Abortion has been legal throughout the United States for more than 40 years, but it remains one of the country’s hottest political flashpoints. Republican presidential candidate Donald Trump stumbled into it when he said in a TV interview that if abortion were made illegal, women seeking one should be criminally punished—a statement that he later tried to reframe with a more formal announcement that he is "prolife with exceptions."1 Meanwhile, Democratic presidential hopefuls Hillary Clinton and Bernie Sanders have both called for expanding access to abortion by ending the Hyde Amendment. At a campaign rally in January, Clinton said the policy only makes it harder for low-income women to exercise their full rights: "Any right that requires you to take extraordinary measures to access it is no right at all," she said.2
The Hyde Amendment, named after the late Rep. Henry Hyde (R-IL), is in many ways the grandfather 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, the Hyde Amendment has severely restricted abortion coverage for women insured by Medicaid and, in turn, has made real reproductive choice a privilege of those who can afford it, rather than a fundamental right.
Having presidential candidates firmly commit to lifting the Hyde Amendment is not new, but it is a welcome advancement to reproductive rights activists. (Similar endorsements from congressional candidates will be important too, given that ending the Hyde Amendment will require an act of Congress.) While policymakers supportive of abortion rights have devoted much effort trying to stave off the surge of abortion restrictions in recent years, challenges to the Hyde Amendment—in the states and Congress—mostly have languished on the back burner. Now, advocates for abortion rights are working to change that by shining a light on the importance of abortion coverage and putting the abortion rights movement back on the offensive.
Abortion and Low-Income Women
Over the last several decades, substantial progress has been made toward enabling American women and their partners to control their childbearing. Improved contraceptive use has helped women to better avoid unintended pregnancies, and as a result of fewer unintended pregnancies, the overall abortion rate declined to 17 per 1,000 women aged 15–44 in 2011, the lowest since 1973 (see "New Clarity for the U.S. Abortion Debate: A Steep Drop in Unintended Pregnancy Is Driving Recent Abortion Declines," 2016).3,4
But not all women are sharing equally in this progress. Although the rate of unintended pregnancy among low-income women declined between 2008 and 2011, major disparities remain. In 2011, the unintended pregnancy rate among women with an income below the federal poverty level ($18,530 for a family of three that year5) was more than five times that among women with an income at or above 200% of poverty (112 vs. 20 per 1,000 women aged 15–44).6 And because of this high rate of unintended pregnancy, women who are struggling financially experience high levels of abortion.
Indeed, over the last few decades, abortion has become increasingly concentrated among the poor. In 2014, 49% of abortion patients had a family income below the federal poverty level—up from 27% in 2000.7,8 An additional 26% of abortion patients in 2014 had an income that was 100–199% of the poverty threshold. In other words, 75% of abortions in 2014 were among low-income patients.
The reasons women give for having an abortion underscore their understanding of the economic impact unplanned childbearing would have on themselves and their families. Most abortion patients say that they cannot afford a child or another child, and most say that having a baby would interfere with their work, school or ability to care for their other children.9 Most women also cite concern for or responsibility to other individuals as a factor in their decision to have an abortion. These concerns make particular sense when one considers that six in 10 women who have an abortion are already a parent.7
Unfortunately, for a pregnant woman who is already struggling to get by, the cost of an abortion may be more than she can afford on her own. The average amount paid for an abortion at 10 weeks’ gestation was $480 in 2011–2012.10 The University of California, San Francisco Turnaway Study—a five-year longitudinal study of roughly 1,000 women seeking abortion care at 30 facilities across the United States—found that for more than half of women who received an abortion, their out-of-pocket costs (for the procedure, as well as for travel and hotel, if needed) were equivalent to more than one-third of their monthly personal income.11
Other studies show that many Americans do not have adequate savings to cover a financial emergency of any kind. In 2013, the Federal Reserve Board conducted a nationally representative household survey designed to "monitor the financial and economic status of American consumers."12 The survey asked respondents how they would pay for a $400 emergency, and 47% said either that they would cover it by borrowing or selling something, or that they would not be able to come up with the money.
