On June 24, 2022, Justice Alito “delivered the opinion of the court” in Dobbs v. Jackson Women’s Health Organization, and in doing so marked the end of Roe v. Wade and eliminated the federal right to abortion.1 State abortion bans began going into effect within hours of the fall of Roe, and 12 months after this US Supreme Court ruling, the landscape of abortion laws in the United States is drastically changed. As of the writing of this issue brief, abortion is banned in 13 states and unavailable in another due to ongoing legal uncertainty.2 Six other states have imposed gestational bans that would have been blatantly unconstitutional under Roe, and additional bans are expected to take effect soon. True to the legacy of so many US policies aimed at sexual and reproductive health, the burden of this ruling and subsequent restrictions is disproportionately borne by historically and currently marginalized communities.3
This distinctly fluid and fiercely contentious policy environment presents unique challenges. The breakneck pace of policy proposals, enactments, reversals and implementation blockades makes policy tracking difficult. Understanding the implications for individuals seeking abortion services, health care providers, social support networks and medical education, among many other effects, is similarly challenging to monitor. Yet, performing that difficult task of tracking the lifecycle of health policies—from the policy development process through passage and assessment of impacts—enhances our collective ability to identify, assess and address the racial inequities that health policy can produce.
Several frameworks for policy analysis have relevance and adaptability for this complex environment. For example, one such framework focuses on a trauma-informed approach to social policy analysis and advocacy and represents, according to its authors, “a pathway for public health professionals to disrupt trauma-driven health disparities through policy action.”4 Another, the advocacy coalition framework, which has been used globally for a variety of policy areas, is a multifaceted framework that posits that the underlying beliefs and ideas motivating a given policy are the causal drivers for political behavior and differential policy.5–7 A limitation of these and many existing frameworks is that they do not necessarily center equity when considering the upstream drivers of policy content or the implementation and postimplementation factors that result in detrimental policy effects.
In the years leading up to the Dobbs decision, stark inequities revealed by the COVID-19 pandemic renewed and heightened focus on racial inequities in health care and health policy. Concurrently, the murder of George Floyd and subsequent massive surge of antiracism activism in the United States and throughout the world have brought greater awareness to the need to apply a racial equity lens to our current policy landscape and thus highlight how implicit forces (such as ideas) and explicit forces (such as structural factors) shape policies and their impact on people’s lives.
The Racial Equity and Policy (REAP) framework8 does just that. This issue brief focuses on the application of this highly relevant, if not prescient, tool that was published a mere six months before the Dobbs decision. REAP can be particularly valuable in coordinating research, policy analysis and advocacy for the benefit of—and reflective of the voices and leadership of9—marginalized groups. Below we give brief examples of ways the REAP framework can help guide the analysis of sexual and reproductive health and rights policies. Through its application in these examples and in our work more broadly, we aim to uncover additional pathways that enhance our comprehension and influence policy analysis and advocacy, ultimately fostering greater equity in a post-Dobbs landscape.
Applying the REAP Framework for Policy Assessment and Advocacy
In this issue brief, we offer two examples of how the REAP framework can yield nuanced and cohesive insights by integrating data and science into systematic assessment of sexual and reproductive health, rights and justice (SRHRJ) policies through a racial equity lens. Although we have limited our analysis to US policies, we recognize that the REAP framework applies equally to global work.
The REAP framework calls for a process-oriented perspective to guide analysis of the policy environment in order to illuminate and enhance “our ability to identify, examine, and eradicate racial inequity through health policy”.8 The framework posits that policy choices are shaped by six domains in the policy environment: institutions, actors, ideas, events, networks and context. Within and across each of these domains, three key themes—disproportionality, decentralization and voice—are interrogated as being “key considerations that emerge from a process-oriented perspective on racial equity and health policy.” The utility of the REAP framework is the critical questions it poses to users when considering each of the three themes.
