on par with the levels of Western Europe. The only reason that’s not happening is because some Republicans have decided it’s politically profitable to grandstand about health care and female sexuality, and they don’t care how many women and children are hurt in their race to pander the hardest to fundamentalist Christians and the right-wing brigade that worships demagogues like Rush Limbaugh and Bill O’Reilly.

The battle over the Affordable Care Act and, specifically, the Medicaid expansion is a classic example of how this works. There is no rational reason for states to refuse to take the Medicaid expansion, which would dramatically increase the number of working poor people in their states who had health insurance at an incredibly low cost to the states—and what they do pay will probably be made up down the road in savings by making sure people get health care while their needs are still inexpensive, rather than waiting until they have catastrophic health-care costs. The only reason to do it is so Republican politicians can score points with voters who, usually because of racist and sexist stereotypes, want to see low-income people suffer.

Because so many governors in red states are refusing to take on the Medicaid expansion, a lot of people who make just a little too much to be on traditional Medicaid but not enough to afford private insurance are going to fall through the cracks. One of the most obvious results of this will be that women who fall into this category will continue to experience outrageously high unintended pregnancy rates. Twenty-one percent of women of reproductive age are uninsured, and while Obamacare will help a lot of them, this hole in the system will mean that we’re not looking at the universal coverage that the law was originally intended to create and would have been successful at creating if the Supreme Court didn’t rule that states could opt out.

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What this means is that nearly all U.S. women who want contraception will be able to get it at no cost at a pharmacy, except this cohort of women who already struggle to pay for it out of pocket—and not just the contraception, but also the doctor’s appointments necessary to get it. There’s very little doubt that the expense of contraception is a major reason that our country’s unintended pregnancy rates are so high. That’s why well-off women have much lower rates of unintended pregnancy than poorer women.

The Contraceptive Choice Project in St. Louis found that offering women free access to birth control, as well as free counseling to determine the best method for them, caused the teen pregnancy and abortion rate to plummet; the teen pregnancy rate for women in the program was one-fifth of the national average and the abortion rate was one-third. The Affordable Care Act was supposed to get as close as humanly possible to replicating that experiment on a national scale, by making both the counseling and actual contraception itself available without a co-pay. This loophole, however, pretty much ensures that the full-blown national experiment of reducing our unintended pregnancy rates will be delayed for a few years, at least.

I remain confident that once the posturing about rejecting the Medicaid expansion loses its political salience, Republican-led states will quietly start bringing the expansion on in order to save money and reduce negative health outcomes in their states. We’ve seen similar behavior before. For instance, in Texas there was a whole lot of anti-contraception fussing (disguised as anti-abortion fussing) that led to massive cuts to family planning services. Now that legislators are having to face up to the surge in unwanted pregnancies their rash political posturing created, however, legislators are actually looking to restore the cut funds. Right-wing extremism is only valuable as long as it gets the voters excited, but when the voters move on to other things, leaders actually often end up having to make the “liberal” choice that just so happens to be the smarter, more cost-effective one.

In other words, the United States may, in fact, be able to catch up with Canada and Western Europe when it comes to lowering our unplanned pregnancy rates. But it won’t happen today and it may not happen for years yet. The reason: pure political posturing. Hard-right voters who show up for primaries want to vote for the candidates they think are most willing to cut off needy people from accessing health care. Republicans who are terrified of losing their seats in a primary run-off to a Tea Party candidate who makes a lot of noise about the evils of health care, and particularly family planning funding, are going to run to the right on these issues for as long as Fox News keeps highlighting them in their nightly coverage. The price for this entirely politically minded delay will be paid by women experiencing unintended pregnancies and the children they have when they don’t feel they can best afford them. That’s a lot of pain and suffering to inflict for no other purpose but to stall for time and win some votes.

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