Guttmacher Policy Review GPR 2016 | Vol. 19 Abortion in the Lives of Women Struggling Financially: Why Insurance Coverage Matters By Heather D. Boonstra bortion has been legal throughout the HIGHLIGHTS United States for more than 40 years, but it remains one of the country’s hottest Although the U.S. abortion rate has reached its lowest level political flashpoints. Republican presiden- • A since 1973, abortion is increasingly concentrated among low- tial candidate Donald Trump stumbled into it when income women. he said in a TV interview that if abortion were made illegal, women seeking one should be crimi- • The Hyde Amendment, in effect since 1977, essentially bans nally punished—a statement that he later tried federal dollars from being used for abortion coverage for to reframe with a more formal announcement women insured by Medicaid, the nation’s main public health that he is “prolife with exceptions.”1 Meanwhile, insurance program for low-income Americans. Democratic presidential hopefuls Hillary Clinton • Women who are low-income and lack insurance coverage and Bernie Sanders have both called for expand- for abortion often struggle to come up with the money to pay ing access to abortion by ending the Hyde for the procedure. As a result, they often experience delays Amendment. At a campaign rally in January, obtaining an abortion or are forced to carry their unintended Clinton said the policy only makes it harder for pregnancy to term. low-income women to exercise their full rights: • Supporters of abortion rights have coalesced behind several “Any right that requires you to take extraordinary state- and national-level initiatives that aim to end the Hyde measures to access it is no right at all,” she said.2 Amendment, so that the nation’s poorest women have greater access to safe and legal abortion care. The Hyde Amendment, named after the late Rep. Henry Hyde (R-IL), is in many ways the grandfa- ther of all abortion restrictions. It was passed in 1976, went into effect in 1977 and was upheld by the U.S. Supreme Court in 1980. Since that time, stave off the surge of abortion restrictions in recent the Hyde Amendment has severely restricted abor- years, challenges to the Hyde Amendment—in the tion coverage for women insured by Medicaid states and Congress—mostly have languished on and, in turn, has made real reproductive choice a the back burner. Now, advocates for abortion rights privilege of those who can afford it, rather than a are working to change that by shining a light on the fundamental right. importance of abortion coverage and putting the abortion rights movement back on the offensive. Having presidential candidates firmly commit to lifting the Hyde Amendment is not new, but it is Abortion and Low-Income Women a welcome advancement to reproductive rights Over the last several decades, substantial prog- activists. (Similar endorsements from congres- ress has been made toward enabling American sional candidates will be important too, given that women and their partners to control their child- ending the Hyde Amendment will require an act bearing. Improved contraceptive use has helped of Congress.) While policymakers supportive of women to better avoid unintended pregnancies, abortion rights have devoted much effort trying to and as a result of fewer unintended pregnancies, Guttmacher Policy Review | Vol. 19 | 2016 www.guttmacher.org 46 the overall abortion rate declined to 17 per 1,000 across the United States—found that for more women aged 15–44 in 2011, the lowest since 1973 than half of women who received an abortion, (see “New Clarity for the U.S. Abortion Debate: A their out-of-pocket costs (for the procedure, Steep Drop in Unintended Pregnancy Is Driving as well as for travel and hotel, if needed) were Recent Abortion Declines,” 2016).3,4 equivalent to more than one-third of their monthly personal income.11 But not all women are sharing equally in this prog- ress. Although the rate of unintended pregnancy Other studies show that many Americans do not among low-income women declined between have adequate savings to cover a financial emer- 2008 and 2011, major disparities remain. In 2011, gency of any kind. In 2013, the Federal Reserve the unintended pregnancy rate among women Board conducted a nationally representative with an income below the federal poverty level household survey designed to “monitor the finan- ($18,530 for a family of three that year5) was more cial and economic status of American consum- than five times that among women with an income ers.”12 The survey asked respondents how they at or above 200% of poverty (112 vs. 20 per 1,000 would pay for a $400 emergency, and 47% said women aged 15–44).6 And because of this high rate either that they would cover it by borrowing or of unintended pregnancy, women who are strug- selling something, or