Analysis Politics

Fact-Checking a Texas Republican’s Claims on Women’s Health ‘Advances’

Andrea Grimes

Texas state Sen. Jane Nelson took to the editorial page of the Austin American-Statesman this week to tout "advances" in women's health care under Republican leadership. But Nelson fudged the facts on her, and her party's, anti-woman voting record.

In an editorial published Wednesday in the Austin American-Statesman headlined “Women’s healthcare advancing under Republican leadership,” Texas state Sen. Jane Nelson (R-Flower Mound) touts what she sees as her, and her party’s, achievements in expanding family planning and cancer-screening care for Texas women. There is no GOP-led “war on women,” she writes, calling the “so-called” war “a purely political campaign designed to paint Republicans as anti-women.”

But the record shows that Sen. Nelson herself cast the first “no” vote against establishing the state’s Medicaid Women’s Health Program in 2005, and Nelson’s editorial deliberately obfuscates some of her party’s most damaging moves toward dismantling the family planning safety net in Texas.

Nelson has become the Texas GOP’s most prominent spokeswoman. She is the Texas senate’s highest-ranking member and the longest-serving chair of the state senate’s Health and Human Services Committee; she also enjoys a number of other top committee and conference committee appointments. When her name is on a bill—or when her vote is called—Republicans take note.

Here, we’ll parse Nelson’s true and not-so-true claims in a paragraph-by-paragraph analysis.

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Nelson begins:

When I was first elected to the Texas Senate, Lt. Gov. Bob Bullock appointed me vice chair of the Health and Human Services Committee.

True: In 1999, Nelson was appointed to a split Health and Human Services Committee, with Nelson chairing “health services,” while Democrat Sen. Judith Zaffirini (D-Laredo) was appointed to lead “human services.”

Back then, health care was considered a “women’s issue.”

True-ish: Health care was certainly considered a “women’s issue” in 1999. But in light of the current legal battles over the Affordable Care Act’s birth control benefit, it’s clear that when “health care” involves care specific to people who may become pregnant, a great many Americans perceive it as a “women’s issue” that should be uniquely separated from “health care” writ large.

I never liked that term because, in my mind, all issues are women’s issues. We care about the same issues as men. But health care is of particular interest to women. Our bodies are different than men’s, and so are our health care needs.

True: Female bodies are indeed different than male bodies.

In this new role, it didn’t take long to recognize that our policies were behind the times when it came to meeting the needs of women. The Women’s Health Program didn’t exist. There was little in the way of education about the unique health care risks for women. Medicaid didn’t cover early treatment for breast and cervical cancer.

Barely true: Certainly the Medicaid Women’s Health Program (MWHP) did not exist in 1999, and women’s health and family planning was not an express focus for state lawmakers. But no concrete action was taken on the matter during Nelson’s first term on the Health and Human Services Committee. The New York Times has reported that in 1999, “family-planning advocates” coordinated an “orchestrated push” for state-funded contraception and well-woman exams, but failed.

Over the years, we changed all that. We expanded treatment options for low-income women battling cancer. We made sure mammograms were safe for women. We invested in prevention of breast and cervical cancer.

False: At least in terms of Nelson’s use of “we,” if she means to include herself and Republican lawmakers, writ large, in that designation. In 2001, Sen. Zaffirini authored a Medicaid reform bill, SB 1156, which in part directed the state to work with the federal government on a family planning program. Sen. Nelson was neither a co-author, sponsor, or co-sponsor of the bill. Three senate Republicans co-authored the bill with seven Democrats, and their house sponsors included three Democrats and one Republican. Most notably, Republican Gov. Rick Perry vetoed the bill.

In 2005, we created the Women’s Health Program, providing screenings, wellness checks and family planning services beyond the traditional Medicaid population.

False: In 2005, Sen. Gregory Luna (D-San Antonio) sponsored SB 747, which created the Medicaid Women’s Health Program (MWHP). Three Republican senators authored the bill, most notably John Carona (R-Dallas), along with Sen. Zaffirini. All of the bill’s senate co-authors were Democrats.

Nelson’s use of “we” in this case is especially misleading: She, as chair of the Senate Health and Human Services Committee, cast the first official “no” vote against the program at a hearing on March 22, 2005. Watch the record vote here:

Nelson only later supported SB 747 after other Republican lawmakers amended the bill to ensure that WHP patients would be barred from receiving emergency contraception and would receive information “emphasizing the health benefits of abstinence from sexual activity,” and after an amendment preventing  “abortion affiliates” from providing MWHP services was attached to the bill. That “abortion affiliate” amendment would ultimately later lead to the ouster of Planned Parenthood from the MWHP in 2012 and the wholesale dismantling of the program. Lawmakers later created the Texas Women’s Health Program (TWHP), a program that, without Planned Parenthood, has seen a 77 percent decline in clients served—at an increased cost per client—compared to the original MWHP. In hindsight, Nelson’s voting record shows that she expressly supported the provisions of the bill that ultimately led to the demise of the program and a drastic decrease in services provided to low-income Texans most in need of affordable family planning care.

