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By Adam Sonfield
Senior Policy Manager
The future of the U.S. healthcare system is one of the key issues in the November 2018 elections. Depending on the outcome, the results could provide congressional conservatives and President Trump new opportunities to undermine or eliminate the Affordable Care Act (ACA), or grant new power to congressional progressives seeking to build on the ACA and further expand U.S. health coverage. Congress also may pursue compromise measures to tamp down rising insurance premiums, and could be forced to address the fallout from continued efforts to overturn the ACA in the courts. One common barrier to each of those goals will be anti-abortion conservatives’ long-standing campaign to eliminate private insurance coverage of abortion.1
Anti-abortion policymakers often have pursued this goal directly at the state level. Eleven states have abortion coverage bans on all state-regulated insurance plans, and many others bar coverage in specific markets.2 By contrast, at the federal level, abortion foes have used federal funding as their main lever against abortion coverage. They have succeeded when it comes to Medicaid: For more than four decades, the Hyde Amendment has barred federal funding for abortion coverage under Medicaid, except in cases of life endangerment, rape, or incest.
The ACA provided anti-abortion policymakers an opportunity to expand those restrictions to private insurance because the law included substantial new federal subsidies to help people afford insurance premiums and cost-sharing. In an attempt to meet the demands of anti-abortion lawmakers, the ACA segregates federal dollars from private dollars to ensure that no federal money pays for abortion coverage or services. However, the anti-abortion movement falsely argues that this policy allows for “indirect” funding of abortion, and has fought relentlessly for a more radical policy: to bar any health insurance plan that receives any amount of federal money from covering abortion.
This demand has been a primary objective for many conservatives throughout the Trump presidency. Every attempt by House and Senate Republican leaders to “repeal and replace” the ACA in 2017 included multiple abortion coverage restrictions along these lines. For example, the American Health Care Act, which passed the House in May 2017, would have barred abortion coverage in any individual or small employer plan receiving federal premium subsidies, and would have attached a similar restriction to a new block grant that states could use to stabilize their insurance markets, such as through direct payments to insurance companies or additional subsidies to individuals or employers buying coverage.3 The September 2017 proposal by Sens. Lindsey Graham (R-SC) and Bill Cassidy (R-LA) included similar restrictions as part of its much larger block grant and as part of its proposed expansion to the use of Health Savings Accounts.4
Anti-abortion politics also have helped to stop multiple bipartisan attempts to address rising insurance premiums. For example, in March 2018, proposals to offer new federal money for reinsurance (which would protect insurance plans against unexpected costs and thereby lower premiums) and to restore federal payments to insurers to offset cost-sharing reductions for low-income consumers (which President Trump terminated last fall, sparking substantial premium hikes) were derailed in part by anti-abortion lawmakers’ insistence on attaching abortion coverage bans.5 Supporters of abortion rights argued that doing so would effectively eliminate abortion coverage in ACA marketplace plans entirely and in any private insurance plan receiving reinsurance dollars.
Even without new federal restrictions, private coverage of abortion is already endangered by state-level restrictions and the ACA’s burdensome requirements to segregate funding. Even when abortion coverage is permitted, it often is unavailable.6,7 Yet, new coverage restrictions would do additional harm to availability. They also would endanger coverage in the four states — California, New York, Oregon, and Washington — that require state-regulated private insurance plans to cover abortion. A federal restriction could force those states either to stop enforcing their requirements or to lose billions in federal insurance subsidies.
Whether health insurance covers abortion has real-world financial implications for patients. An abortion typically costs around $500 at 10 weeks’ gestation, and considerably more later in pregnancy.8 That can be simply unaffordable without insurance: About one-third of lower income people say they would be unable to pay for an unexpected $500 medical bill, and another third would have to borrow money.9
Patients without abortion coverage report delaying payments for utility bills, rent, food, and other necessities to pay for the abortion procedure and related costs.10 Moreover, the time spent scraping together funds for an abortion can lead to delays in obtaining care, which can make it harder to find a provider and lead to increased costs and further delays.
In other cases, lack of abortion coverage can lead to an unwanted birth, with all the consequences that come with it. Most abortion patients say they cannot afford a child or another child, and that having a baby would interfere with their work, school, or ability to care for their other children.11
Financial Disclosure: Consulting Editor Robert A. Hatcher, MD, MPH, Nurse Planner Melanie Deal, MS, WHNP-BC, FNP-BC, Author Rebecca Bowers, Executive Editor Shelly Morrow Mark, Copy Editor Josh Scalzetti, and Editorial Group Manager Terrey L. Hatcher report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study.