This summer, after a series of deceptive undercover videos falsely claimed to show Planned Parenthood staff selling fetal tissue, conservative lawmakers in Congress threatened to shut down the government over any federal budget that included funding to the healthcare provider. While the political debate over abortion continues, for many women, Planned Parenthood is their only option for reproductive healthcare, including birth control, screenings for sexually transmitted infections (STIs), cancer screenings and treatment and abortion. Political posturing against Planned Parenthood and ideological opposition to abortion cloud the root issues of reproductive health inequities and distract from poorer health outcomes based on sex, race and class marginalization that have persisted for decades.
Professor and public health scholar Margaret Whitehead described health inequities in “Concepts and Principles for Tackling Social Inequalities in Health,” her groundbreaking 1990 paper, as “differences [in health] which are unnecessary and unavoidable but, in addition, are also considered unfair and unjust.” Since Whitehead published her paper, ideological opposition to reproductive healthcare—specifically, abortion—has grown and contributed to widening disparities.
HYDE: ‘A CRUEL BLOW’
For a short time after abortion was legalized by the Supreme Court in Roe v. Wade, Medicaid did not distinguish between coverage for abortion and other medical services. Then emerged the Hyde Amendment—the epitome of social, economic and reproductive health injustice facing low-income women and women of color. The Hyde Amendment prohibits Medicaid coverage of abortion services except in the most dire circumstances—pregnancies from rape or incest or that endanger the life of the woman. Rep. Henry Hyde of Illinois intended that his rider to the annual appropriations bill for the Departments of Labor, Health, Education and Welfare (now known as the Department for Health and Human Services) would discriminate against low-income women.
Once the Hyde Amendment went into effect, abortion coverage was eliminated except in very limited circumstances, leaving a disproportionate number of low-income women and women of color struggling to get by. Passage of the Hyde Amendment was one of the first major blows to abortion access post-Roe, setting a precedent that dispatched a flurry of abortion restrictions in its wake.
In the landmark case Harris v. McRae, a closely divided Supreme Court upheld the constitutionality of the Hyde Amendment. Justice Thurgood Marshall, the court’s first African American justice, wrote in his dissent:
“The Court’s opinion studiously avoids recognizing the undeniable fact that, for women eligible for Medicaid—poor women—denial of a Medicaid-funded abortion is equivalent to the denial of legal abortion altogether. By definition, these women do not have the money to pay for an abortion themselves…. Because legal abortion is not a realistic option for such women, the predictable result of the Hyde Amendment will be a significant increase in the number of poor women who will die or suffer significant health damage because of an inability to procure necessary medical service…. The Court’s decision … represents a cruel blow to the most powerless members of our society.”
Restrictions on Medicaid coverage for abortion serve only to deepen the economic divide between the haves and the have-nots. As Justice Marshall predicted, some women can afford an abortion, whereas other women, inordinately low-income and women of color, struggle to make ends meet. The Hyde Amendment further compounds the reproductive oppression of low-income women and women of color. Abortion is a common occurrence, with one in three women having an abortion in her lifetime. But with the focus of abortion discourse so squarely on ideology and politics, it becomes easy to lose sight of reproductive healthcare within the broader context of women’s lived experiences.
WHEN ABORTION IS OUT OF REACH
Prohibiting Medicaid coverage of abortion harms the health and well-being of low-income women and women of color. Some women must delay their treatment until it is much more costly and medically complicated while they scrape together the money for the procedure. They may have to divert money for rent, their children or food, or even sell their belongings to afford abortion care. According to a study by Rachel K. Jones and Megan L. Kavanaugh of the Guttmacher Institute, approximately 42 percent of abortions occur among low-income women living below 100 percent of the federal poverty level (FPL), and 69 percent of abortions occur among women below 200 percent of the FPL ($20,090 and $40,180, respectively, for a family of three in 2015). The same study found that approximately 60 percent of women who obtain an abortion are already mothers, with more than 30 percent already having two or more children.
Some women may be unable to come up with the money for an abortion and are instead forced to continue the pregnancy. Approximately 18 to 37 percent of women on Medicaid who would otherwise have gotten an abortion are forced to continue a pregnancy due to the lack of coverage. Researchers at the University of California San Francisco found in the Turnaway Study that a woman who is denied abortion care is three times more likely to slip into poverty than a woman who is able to get an abortion.
FALLING THROUGH THE MEDICAID SAFETY NET
Hyde is one among many attacks on the safety net that contribute to persistent health disparities and lack of access to quality healthcare for underserved women. Many states still refuse to expand the Medicaid program under the Affordable Care Act (ACA), which would provide coverage for more low-income adults. States—largely concentrated in the South, including Alabama, Georgia, Louisiana, Mississippi and Texas—have publicly declared their opposition to Medicaid expansion. Political opposition to the healthcare law and Medicaid expansion—often based on distortions of the facts—disproportionately harms low-income people of color. For example, approximately 34 percent of the almost three million uninsured African American adults who would otherwise be eligible for Medicaid fall in the “coverage gap” (meaning they make too much to qualify for Medicaid and too little to be eligible for premium tax credits to purchase marketplace coverage).
Under the ACA, the federal government assumes 100 percent of the cost for Medicaid expansion to newly eligible individuals for the first three years and no less than 90 percent of the cost thereafter. The Center on Budget and Policy Priorities estimates that the federal government will pay approximately 95 percent of Medicaid expansion costs over the next 10 years (2016–2025). And yet, Mississippi governor Phil Bryant told the Associated Press why he chose not to expand Medicaid: “For us to enter into an expansion program would be a fool’s errand…. I mean, here we would be saying to 300,000 Mississippians, ‘We’re going to provide Medicaid coverage to you,’ and then the federal government through Congress or through the Senate, would do away with or alter the Affordable Care Act, and then we have no way to … continue the coverage.”