Example 1: Examining the Hyde Amendment and related policies using REAP
The Hyde Amendment, passed three years after Roe v. Wade was decided, prohibits the use of federal funding for abortion, thereby preventing people enrolled in Medicaid and other public programs in most states from using their health insurance to cover abortion care.10 Although states have had some flexibility to fund abortion services, they have not done so universally, and coverage levels vary widely among those that do cover abortion care. As a result, for more than 40 years, the Hyde Amendment has perpetuated inequality by selectively presenting barriers to accessing abortion services for individuals with low incomes, particularly people of color. Moreover, it has been used as the basis for subsequent policies to restrict abortion access for other groups, including military personnel and their dependents, federal employees, women insured by Indian Health Services, incarcerated individuals and others. While some of these restrictions have been lifted, the post-passage process has heightened inequalities. Using the REAP Framework’s themes of disproportionality, decentralization and voice, as reflected within the domain of events, we can better understand the context that drove this decision and its impact.
- Regarding decentralization, the framework asks, “What are the relevant events or policies at the national, state or local level?” Since Medicaid is a joint federal-state program, Medicaid policy on abortion care is decentralized, with states able to use their own funds to cover abortion care through Medicaid. Unfortunately, most states follow the federal standard set by the Hyde Amendment and leave those who qualify for public health insurance without coverage for this critical care.9 This disproportionately impacts Black women and other people of color, who are more likely than other groups to have low incomes, due to systemic racism. By 2015, there were 15 states covering abortion through Medicaid either voluntarily or through court order;11 as of this writing, that number has increased only slightly, to 17.12,13
- Regarding disproportionality, the framework asks readers to consider, “How have these events or policies affected communities of color?” People who are unable to obtain a wanted abortion due to regulatory and financial barriers, including those imposed by the Hyde Amendment, face an array of adverse impacts.14,15 Black and Brown people, as well as other vulnerable groups, are disproportionately affected by Hyde and bear a disproportionate share of the burdens it imposes.9
- Regarding voice, the framework asks readers to reflect on, “How salient or significant are the effects of events or policies on communities of color?” Hyde and state-level restrictions on abortion access have spurred the creation of two important pieces of federal legislation: the Equal Access to Abortion Coverage in Health Insurance Act (EACH Act)16,17 and the Women’s Health Protection Act (WHPA).18,19 The different manner in which Congress has addressed the introduction (or reintroduction) of these bills offers a recent and powerful example of the saliency of voice in public policy. The EACH Act was designed to “reverse the Hyde Amendment and related abortion coverage restrictions,” and the campaign supporting it is led by a reproductive justice advocacy organization and coalition.20 WHPA, on the other hand, was designed to “re-establish a nationwide right to access abortion care in the United States,” and the campaign supporting it is led by a reproductive rights coalition not focused on reproductive justice. While there is a great deal of overlap among organizational members of the EACH and WHPA campaigns, the voice of reproductive justice and reproductive rights is different.21 For EACH, the voice of this coalition led by people of color has been incorporated into both the House bill and the Senate bill, which specifically and robustly lift up the disparate effects of the Hyde Amendment. For WHPA, the reproductive justice voice was included in the House bill but excluded from the Senate bill; a distinction that prompted reproductive justice leaders to lift their voices in the media.22
Example 2: Examining the US Food and Drug Administration (FDA) risk evaluation and mitigation strategy (REMS) for mifepristone using REAP
The REAP framework is also useful in considering mifepristone access, as access to medication is an important facet of health equity. Although the framework identifies six key domains, we focus here on just two—the domains of institutions and actors. Per the framework, “each policy reflects the operation of a distinct set of actors and institutions at varying levels of government…Institutions form the boundaries these actors work within (and sometimes against) to determine which policy choices to oppose or support.”8
- Regarding institutions, the framework asks readers to consider the role of key national, state or local decision-making bodies. In deciding to approve the drug mifepristone in 2000, the FDA served as the primary institution guiding the policymaking process. The FDA has the regulatory authority to require REMS programs “for certain medications with high safety concerns to help ensure the benefits of the medication outweigh its risks.”23 By requiring a REMS when approving mifepristone, the FDA in effect placed restrictions on availability and access to the medication. As described below, the institution shaping this policy did so through a process largely devoid of the voice of those affected and without contemplating disproportionality.
