Analysis Contraception

Pennsylvania’s New Medicaid Plan Likely to Reduce Access to Birth Control for Low-Income Women

Tara Murtha

The plan will result in less access to affordable, consistent birth control for the poor working women of Pennsylvania—which, as the federal birth control mandate demonstrates, is counter to the intention of health-care reform.

Pennsylvania Gov. Tom Corbett recently unveiled Healthy PA, his proposed alternative to Medicaid expansion. Within hours, health policy experts were panning the plan, calling it “unnecessarily punitive toward potential enrollees” and “laden with red tape.”

Experts say one of the big problems that hasn’t been discussed yet is that it reduces access to affordable birth control for low-income women in Pennsylvania.

“[Corbett] is for no apparent reason, certainly not financial, changing family planning in Pennsylvania,” said Janet Weiner, associate director for health policy at the University of Pennsylvania’s Leonard Davis Institute. “And that’s a problem.”

The Affordable Care Act has been called “the greatest advance for women’s health in a generation” for pro-actively addressing women’s health issues, including providing access to birth control without co-pay. The mandate reflects a goal set in the U.S. Department of Health and Human Services’ Healthy People 2020 report to prioritize family planning in order to reduce “the negative health and economic consequences” that come with unplanned pregnancies.

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But as currently proposed, Healthy PA undermines that intention.

Using Arkansas’ plan as a blueprint, Corbett presents Healthy PA as a free-market alternative to traditional Medicaid expansion option as offered in the Affordable Care Act (ACA). Under the ACA, states are encouraged to expand access to Medicaid coverage, with the federal government picking up the tab for the first three years, then paying no less than 90 percent on a permanent basis.

Instead of pursuing the ready-made expansion, though, Corbett submitted a 97-page waiver requesting the federal government let Pennsylvania use those funds to help low-income residents purchase privatized Medicaid insurance through state exchanges—which, in Pennsylvania, is run by the federal government.

The proposal includes a searching-for-work requirement. In order to receive coverage, un- and underemployed enrollees will have to prove they are searching for full-time work to receive benefits. Every expert Rewire spoke with speculated this provision would not be approved. Many critics cite the fact that a similar requirement was rejected in Utah.

In any case, it is a solution in search of a problem.

“Seventy-five percent of individuals that qualify under the Medicaid expansion have at least one full-time worker in their household,” Antoinette Kraus, director of the Pennsylvania Health Access Network, told Rewire.

With record-low approval ratings a year away from his re-election campaign, it seems Corbett is just playing to his conservative base. But playing politics will just slow down the overall approval process.

“Our neighboring states, starting January 1, will be able to get coverage. This waiver process is probably going to take the better part of the year. So now we’re still going to have a half a million people without health insurance coverage,” Kraus said.

The proposed private option would also require, for the first time, that Medicaid recipients earning more than 50 percent of the federal poverty line pay monthly premiums (with exceptions for pregnant women, people with disabilities, the elderly, and residents of institutions).

However, the federal government rejected a similar proposal in Iowa. According to the New York Times, “Federal officials said Iowa could charge only those with incomes above 100 percent of poverty.”

Under the new plan, premiums will be required to be paid a month in advance, with the state sending monthly invoices to recipients. Reduced premiums incentivize enrollees to meet certain healthy-behavior objectives. But enrollees are also punished if they don’t pay on time. From the waiver:

If the eligible adult or household fails to pay their premium for the three subsequent months, the adult’s or household’s eligibility will be terminated.

The first time an enrollee misses three consecutive payments, they—and possibly their household—will lose their heath insurance for the next three months. Time frames for punitive denial of health care extend from there.

By wielding a lack of health care as punishment for non-compliance—for being too poor to pay the premiums—Healthy PA institutionalizes discontinuity of care for the working poor.

The results of haphazard access to preventative health care are predictable: a diabetic could go into shock, a mentally ill person’s condition may get worse, and a woman of reproductive age may become pregnant with an unplanned pregnancy.

Less than a year ago, the state conducted an analysis of its own data and concluded that providing poor women with more access to contraception improved health outcomes and was cost-effective for taxpayers.

Despite these findings, Healthy PA, as proposed, reduces low-income women’s access to contraception.

