By Jeffrey T. Jensen, MD, MPH, Editor

Leon Speroff Professor and Vice Chair for Research, Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland

Dr. Jensen reports that he is a consultant for and receives grant/research support from Bayer, Abbvie, ContraMed, and Merck; he receives grant/research support from Medicines 360, Agile, and Teva; and he is a consultant for MicroChips and Evofem.

Earlier this year, I reported on reproductive health policy changes proposed by the Trump administration that threatened to eliminate the family planning safety net by defunding Planned Parenthood and abolishing the contraception coverage mandate of the Affordable Care Act (ACA). Since taking office, the new administration has double-downed on these positions, and made administrative changes that undermine international family planning efforts by reintroduction of the global gag rule. Together, these domestic and international policies will reduce access to necessary family planning services and likely increase unintended pregnancy and abortion. In the wake of these discouraging developments, many states have quietly advanced legislation to mandate contraceptive coverage even if Congress repeals the protections of the ACA. Symptoms of these changes — a patchwork of laws around the country — have contributed to confusion among many women. Internationally, a reduction in U.S. support for family planning sends the wrong message to conservative governments opposed to contraception. The resulting undesired births threaten to further destabilize failed states and increase the pressure for economic migration. Many of these policy shifts have occurred through the action of deeply conservative political appointees unaffected by the political storm enveloping the executive branch and occupying the bandwidth of the media. We must return to a respect for evidence and facts, and women’s healthcare providers must use every opportunity to educate the public of the dire consequences of policy changes that endanger women’s health domestically and abroad.

The Trump administration has made good on a number of promises to roll back reproductive rights. As clinicians, we need to fight back to ensure access for our patients to essential services. This article seeks to document where we stand as of summer 2017, and present opportunities for engagement.

The Global Gag Rule

Trump signed an executive policy to re-institute and expand antiabortion restrictions in U.S. foreign aid. The United States first instituted these policies under the Reagan administration in 1984 (Mexico City policy). The order bans U.S. assistance for family planning programs overseas to foreign nongovernmental organizations that used their own non-U.S. government funding to provide abortion services, information, counseling, or referrals, or to advocate for liberalizing or otherwise improving their country’s abortion laws. Since then, the restrictions have been lifted by every Democratic president, and reinstated by every Republican. Congressional approval is not required.

The ruling affects more than a billion women in 64 countries, disrupting critical healthcare services that also provide maternity services and response to outbreaks such as Zika virus.1 Removing U.S. funding from clinics disrupts long-standing relationships and encourages anti-family planning agendas in many nations with high fertility rates. Simply said, this is the wrong message delivered at a critical time when nations desperately need to empower women and stabilize populations to improve standards of living and reduce poverty. Evidence supports that the global gag rule increases the risk of unplanned pregnancy and illegal abortion, both negative consequences for maternal health. I imagine how the world must look at our policy. We turn our backs on family planning assistance, an action that will increase fertility and poverty, and lead to economic migration. We propose to build a wall around our wealth and increase trade barriers to further impoverish many low-income nations. We complain about illegal immigrants.

The Supreme Court

The confirmation of Neil Gorsuch to the Supreme Court fulfilled a campaign promise by President Trump and the Republican-controlled Congress. Delivery of this Supreme Court seat to a pro-corporate conservative justice will threaten reproductive rights and meaningful campaign finance reform laws for a generation. Although many argue that the confirmation of Gorsuch simply returns the balance of power to that seen with Anthony Scalia, this cannot be viewed as positive for women. States continue to pass significant restrictions on abortion access, and, undoubtedly, we will see a law that threatens to invalidate Roe v. Wade to the court. A missed opportunity to create a firewall for abortion rights through a shift in power in the court means that advocates must continue to invest significant resources to strategically fight restrictions at the state level. Clinicians need to educate their patients and communities of the importance of abortion rights and donate to these causes.

Changes in Contraception Coverage

The house passed the American Health Care Act (AHCA), the repeal and replace legislation for the ACA. Let’s review how the provision for subsidized private plans helped more people get coverage under the ACA.2 Between 2013 and 2015, the proportion of women 15-44 years of age who were uninsured fell by 36%. Allowing states (31 states and the District of Columbia) to expand Medicaid eligibility to individuals with incomes up to 138% of the federal poverty level has been a particular benefit to single women. Individuals with incomes between 100% and 400% of the federal poverty level get refundable tax credits to lower the cost of their monthly premiums. Even without repeal of the ACA, the Trump administration has created market uncertainty resulting from concern over the future of these reforms, causing major insurers to withdraw from the exchanges. This may accelerate efforts to pass substitute legislation that will increase the number of uninsured and eliminate comprehensive coverage for family planning.