- Regarding actors, the framework asks readers to consider the role of key national, state or local actors. Many government actors have been involved in shaping (though mostly hindering) access to mifepristone, from the initial approval considerations to now.24,25 Much of this legislative or regulatory discourse was absent explicit acknowledgement of or reference to themes of racial disproportionality or voice. Most recently however, main actors have shifted from legislators to the courts, where a single federal Judge in Texas attempted to overturn the approval of mifepristone 23 years after the FDA awarded it.26–28 If withheld, that Texas ruling (currently blocked while under appeal) would eliminate access to mifepristone in all 50 states. This call for centralization (to achieve a de facto national ban on medication abortion using mifepristone) represents a sharp departure from the frequent calls for decentralization (to state rights) that typically underpin policy proposals grounded in disproportionate burden and silencing of voice. It also ignores the overwhelming evidence of the safety of medication abortion and public support for access to abortion services.29
Moving Forward in a Post-Dobbs World: Beyond Bringing Disparities to Light
In 2020, the Guttmacher Institute made “equity and justice” a core guiding principle,30 and in 2022, our Board of Directors adopted an expanded Racial Equity Statement.31 The REAP framework gives us an additional and important tool to help us advance the guiding principle of equity and justice, and accelerate and deepen the ways in which we operationalize our Racial Equity Statement with respect to how we conduct research and generate evidence and analysis for policy impact.
We view the endeavor to apply an equity lens to our programmatic and advocacy work as pivotal to advance our mission in the post-Roe era. Guttmacher enjoys a long history of conducting research and policy surveillance and analyses that bring racial and other disparities to the fore. For example, by leveraging evidence about the association between inequitable access to contraceptives and having more limited ability to bear fewer children if desired,32,33 the Institute helped lay the groundwork for Title X. Since 1970, Title X has served as the only federal program providing family planning services for people living with low incomes.34
Fast-forward half a century: Guttmacher continues to conduct research that influences policy decisions with respect to Title X. The Institute’s data about the impact of COVID on fertility intention and access to contraception35–37 were brought to bear directly into COVID-related policymaking discussions. Such findings informed the inclusion of a $50 million appropriation for Title X in the American Rescue Plan Act.38,39 These data illustrated the disproportionate impacts on fertility desires by race/ethnicity, sexual orientation and income. Specifically, as of mid-2021, 44% of Black women and 48% of Hispanic women (compared with 28% of White women), 46% of nonheterosexual women (compared with 33% of straight women) and 37% lower-income women (compared with 32% higher-income women) reported wanting fewer children or wanting children later due to the pandemic.33 The same study found that a disproportionate burden of decreased access to contraception and other reproductive health care services was borne by Black women, Hispanic women, LGBTQ+ women and women with low incomes.
While Guttmacher evidence and analysis have consistently aimed to explore disparities in service access and highlight areas of utmost need—often playing a crucial role in driving significant changes—the REAP Framework challenges us to delve even deeper in our analyses. It challenges us to more consciously consider (and study) aspects of the policy environment that drive policy content and ultimately influence how the themes of disproportionality, decentralization and voice are reflected in policy proposals and implementation. Applying this framework consistently can allow us to drive change more effectively.
The core themes embedded within the framework—decentralization, disproportionality and voice—compel us to incorporate this level of examination and thoughtful consideration as we shape our research inquiries and conduct analyses that contribute to the sexual and reproductive health, rights and justice ecosystem in a post-Dobbs world. The REAP framework expands our collective arsenal of resources for driving policy changes that prioritize the voices and experiences of individuals and communities who have long been overlooked and, worse, harmed by policies like those unleashed by the Dobbs decision.