Pennsylvania Touts Success of Birth Control Program It’s Now Cutting

Currently, the state offers a plan called SelectPlan for Women. SelectPlan enables women who earn up to 185 percent of the federal poverty line to access free contraception and related reproductive health services such as pap smears, sexually transmitted disease screenings, and associated lab tests—even emergency contraception.

SelectPlan began as an experiment in distributing Medicaid funds in a specific population to achieve a better overall public health result. In bureaucratic terms, that meant it was a Medicaid “demonstration” project. All demonstration plans have five years to prove their value to the Center for Medicare and Medicaid Services (CMS). Initially approved in 2007, SelectPlan was scheduled to expire in May 2012.

In a report submitted to the CMS requesting renewal of the program just last April, the Pennsylvania Department of Public Welfare outlined the program’s resounding success. The DPW concluded that providing poor and working women consistent access to birth control significantly decreased unplanned pregnancies, saving the state millions of dollars in Medicaid funds on maternity, delivery, and newborn care.

Pennsylvania’s results echoed those found by a meta-study of the 22 states that expanded eligibility for family planning services under Medicaid between 1997 and 2011 thanks to “a long-standing provision of the Medicaid statute allows states to claim federal reimbursement for 90% of the cost of these services and supplies.” In fact, it’s the clear cost-effectiveness of subsidizing family planning in almost half the states in the country that informed facilitating access to these services under ACA in the first place.

In Pennsylvania, state data shows that between 2008 and 2010, the approximately $23.7 million spent on birth control and related services for 64,885 women earning between 100 percent and 185 percent of the federal poverty line prevented 7,061 unwanted pregnancies, saving Medicaid $113.8 million in payments for maternity, delivery and newborn care. (It is unclear if the estimated number of births resulting from unplanned pregnancies factors in the percentage of women who would have chosen abortion under the circumstances.)

According to the state’s own report, increasing access to contraception for low-income women improved the health outcomes of women and babies. Contraception helps women space pregnancies, and successive closely-spaced pregnancies can lead to pre-term births—a problem that is at crisis level in Pennsylvania and especially in Philadelphia, where 40 percent of babies are born pre-term.

Now, just months after demonstrating a compelling government interest in increasing access to birth control, that state is planning to drop the program to make way for Healthy PA. SelectPlan is currently scheduled to expire in June 2014, according to a spokesperson for the Department of Public Welfare.

Healthy PA Cuts Women’s Access to Contraception

The proposed start date for Healthy PA is January 1, 2015. It’s unclear what benefits women currently enrolled in SelectPlan will receive between June 2014 and January 2015. (The DPW was unable to respond to a request for comment before publication.)

It’s also altogether unclear what will happen to the women who fall into gap—women earning between 133 percent (the cap to qualify for Healthy PA) and 185 percent (the cap to qualify for SelectPlan) who can still not afford to purchase coverage through the exchange.

According to Corbett’s proposal, women currently on the plan with earnings at or below 133 percent of the federal poverty line will be rolled into a private subsidized Healthy PA plan, which will require paying premiums and wields access to health care, including contraception, as punishment for not meeting various conditions. (It’s worth noting here that many women who take birth control pills do so for reasons other than preventing pregnancy.)

The cumulative result is less access to affordable, consistent birth control for the poor working women of Pennsylvania—which, as the federal birth control mandate demonstrates, is counter to the intention of health-care reform.

Meanwhile, Corbett has spent his administration strategically reducing poor women’s access to other free-market contraceptive services by shutting down freestanding clinics that also provided abortion services. In 2012, after the state passed new regulations requiring freestanding abortion clinics to comply with guidelines developed for ambulatory surgical centers, three freestanding clinics closed “voluntarily” and another closed because it could not afford the renovations required to comply with new regulations. There is no evidence that the new regulations improve patient safety.

State Rep. Brian Cutler (R-Lancaster), a leader in the Pennsylvania legislature’s unofficial “Pro-Life Caucus” recently announced he will be pursuing admitting privileges legislation in the wake of similar legislation passed in Texas that is likely to shut down a third of the state’s clinics.

While Pennsylvania reduces poor women’s access to contraception, unintended pregnancy rates among poor and low-income women are five times higher than for high-income women. The rates have been increasing in that group even as it declines in others, according to the Guttmacher Institute.

As per the DWP’s analysis, by reducing access to contraception, Healthy PA will likely increase the state’s expenditures on subsequent maternity, delivery, and newborn care for women who choose to carry unplanned pregnancies to term.