The ACA mandated that marketplace plans cover core sexual and reproductive health services. All marketplace plans must cover a set of 10 “essential health benefits,” including maternity and newborn care. This requirement has resulted in more comprehensive coverage for everyone. Prior to the ACA, only 12% of individual private insurance plans provided comprehensive maternity coverage and 79% provided no coverage. Although members of some communities have focused on the requirement for mandatory contraception coverage as a reason to oppose the ACA, as clinicians we should understand how these comprehensive requirements support the reproductive life cycle needs of our patients. It is also important to note that the ACA does not mandate coverage for abortion or use federal funds for abortion care. Although many advocates (including me) would argue strongly for inclusion of this coverage, abortion has never been part of the ACA, so objections to family planning services, which reduce the number of abortions,3 ring hollow. As obstetricians and gynecologists, we should strongly advocate for comprehensive family planning and maternity care. The American Congress of Obstetricians and Gynecologists (ACOG) agrees with me. ACOG President Haywood Brown reported in the June 2017 edition of ACOG News that the Trump administration may soon move to dismantle the ACA provision for no-cost access to contraceptive coverage. In the words of Brown: “This move, coupled by House passage of the American Health Care Act, exhibits a deep disregard for women’s health.”

Estimates from the Congressional Budget Office suggest that the AHCA would increase the number of uninsured by 14 million one year after enactment and 23 million over the next decade.4 Premiums would increase and benefits would decline. Maternity coverage in states that do not require this as an essential health benefit could increase by as much as $12,000 per year. As I write this, the prospect for repeal and replacement of the ACA in the Senate seems slim given the failure of the “skinny” repeal by one vote, but this does not erase the concern for selective reductions in coverage that harm women through a Senate bill. The administration has indicated a willingness to collapse the ACA through non-enforcement of the insurance mandate and by withholding subsidies to insurers intended to stabilize the market.

State-level Changes

Even in the absence of repeal of the ACA, administrative actions may lead to a dramatic race by conservative states to further erode reproductive health coverage. Texas has requested a waiver from the Trump administration to reinstate federal Medicaid funds forfeited in 2011, when the state excluded all organizations that perform or “promote” abortions, including Planned Parenthood, from participating in the program. As a result, tens of thousands of low-income Texas women have lost access to family planning and other preventive services. If Texas is successful, other states may follow this lead. See the March issue of OB/GYN Clinical Alert for more details on the vital importance of Planned Parenthood clinics.5

On the positive side, many states have passed legislation to ensure reproductive health coverage even if changes occur at the national level. On June 9, Nevada’s Republican Governor Brian Sandoval signed legislation requiring insurers to cover 12 months of birth control at a time, with no copayment, joining 28 other states with contraception equity laws.6 I encourage all of you to contact your elected officials to demand adoption of a similar measure in your state.

Abortion Coverage

A sad fact is that the public policies proposed by the Trump administration will disproportionately burden the poor. Many Americans with employer-based health insurance feel insulated from the effect of policy changes, as they do not see themselves at risk. Conservative think tanks have successfully promoted a narrative of tax burden, wasteful spending, and government incompetence. We then elect conservative leaders who reinforce this illusion by cutting taxes, thereby reducing our social safety net and increasing stress on the system. The erosion of public education and public health significantly reduce the opportunity to move out of poverty.

Abortion providers will talk about the two kinds of women who seek abortion: poor women with unintended pregnancy who need routine abortions, and well-to-do women who require “special” abortions for unintended pregnancy due to “unique” circumstances. This entitled class around the world always has and always will have access to abortion care, regardless of the law.

A third type of patient has become increasingly common: women with desired pregnancies with serious fetal chromosomal or developmental abnormalities. The decision to choose abortion in the setting of a deeply desired pregnancy requires tremendous courage. I have spent hours counseling couples on options for these tragic losses. It boils my blood that referrals frequently come from qualified obstetricians practicing in Catholic hospitals. This seems like abandonment by the physician in a moment of deep emotional vulnerability. Why do clinicians offer testing, including invasive procedures like amniocentesis, if they cannot provide counseling and services in the event of an abnormal outcome? In my state of Oregon, women (including those on Medicaid) typically have healthcare coverage for abortion. Imagine providing information on a lethal fetal anomaly to one of your patients and discovering that her insurance cannot cover an abortion procedure for any indication?