Today there are four main programs specifically tailored to women. They are expected to reach more than 400,000 women and have a combined budget of over $240 million.

Truthy: Nelson appears to be speaking of the following: the Texas Women’s Health Program, another state family planning program, the Expanded Primary Health Care Program, and a fund for breast and cervical cancer screenings, as laid out on page 11 of this February 2014 Department of State Health Services presentation. Those four programs do indeed have a combined budget of $240.1 million. At first glance, this appears to be a massive increase from the previous fiscal biennium’s $127.3 million budget. But what Nelson fails to mention is that she personally signed her name to a 2011 budget that slashed family planning funds by $67 million—meaning that any actual funding increase is more to the tune of $40 million, and of services paid for by the $100 million increase, only two-thirds of the primary care program must be family planning services. If Nelson claims that the funding increases are remarkable, it is true only because the previous budget cuts she herself endorsed were so substantial.

Women’s health has advanced under Republican leadership.

False: Over the last 15 years—under a decade and a half of statewide Republican leadership and strong GOP majorities in both the Texas house and senate—maternal mortality in the state has quadrupled. According to the Texas Policy Evaluation Project at the University of Texas, 59 reproductive health-care clinics—none of which provided abortion care and most of which were located in rural and underserved areas of the state—closed as a result of the 2011 budget cuts; only a handful have reopened as of 2014. Those that remain open or which have reopened must navigate a retooled contraceptive discount system that significantly negatively affects their ability to prescribe the most effective and long-acting forms of contraception.

From 2007 to 2012, the operative years of the Medicaid Women’s Health Program (MWHP) during which Planned Parenthood provided services to about half of the program’s clients, enrollment climbed and the state enjoyed a nine-to-one federal match in funds. The state lost that federal match when Republican lawmakers ousted Planned Parenthood from the MWHP—the provider’s exclusion violates federal law that allows patients to seek care wherever they choose—and enrollment plummeted by the tens of thousands. According to the Department of State Health Services, Texas’ state-funded family planning providers are currently seeing 77 percent fewer clients, at an increased cost of 17 percent per client, than they were before the 2011 budget cuts that Nelson signed off on. In 2013, the Department of State Health Services lost its long-standing claim to a federal Title X grant to an independent organization of Texas reproductive health-care providers who have taken on the work of attempting to repair some of the damage done by the 2011 budget cuts.

And safe, legal abortion in Texas is harder to access than ever today, in part thanks to Jane Nelson, who in 2011 co-sponsored the state’s mandatory ultrasound bill, which forces people seeking abortions to submit to a sonogram at least 24 hours before the procedure, and requires them to listen to their provider’s verbal description of the sonogram. In 2013, Nelson co-sponsored SB 1, the senate’s version of the omnibus anti-abortion bill that has reduced Texas to just 24 legal abortion providers, down from 44 in 2011. In September 2014, when the entirety of the bill goes into full effect, Texas will have just six legal abortion providers.

Sadly, our progress is being undermined by those trying to manufacture a so-called “War on Women” — a purely political campaign designed to paint Republicans as anti-women.

False: While in its literal sense, the use of the term “war” may be considered hyperbolic, in light of the demonstrable crisis in access to affordable reproductive health care in Texas, evidence clearly shows that when family planning and women’s health programs suffer in Texas, they do so at the hands of conservative lawmakers who, leaning ever more to the political right, have privileged political rhetoric against abortion (and “abortion affiliates”) over fiscally conservative, cost-saving family planning policies that serve low-income Texans and lessen the taxpayer burden statewide, in addition to reducing the need for abortion in the first place.

They claim funding, which was reduced during the recession, has not been restored. That is not correct. Not only did we restore funds, we increased them to an all-time high.

True and false: In saying family planning funding “was reduced,” Nelson again fails to mention that she signed off on the budget cuts. And while some specific family planning has been restored since the 2011 cuts, again, the new $100 million increase in funds that prompts Nelson to tout the “all-time high” is directed to the Expanded Primary Health Care Program (EPHC), which may or may not meet its family planning goals in its infancy. In fact, explicitly directed family planning funds are at a four-year low, down to $140.1 million from $201.4 million in fiscal year 2010-11.

They claim the funds approved last session will not enhance family planning. Untrue. We required that approximately two-thirds of the women served through these new resources will receive contraception and other family planning services.

Unknown: Certainly critics of the EPHC have expressed concerns that providers will be unable to make up the difference in clients lost due to family planning cuts; with the EPHC’s recent launch, it is simply too early to tell whether that will truly be the case.

They claim that excluding abortion providers and their affiliates continues to diminish our provider network. Not so. Over 3,000 providers are signed up for the Women’s Health Program — more than double the number participating in 2011.