that they would not be able gling financially experience high levels of abortion. to come up with the money. Indeed, over the last few decades, abortion has Enter Hyde become increasingly concentrated among the In 2015, roughly 90% of Americans had health poor. In 2014, 49% of abortion patients had a fam- insurance coverage to help defray the costs of any ily income below the federal poverty level—up medical bills.13 However, unlike most other types from 27% in 2000.7, 8 An additional 26% of abortion of health care services, abortion is highly politi- patients in 2014 had an income that was 100–199% cized, and insurance coverage for abortion has of the poverty threshold. In other words, 75% of been the target of severe restrictions. abortions in 2014 were among low-income patients. Forty years ago, in the wake of Roe v. Wade, The reasons women give for having an abortion Congress passed the Hyde Amendment—which underscore their understanding of the economic bans the use of federal funds for abortion services impact unplanned childbearing would have on in all but the most extreme circumstances—by themselves and their families. Most abortion attaching it to the annual spending bill funding patients say that they cannot afford a child or what is now the Department of Health and Human another child, and most say that having a baby Services. From the start, antiabortion politicians would interfere with their work, school or ability have acknowledged that, without a path to ban to care for their other children.9 Most women also abortion outright, they have used the power of the cite concern for or responsibility to other individu- purse to interfere with women’s decision-making als as a factor in their decision to have an abor- around abortion. During debate over the measure, tion. These concerns make particular sense when Hyde told his colleagues, “I certainly would like to one considers that six in 10 women who have an prevent, if I could legally, anybody having an abor- abortion are already a parent.7 tion, a rich woman, a middle-class woman, or a poor woman. Unfortunately, the only vehicle avail- Unfortunately, for a pregnant woman who is able is the…Medicaid bill.”14 already struggling to get by, the cost of an abor- tion may be more than she can afford on her own. The Hyde Amendment was hotly debated through- The average amount paid for an abortion at 10 out the 1970s and has changed over time. In weeks’ gestation was $480 in 2011–2012.10 The 1980, the U.S. Supreme Court upheld the Hyde University of California, San Francisco Turnaway Amendment, ruling that the Hyde restrictions do not Study—a five-year longitudinal study of roughly interfere with the right recognized in Roe because 1,000 women seeking abortion care at 30 facilities “a woman’s freedom of choice [does not carry] Guttmacher Policy Review | Vol. 19 | 2016 www.guttmacher.org 47 with it a constitutional entitlement to the financial of state funds to cover abortions for low-income resources to avail herself of the full range of pro- women enrolled in Medicaid, but just 15 states tected choices.” Justice William Brennan wrote in appear to be doing so in practice (see map).15 a dissenting opinion that the Hyde Amendment (Arizona and Illinois are funding so few abortions “is nothing less than an attempt by Congress to that they appear to be in violation of their court circumvent the dictates of the Constitution and orders.16) In states where Medicaid covers abortion achieve indirectly what Roe v. Wade said it could services, 89% of abortion patients with Medicaid not do directly.” Also of concern to the justices was used their insurance to access abortion care.7 the fact that Hyde specifically targets the constitu- tional rights of poor women. The Hyde Amendment, In addition to the Hyde Amendment itself, Congress wrote Justice Thurgood Marshall, “is designed to has enacted numerous laws that similarly restrict deprive poor and minority women of the constitu- abortion coverage or services for other groups tional right to choose abortion.” of women who obtain their health insurance or health care from the federal government, includ- Since fiscal year 1994, the Hyde Amendment ing federal employees, military personnel, federal has limited federal reimbursement for abortions prison inmates, poor residents of the District of under Medicaid to cases of rape, incest or when a Columbia (because Congress has jurisdiction over woman’s life is threatened. The harmful impact of the District’s policy) and Native American women the Hyde Amendment is only mitigated for women (see graphic). These policies have changed over who happen to live in states that use their own time and all now mirror the Hyde Amendment, in funds to provide abortion coverage for Medicaid that they include exceptions in cases of rape, incest recipients.