The Trump administration and the 115th Congress will have powerful levers at their disposal to roll back decades’ worth of progress in sexual and reproductive health and rights. As of mid-December 2016, few of the specifics are certain. What we do know is that many of the conservatives now in power — including Vice President Mike Pence and Tom Price, Trump’s nominee to head the Department of Health and Human Services (HHS) — have long histories of anti-abortion and anti-family planning activism — and long wish lists to match.

Several attacks are almost certain to come in January 2017. In his first week in office, President Trump is expected to reinstate the global gag rule, which would prohibit U.S. international family planning aid from going to foreign nongovernmental organizations that use their own, non-U.S. funds for abortion services or advocacy. That policy was first instituted by President Reagan and also was in place under the two Bush administrations. Historically, the gag rule has had the effect of forcing many family planning providers to fire staff, reduce services, or even close their clinics altogether, undermining patients’ access to needed care.1 Advocates worry that the new administration also might extend the policy to other global health accounts, such as HIV or maternal and child health.

ACA Under Attack

Also expected is an attempt by the new Congress to strike down much of the Affordable Care Act (ACA). Congressional leaders are planning to use a special process known as reconciliation, which is designed to ease passage of budget-related legislation and cannot be filibustered in the Senate, meaning that only 50 votes in the Senate (plus a tie-breaking vote by the vice president) would be needed. Through this process, Congress could repeal central provisions of the ACA, including the broad Medicaid expansions, the subsidies to make marketplace health insurance coverage affordable for low-income Americans, and the individual and employer mandates. Lawmakers may delay those effects for several years to give themselves time to work out a replacement, and to attempt to delay the impact past the 2018 elections. However, independent analyses predict that a repeal without an immediate replacement could leave insurance markets in chaos and result in millions of Americans losing coverage.2

Likely as part of the same reconciliation legislation, Congress also is expected to try to prohibit federal Medicaid funds from going to Planned Parenthood Federation of America and its affiliates. Along the same lines, the Trump administration is expected to reverse two recent Obama administration actions to protect family planning providers from discrimination by state agencies on the grounds that the provider is affiliated with Planned Parenthood or otherwise has ties to abortion: an April 2016 letter to state Medicaid directors and a regulation for the Title X program finalized in December 2016.3,4 Defunding Planned Parenthood has been a long-time goal of social conservatives, and the Obama administration and the federal courts have served as a bulwark against such attempts. Planned Parenthood health centers have an especially strong record of providing women with timely access to a wide range of contraceptive services and supplies, and excluding them from public funding would tear a severe gap in the safety net.5

Conservative policymakers also have vowed to roll back the ACA’s contraceptive coverage guarantee, which requires most private insurance plans to cover the full range of contraceptive methods and services for women at no out-of-pocket cost to them. The Trump administration could do this in several ways: eliminating it entirely (since contraception is not specifically included in the statutory provision requiring coverage of preventive services), broadening the religious exemption (so that employers that object to contraception on religious or moral grounds could exclude it from the health insurance they sponsor for employees and dependents), or reducing the range of contraceptive methods covered. Congress could eliminate or undermine this guarantee as well, either in a targeted way or in legislation that repeals or revamps the entirety of the ACA.

What May Come?

Beyond those immediate concerns, lawmakers may go after reproductive health and rights in numerous other ways in the months and years to come. Through the annual appropriations process, conservatives in Congress might seek to dismantle Title X — by defunding or cutting the program, denying funds to providers that have any association with abortion, or steering all the funds to state health departments and federally qualified health centers. In addition, Congress could defund teen pregnancy prevention programs and shift that money to abstinence-only-until-marriage programs. On the international front, Congress could make deep cuts to international family planning, including completely defunding the United Nations Population Fund.

Congress or the new administration could try to expand the scope of federal refusal rights for healthcare personnel, institutions, insurers, and employers. And, of course, anti-abortion members of Congress will be seeking to push through a wide range of measures on their wish list, such as extending the reach of the Hyde Amendment (which severely restricts abortion coverage for people insured by Medicaid), restricting minors’ access to abortion care, and restricting abortions based on the stage of pregnancy, the specific surgical method used, or the reason a woman is seeking the procedure.

REFERENCES

  1. Barot S, Cohen SA. The global gag rule and fights over funding UNFPA: The issues that won’t go away. Guttmacher Policy Review 2015;18:27-34.
  2. Blumberg LJ, Buettgens M, Holahan J. Implications of Partial Repeal of the ACA through Reconciliation. Washington, DC: Urban Institute; 2016.
  3. Centers for Medicare and Medicaid Services. SMD # 16-005 re: Clarifying “free choice of provider” requirement in conjunction with state authority to take action against Medicaid providers, April 19, 2016. Available at: http://bit.ly/1MGCxQ0.
  4. Office of Population Affairs, Department of Health and Human Services. Compliance with Title X requirements by project recipients in selecting subrecipients, RIN 937-AA04, Dec. 14, 2016. Available at: http://bit.ly/2hxruNW.
  5. Frost J, Hasstedt K. Quantifying Planned Parenthood’s critical role in meeting the need for publicly supported contraceptive care. Health Affairs Blog. Available at: http://bit.ly/1K4WVlL. Accessed Dec. 21, 2016.