The AHCA includes language barring federal money from being used to support any private insurance plan that covers abortion6 — any abortion for any indication. Since only those plans that did not include abortion coverage would be eligible for federal tax credits, it seems likely that no plans in the individual market would include this coverage. Although women would be allowed to purchase a separate rider for abortion care, few would likely do so as most don’t anticipate the need. Even if you don’t provide abortion care, consider how that might affect your practice.

Perhaps this is your current reality. Twenty-five states bar abortion coverage in the ACA’s insurance marketplaces, 10 additional states bar abortion coverage under any private insurance plan the state regulates, and 21 states specifically bar abortion coverage for public employees.7 Including military and federal employees further increases the coverage gap.

About four in 10 privately insured abortion patients use insurance to pay for the procedure.6 Although the average cost of $500 for a first-trimester abortion represents a financial difficulty for many low-income women, a second trimester dilation and extraction or induction abortion could cost several thousand dollars. Imagine the grief facing your privately insured patient on the discovery of a lethal fetal anomaly at 20 weeks, compounded by the shock of learning she will need to pay thousands of dollars out of pocket for a necessary healthcare procedure. I doubt most couples consider this scenario as they plan pregnancy.

Repeal of the Affordable Care Act

As of July 18, Mitch McConnell withdrew the Senate bill to repeal and replace the ACA, after more public defections from Republicans indicated that the legislation would not pass. McConnell attempted to submit a simple repeal bill, but a number of Senate Republicans also refused to support this effort (despite voting for repeal during the Obama presidency). This initial chapter came to an end with the 51- 49 vote against the “skinny repeal” bill on July 28. The response from the president: “Let Obamacare fail.” The administration can use several approaches (not enforce individual mandate, not reimburse insurers for subsidies to reduce out-of-pocket costs for low-income patients) that would destabilize the insurance marketplace. Will Republicans and Democrats work together to protect our healthcare system, or will they throw millions of Americans under the bus (without insurance coverage!) for partisan gain? Compromises that reduce comprehensive family planning and maternity benefits will be key for women’s healthcare providers.

Conclusion

Our lives and practices are busy, and I recognize that thorny political discussions are not everyone’s cup of tea. However, I strongly believe in our obligation as clinicians to improve both individual and public health. The acceptance of “alternative facts” degrades humanity and threatens our society. Reproductive rights have not always been a partisan issue. Thirty years ago, support for reproductive rights and the scientific process was overwhelmingly bipartisan. As clinicians and trusted members of our communities, we need to heal our society by using every opportunity we have to communicate facts and combat “alternative facts.” I will repeat my words from March: Our collective voices have great influence. Silence on these matters suggests acquiescence.

REFERENCES

  1. Barot S. When Antiabortion Ideology Turns into Foreign Policy: How the Global Gag Rule Erodes Health, Ethics and Democracy. Guttmacher Policy Rev 2017;20:73-77.
  2. Hasstedt K. How Dismantling the ACA’s Marketplace Coverage Would Impact Sexual and Reproductive Health. Guttmacher Policy Rev 2017;20:48-52.
  3. Secura GM, Madden T, McNicholas C, et al. Provision of no-cost, long-acting contraception and teenage pregnancy. N Engl J Med 2014;371:1316-1323.
  4. Congressional Budget Office Cost Estimate. H.R. 1628. American Health Care Act of 2017. Available at: https://www.cbo.gov/system/files/115th-congress-2017-2018/costestimate/hr1628aspassed.pdf. Accessed Aug. 10, 2017.
  5. Jensen JT. Reproductive Rights in 2017: Standing Strong for Women. OB/GYN Clinical Alert 2017;33:85-88.
  6. Stolbergjune CA. States Lead the Fight Against Trump’s Birth Control Rollback. The New York Times Available at: https://www.nytimes.com/2017/06/09/us/politics/states-lead-the-fight-against-trumps-birth-control-rollback.html?smprod=nytcore-ipad&smid=nytcore-ipad-share&_r=0. Accessed July 18, 2017.
  7. Sonfield A. Conservatives Are Using the American Health Care Act to Restrict Private Insurance from Covering Abortion. Guttmacher Health Policy Blog 2017.