True, but only through a very short lens: No abortion providers were ever involved in the provision of publicly funded family planning care in Texas; for them to do so would have been a violation of the nearly 40-year-old Hyde Amendment, which bars federal funds from going to abortion care. In 2012, Texas lawmakers deemed Planned Parenthood locations that do not provide abortion, and which keep their funding and operational structure wholly separate from their abortion-providing entities, to be abortion “affiliates,” which did indeed result in an initially drastically diminished provider care network, as Planned Parenthood provided services to about half of the MWHP’s 130,000 or so clients. Since the creation of the state’s replacement program, the Texas Women’s Health Program, the overall provider numbers may indeed have increased, but their individual capacity to efficiently handle the volume of clients at the same low cost as Planned Parenthood, has been questioned.

These claims are irresponsible, politically motivated and hinder our ability to enroll women in these programs. No one should be discouraged from receiving the health care they need because of this misinformation. The services are there. The funding is there.

False: It was Republican-fueled funding cuts and the party’s crusade against Planned Parenthood that hindered the state’s ability to enroll women in family planning programs. In October 2013, a spokesperson for the Texas Health and Human Services Commission admitted as much to the Houston Chronicle, saying that “Planned Parenthood not only served many of the clients, they also helped their patients enroll in the Women’s Health Program.” With regards to misinformation, the Department of State Health Services itself spread a great deal of it in the run-up to the dismantling of the MWHP by advising enrollees to call colonoscopy centers for pap smears. Today, it may be true that between the partially restored family planning funding and the primary health-care expansion that services and funding are available; whether Texans can avail themselves of services offered, again, remains to be seen. If Texans do not or cannot receive services, it will be because Republican lawmakers—and some anti-choice Democrats—intentionally fractured a cost-effective safety net that saved taxpayer dollars and helped Texans plan their families.

We recognize there is more work to do. At our recent hearings, we identified four areas of focus to enhance women’s health: improve education, make it easier to navigate the system, expand our reach in underserved areas and strengthen family planning.

True: The senate Health and Human Services Committee met in February 2014 to discuss what Nelson described as “legislative achievements in women’s health care.”

We will work across the aisle on areas of common ground — without abandoning our principles. We budget within our means. We don’t agree that embracing Obamacare is the right way to expand women’s health care. We oppose using public funds to pay for abortions. These positions are often twisted to mean things they don’t, but the truth is these views are held by most Texans.

True, inasmuch as an opposition to the Affordable Care Act and a stated goal of general fiscal conservatism are an accurate representations of Republican party positions. But it bears repeating that the Hyde Amendment, passed in 1976, already expressly bans public federal funding for abortion, except in extremely limited cases involving rape or incest or the health of the pregnant person. According to the Center for Medicaid Services, only 150 abortions nationwide were funded by Medicaid in 2012. And with regard to Texans’ views on abortion legislation, a 2013 poll conducted by the University of Texas and the Texas Tribune found that only 38 percent of Texans would like to see the kind of stricter abortion restrictions favored by Nelson and her cohorts in the GOP. And while Republicans do oppose the ACA, the attendant Medicaid expansion offered by the federal government, which has been outright refused by Gov. Rick Perry and his GOP allies, would allow an estimated one million Texans—in a state with the highest rate of uninsured adults in the country—to access affordable health care, including family planning services.

Since I became the 10th woman ever elected to the Texas Senate, women’s health has come a long way, and there are more women making decisions about our health care policies than ever before. Seven women now serve in the Senate. Three of us served on the four-person panel that wrote the Senate’s health and human services budget last session.

True: Texas women now hold seven of 31 senate seats. Four of them are Democrats.

That budget, championed by Republicans, included a historic commitment to women’s health. Not only does my party care deeply about the rights, respect and needs of Texas women, Republicans have delivered results for women since becoming the majority party.

False: Republican lawmakers only came around to the idea of increasing family planning funds when they were assured that funds would be funneled through non-specialty primary care providers, and it’s important to remember that the “historic commitment” came after a historic decimation of the family planning safety net in 2011. In the wider view, it would be difficult to say that any part of Texas’ 2013 budget was roundly “championed” by Republicans, despite the fact that they ruled the legislature with a sound majority. Even the right-leaning Texas Public Policy Foundation at one point described the “great Texas budget debate of 2013” thusly: “four conservative senators joined 30 conservative House members in voting against the budget; never had so many members of the majority party voted against the budget.”

Nelson closes her editorial with this:

Women can’t be defined by a narrow list of political wedge issues. We can be anything we want, including proud Red State women who are fighting for women’s health.

Taken as a whole, Texas lawmakers’ efforts in dismantling the state’s family planning safety net make it clear that if any group can be said to be driving “political wedges” into legislation that affects women, it is the Republican party, which has used its opposition to legal abortion—and its party members’ enthusiasm for relegating Roe v. Wade to a historical footnote—to play ping-pong with the most marginalized, lowest-income Texans’ ability to access affordable reproductive health care.

The only Texas women who can be “anything [they] want” are the Texas women who, like Jane Nelson, have the money, means, and privilege to do so. And that group remains as exclusive as ever, especially in light of the fact that Texas Republicans continue to oppose the adoption of a state version of the Lilly Ledbetter Fair Pay Act that was proposed by state Sen. Wendy Davis in 2013—a bill that Sen. Jane Nelson also voted against.

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.”