Analysis Politics

The 2016 Republican Platform Is Riddled With Conservative Abortion Myths

Ally Boguhn

Anti-choice activists and leaders have embraced the Republican platform, which relies on a series of falsehoods about reproductive health care.

Republicans voted to ratify their 2016 platform this week, codifying what many deem one of the most extreme platforms ever accepted by the party.

“Platforms are traditionally written by and for the party faithful and largely ignored by everyone else,” wrote the New York Times‘ editorial board Monday. “But this year, the Republicans are putting out an agenda that demands notice.”

“It is as though, rather than trying to reconcile Mr. Trump’s heretical views with conservative orthodoxy, the writers of the platform simply opted to go with the most extreme version of every position,” it continued. “Tailored to Mr. Trump’s impulsive bluster, this document lays bare just how much the G.O.P. is driven by a regressive, extremist inner core.”

Tucked away in the 66-page document accepted by Republicans as their official guide to “the Party’s principles and policies” are countless resolutions that seem to back up the Times‘ assertion that the platform is “the most extreme” ever put forth by the party, including: rolling back marriage equalitydeclaring pornography a “public health crisis”; and codifying the Hyde Amendment to permanently block federal funding for abortion.

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Anti-choice activists and leaders have embraced the platform, which the Susan B. Anthony List deemed the “Most Pro-life Platform Ever” in a press release upon the GOP’s Monday vote at the convention. “The Republican platform has always been strong when it comes to protecting unborn children, their mothers, and the conscience rights of pro-life Americans,” said the organization’s president, Marjorie Dannenfelser, in a statement. “The platform ratified today takes that stand from good to great.”  

Operation Rescue, an organization known for its radical tactics and links to violence, similarly declared the platform a “victory,” noting its inclusion of so-called personhood language, which could ban abortion and many forms of contraception. “We are celebrating today on the streets of Cleveland. We got everything we have asked for in the party platform,” said Troy Newman, president of Operation Rescue, in a statement posted to the group’s website.

But what stands out most in the Republicans’ document is the series of falsehoods and myths relied upon to push their conservative agenda. Here are just a few of the most egregious pieces of misinformation about abortion to be found within the pages of the 2016 platform:

Myth #1: Planned Parenthood Profits From Fetal Tissue Donations

Featured in multiple sections of the Republican platform is the tired and repeatedly debunked claim that Planned Parenthood profits from fetal tissue donations. In the subsection on “protecting human life,” the platform says:

We oppose the use of public funds to perform or promote abortion or to fund organizations, like Planned Parenthood, so long as they provide or refer for elective abortions or sell fetal body parts rather than provide healthcare. We urge all states and Congress to make it a crime to acquire, transfer, or sell fetal tissues from elective abortions for research, and we call on Congress to enact a ban on any sale of fetal body parts. In the meantime, we call on Congress to ban the practice of misleading women on so-called fetal harvesting consent forms, a fact revealed by a 2015 investigation. We will not fund or subsidize healthcare that includes abortion coverage.

Later in the document, under a section titled “Preserving Medicare and Medicaid,” the platform again asserts that abortion providers are selling “the body parts of aborted children”—presumably again referring to the controversy surrounding Planned Parenthood:

We respect the states’ authority and flexibility to exclude abortion providers from federal programs such as Medicaid and other healthcare and family planning programs so long as they continue to perform or refer for elective abortions or sell the body parts of aborted children.

The platform appears to reference the widely discredited videos produced by anti-choice organization Center for Medical Progress (CMP) as part of its smear campaign against Planned Parenthood. The videos were deceptively edited, as Rewire has extensively reported. CMP’s leader David Daleiden is currently under federal indictment for tampering with government documents in connection with obtaining the footage. Republicans have nonetheless steadfastly clung to the group’s claims in an effort to block access to reproductive health care.

Since CMP began releasing its videos last year, 13 state and three congressional inquiries into allegations based on the videos have turned up no evidence of wrongdoing on behalf of Planned Parenthood.

Dawn Laguens, executive vice president of Planned Parenthood Action Fund—which has endorsed Hillary Clinton—called the Republicans’ inclusion of CMP’s allegation in their platform “despicable” in a statement to the Huffington Post. “This isn’t just an attack on Planned Parenthood health centers,” said Laguens. “It’s an attack on the millions of patients who rely on Planned Parenthood each year for basic health care. It’s an attack on the brave doctors and nurses who have been facing down violent rhetoric and threats just to provide people with cancer screenings, birth control, and well-woman exams.”