Three states—Alabama, Arkansas and Louisiana—have already taken action to cut Medicaid funding to Planned Parenthood as a result of doctored videos released late this summer. In Arkansas, Gov. Asa Hutchinson ordered the state Department of Human Services to terminate its Medicaid contract with the organization. The state reported that Planned Parenthood received approximately $51,000 in Medicaid payments during the last fiscal year to pay for family planning and gynecological services, not including abortion. However, as of this writing, a federal judge has temporarily prevented Arkansas from excluding Planned Parenthood from the state Medicaid program. Planned Parenthood has also taken Alabama governor Robert Bentley’s administration to court over his decision to end Medicaid payments to two of their clinics in the state. Alabama has provided less than $5,000 in Medicaid funds to Planned Parenthood over the last two years, and this money went to cover contraception and other preventive healthcare for Alabama women.
Louisiana governor Bobby Jindal joined in, stating that “Planned Parenthood does not represent the values of the people of Louisiana and shows a fundamental disrespect for human life.” Never mind that Planned Parenthood provided healthcare to more than 5,200 women in Louisiana, that nearly one in five women in the state is uninsured or that Louisiana ranks sixth in the nation for cervical cancer deaths—many of which could be prevented by the screening and treatment that Planned Parenthood provides, according to Steve Spires of the Louisiana Budget Project. The very services that Planned Parenthood delivers address some of the most pronounced health disparities in Louisiana.
Alabama, Arkansas, and Louisiana rank among those with the highest poverty rates, with almost one-fifth of the population living below the poverty line in 2013, according to census data. They also generally fare poorer on key health indicators among many underserved communities. The Medicaid payments that they are seeking to withhold from Planned Parenthood represent only a small fraction of what is likely needed to address the unmet healthcare needs of low-income communities and people of color within these states, but these populations need a greater investment in their health, not less.
POORER HEALTH OUTCOMES
Health coverage matters. Low-income women and women of color consistently have poorer reproductive health outcomes than their white counterparts, and these disparities are only exacerbated by Hyde and other abortion restrictions:
- According to Centers for Disease Control and Prevention (CDC) statistics, women of color experience unintended pregnancy at twice the rate of their white counterparts, with rates generally higher in the South.
- According to the CDC, of all new diagnoses of HIV infections among women in the United States, 64 percent were African American women. In addition, according to a joint report to the United Nations Committee on the Elimination of Racial Discrimination from the Center for Reproductive Rights, African American women die during childbirth at a rate three to four times that of their white counterparts. Not coincidentally, many of the states with the highest maternal mortality rates and number of new HIV infections are concentrated in the South—the same states refusing to expand their Medicaid programs under the ACA.
- Though there is a paucity of data, the CDC has found that American Indian and Alaska Native (AI/AN) women suffer from intimate partner violence and sexual assault at rates far exceeding women of other racial and ethnic groups. Nearly half of all AI/AN women have experienced rape, physical violence and/or stalking by an intimate partner. Yet reproductive healthcare from the Indian Health Service follows similar restrictions as the Hyde Amendment—or may even be more restrictive, according to a 2014 article in the American Journal of Public Health.
- Lawfully present immigrant women are explicitly denied access to Medicaid coverage for at least five years. The CDC has found that Latina women are 45 percent more likely to be newly diagnosed with cervical cancer, which is largely preventable with early screening and treatment, and 40 percent more likely to die from the disease than white women.
- Screening rates of Pap tests among Asian/Pacific Islander women are disproportionately low, with one study estimating that only 35 percent of women of Chinese, Vietnamese, Korean or Cambodian descent report having had a Pap test. A study led by Victoria M. Taylor found that cervical cancer disparities are particular pronounced among Vietnamese American women, who are over five times more likely to be diagnosed with invasive cervical cancer than their white counterparts.
- As Florida representative Lois Frankel pointed out, the movement to defund Planned Parenthood failed to grasp how big of an impact the organization has on women’s lives: “If you want to have a truthful debate, then let’s talk about the 400,000 Pap smears, the 500,000 breast exams, the 4.5 million STD and HIV tests that Planned Parenthood does each year.”
FOCUSING ON THE ‘INVISIBLE’
All women need access to comprehensive reproductive healthcare that is patient-centered and evidence-based. Abortion coverage is reproductive healthcare just like contraception, maternity care and STI screenings—and it should be available to all individuals regardless of income or socioeconomic status. Abortion must be considered within the context of a seamless continuum of a woman’s reproductive healthcare across her lifespan. Anything less only jeopardizes her health and can push her deeper into poverty.
Repealing the Hyde Amendment is one of the most pressing public health and economic justice issues of our time. Although efforts to erode women’s access to abortion and comprehensive reproductive healthcare show no signs of abating, it is encouraging that Rep. Barbara Lee (D-CA) and other women’s health champions in the House introduced the Equal Access to Abortion Coverage in Health Insurance (EACH Woman) Act. This bill would put an end to discriminatory abortion coverage restrictions like Hyde and instead allow a woman to make personal healthcare decisions that are best for herself and her family.
As the debate over abortion continues, advocates for social justice and health equity must not allow the most underserved and marginalized communities who will be most harmed by these destructive policies to be left out of the conversation or—as race and gender scholar and professor Kimberlé Crenshaw puts it—“invisible in plain sight.”