Myth #2: The Supreme Court Struck Down “Commonsense” Laws About “Basic Health and Safety” in Whole Woman’s Health v. Hellerstedt

In the section focusing on the party’s opposition to abortion, the GOP’s platform also reaffirms their commitment to targeted regulation of abortion providers (TRAP) laws. According to the platform:

We salute the many states that now protect women and girls through laws requiring informed consent, parental consent, waiting periods, and clinic regulation. We condemn the Supreme Court’s activist decision in Whole Woman’s Health v. Hellerstedt striking down commonsense Texas laws providing for basic health and safety standards in abortion clinics.

The idea that TRAP laws, such as those struck down by the recent Supreme Court decision in Whole Woman’s Health, are solely for protecting women and keeping them safe is just as common among conservatives as it is false. However, as Rewire explained when Paul Ryan agreed with a nearly identical claim last week about Texas’ clinic regulations, “the provisions of the law in question were not about keeping anybody safe”:

As Justice Stephen Breyer noted in the opinion declaring them unconstitutional, “When directly asked at oral argument whether Texas knew of a single instance in which the new requirement would have helped even one woman obtain better treatment, Texas admitted that there was no evidence in the record of such a case.”

All the provisions actually did, according to Breyer on behalf of the Court majority, was put “a substantial obstacle in the path of women seeking a previability abortion,” and “constitute an undue burden on abortion access.”

Myth #3: 20-Week Abortion Bans Are Justified By “Current Medical Research” Suggesting That Is When a Fetus Can Feel Pain

The platform went on to point to Republicans’ Pain-Capable Unborn Child Protection Act, a piece of anti-choice legislation already passed in several states that, if approved in Congress, would create a federal ban on abortion after 20 weeks based on junk science claiming fetuses can feel pain at that point in pregnancy:

Over a dozen states have passed Pain-Capable Unborn Child Protection Acts prohibiting abortion after twenty weeks, the point at which current medical research shows that unborn babies can feel excruciating pain during abortions, and we call on Congress to enact the federal version.

Major medical groups and experts, however, agree that a fetus has not developed to the point where it can feel pain until the third trimester. According to a 2013 letter from the American Congress of Obstetricians and Gynecologists, “A rigorous 2005 scientific review of evidence published in the Journal of the American Medical Association (JAMA) concluded that fetal perception of pain is unlikely before the third trimester,” which begins around the 28th week of pregnancy. A 2010 review of the scientific evidence on the issue conducted by the British Royal College of Obstetricians and Gynaecologists similarly found “that the fetus cannot experience pain in any sense prior” to 24 weeks’ gestation.

Doctors who testify otherwise often have a history of anti-choice activism. For example, a letter read aloud during a debate over West Virginia’s ultimately failed 20-week abortion ban was drafted by Dr. Byron Calhoun, who was caught lying about the number of abortion-related complications he saw in Charleston.

Myth #4: Abortion “Endangers the Health and Well-being of Women”

In an apparent effort to criticize the Affordable Care Act for promoting “the notion of abortion as healthcare,” the platform baselessly claimed that abortion “endangers the health and well-being” of those who receive care:

Through Obamacare, the current Administration has promoted the notion of abortion as healthcare. We, however, affirm the dignity of women by protecting the sanctity of human life. Numerous studies have shown that abortion endangers the health and well-being of women, and we stand firmly against it.

Scientific evidence overwhelmingly supports the conclusion that abortion is safe. Research shows that a first-trimester abortion carries less than 0.05 percent risk of major complications, according to the Guttmacher Institute, and “pose[s] virtually no long-term risk of problems such as infertility, ectopic pregnancy, spontaneous abortion (miscarriage) or birth defect, and little or no risk of preterm or low-birth-weight deliveries.”

There is similarly no evidence to back up the GOP’s claim that abortion endangers the well-being of women. A 2008 study from the American Psychological Association’s Task Force on Mental Health and Abortion, an expansive analysis on current research regarding the issue, found that while those who have an abortion may experience a variety of feelings, “no evidence sufficient to support the claim that an observed association between abortion history and mental health was caused by the abortion per se, as opposed to other factors.”

As is the case for many of the anti-abortion myths perpetuated within the platform, many of the so-called experts who claim there is a link between abortion and mental illness are discredited anti-choice activists.

Myth #5: Mifepristone, a Drug Used for Medical Abortions, Is “Dangerous”

Both anti-choice activists and conservative Republicans have been vocal opponents of the Food and Drug Administration (FDA’s) March update to the regulations for mifepristone, a drug also known as Mifeprex and RU-486 that is used in medication abortions. However, in this year’s platform, the GOP goes a step further to claim that both the drug and its general approval by the FDA are “dangerous”:

We believe the FDA’s approval of Mifeprex, a dangerous abortifacient formerly known as RU-486, threatens women’s health, as does the agency’s endorsement of over-the-counter sales of powerful contraceptives without a physician’s recommendation. We support cutting federal and state funding for entities that endanger women’s health by performing abortions in a manner inconsistent with federal or state law.

Studies, however, have overwhelmingly found mifepristone to be safe. In fact, the Association of Reproductive Health Professionals says mifepristone “is safer than acetaminophen,” aspirin, and Viagra. When the FDA conducted a 2011 post-market study of those who have used the drug since it was approved by the agency, they found that more than 1.5 million women in the U.S. had used it to end a pregnancy, only 2,200 of whom had experienced an “adverse event” after.

The platform also appears to reference the FDA’s approval of making emergency contraception such as Plan B available over the counter, claiming that it too is a threat to women’s health. However, studies show that emergency contraception is safe and effective at preventing pregnancy. According to the World Health Organization, side effects are “uncommon and generally mild.”

News Abortion

Study: United States a ‘Stark Outlier’ in Countries With Legal Abortion, Thanks to Hyde Amendment

Nicole Knight Shine

The study's lead author said the United States' public-funding restriction makes it a "stark outlier among countries where abortion is legal—especially among high-income nations."

The vast majority of countries pay for abortion care, making the United States a global outlier and putting it on par with the former Soviet republic of Kyrgyzstan and a handful of Balkan States, a new study in the journal Contraception finds.

A team of researchers conducted two rounds of surveys between 2011 and 2014 in 80 countries where abortion care is legal. They found that 59 countries, or 74 percent of those surveyed, either fully or partially cover terminations using public funding. The United States was one of only ten countries that limits federal funding for abortion care to exceptional cases, such as rape, incest, or life endangerment.

Among the 40 “high-income” countries included in the survey, 31 provided full or partial funding for abortion care—something the United States does not do.

Dr. Daniel Grossman, lead author and director of Advancing New Standards in Reproductive Health (ANSIRH) at the University of California (UC) San Francisco, said in a statement announcing the findings that this country’s public-funding restriction makes it a “stark outlier among countries where abortion is legal—especially among high-income nations.”

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The researchers call on policymakers to make affordable health care a priority.

The federal Hyde Amendment (first passed in 1976 and reauthorized every year thereafter) bans the use of federal dollars for abortion care, except for cases of rape, incest, or life endangerment. Seventeen states, as the researchers note, bridge this gap by spending state money on terminations for low-income residents. Of the 14.1 million women enrolled in Medicaid, fewer than half, or 6.7 million, live in states that cover abortion services with state funds.

This funding gap delays abortion care for some people with limited means, who need time to raise money for the procedure, researchers note.

As Jamila Taylor and Yamani Hernandez wrote last year for Rewire, “We have heard first-person accounts of low-income women selling their belongings, going hungry for weeks as they save up their grocery money, or risking eviction by using their rent money to pay for an abortion, because of the Hyde Amendment.”

Public insurance coverage of abortion remains controversial in the United States despite “evidence that cost may create a barrier to access,” the authors observe.

“Women in the US, including those with low incomes, should have access to the highest quality of care, including the full range of reproductive health services,” Grossman said in the statement. “This research indicates there is a global consensus that abortion care should be covered like other health care.”

Earlier research indicated that U.S. women attempting to self-induce abortion cited high cost as a reason.

The team of ANSIRH researchers and Ibis Reproductive Health uncovered a bit of good news, finding that some countries are loosening abortion laws and paying for the procedures.

“Uruguay, as well as Mexico City,” as co-author Kate Grindlay from Ibis Reproductive Health noted in a press release, “legalized abortion in the first trimester in the past decade, and in both cases the service is available free of charge in public hospitals or covered by national insurance.”