In 2015, roughly 90% of Americans had health insurance coverage to help defray the costs of any medical bills.13 However, unlike most other types of health care services, abortion is highly politicized, and insurance coverage for abortion has been the target of severe restrictions.
Forty years ago, in the wake of Roe v. Wade, Congress passed the Hyde Amendment—which bans the use of federal funds for abortion services in all but the most extreme circumstances—by attaching it to the annual spending bill funding what is now the Department of Health and Human Services. From the start, antiabortion politicians have acknowledged that, without a path to ban abortion outright, they have used the power of the purse to interfere with women’s decision-making around abortion. During debate over the measure, Hyde told his colleagues, "I certainly would like to prevent, if I could legally, anybody having an abortion, a rich woman, a middle-class woman, or a poor woman. Unfortunately, the only vehicle available is the…Medicaid bill."14
The Hyde Amendment was hotly debated throughout the 1970s and has changed over time. In 1980, the U.S. Supreme Court upheld the Hyde Amendment, ruling that the Hyde restrictions do not interfere with the right recognized in Roe because "a woman’s freedom of choice [does not carry] with it a constitutional entitlement to the financial resources to avail herself of the full range of protected choices." Justice William Brennan wrote in a dissenting opinion that the Hyde Amendment "is nothing less than an attempt by Congress to circumvent the dictates of the Constitution and achieve indirectly what Roe v. Wade said it could not do directly." Also of concern to the justices was the fact that Hyde specifically targets the constitutional rights of poor women. The Hyde Amendment, wrote Justice Thurgood Marshall, "is designed to deprive poor and minority women of the constitutional right to choose abortion."
Since fiscal year 1994, the Hyde Amendment has limited federal reimbursement for abortions under Medicaid to cases of rape, incest or when a woman’s life is threatened. The harmful impact of the Hyde Amendment is only mitigated for women who happen to live in states that use their own funds to provide abortion coverage for Medicaid recipients. Seventeen states have a policy (either voluntarily or by court order) requiring the use of state funds to cover abortions for low-income women enrolled in Medicaid, but just 15 states appear to be doing so in practice (see map).15 (Arizona and Illinois are funding so few abortions that they appear to be in violation of their court orders.16) In states where Medicaid covers abortion services, 89% of abortion patients with Medicaid used their insurance to access abortion care.7
In addition to the Hyde Amendment itself, Congress has enacted numerous laws that similarly restrict abortion coverage or services for other groups of women who obtain their health insurance or health care from the federal government, including federal employees, military personnel, federal prison inmates, poor residents of the District of Columbia (because Congress has jurisdiction over the District’s policy) and Native American women (see graphic). These policies have changed over time and all now mirror the Hyde Amendment, in that they include exceptions in cases of rape, incest or when a woman’s life is endangered.
The number of women potentially affected by the Hyde Amendment is substantial. Of women aged 15–44 enrolled in Medicaid, 60% live in the 35 states and the District of Columbia that do not cover abortion, except in limited circumstances.17 This amounts to roughly seven million women of reproductive age, including 3.4 million who are living below the federal poverty level.
The Hyde Amendment falls particularly hard on women of color. Because of social and economic inequality linked to racism and discrimination, women of color are disproportionately likely to be insured by the Medicaid program: Thirty percent of black women and 24% of Hispanic women aged 15–44 are enrolled in Medicaid, compared with 14% of white women (see graphic).17
A number of studies conducted over the last four decades have assessed the impact of the Hyde Amendment.18 To afford an abortion, many low-income women without coverage for the procedure delay or forgo paying utility bills or rent, or buying food for themselves and their children;19 others rely on family members for financial help, receive financial assistance from clinics or sell their personal belongings.7,19
Moreover, women who have decided to have an abortion can get caught in a cruel cycle, in which the delays associated with raising the funds to pay for the abortion can lead to additional costs and delays. Abortion in the second trimester can cost 2–3 times as much as abortion in the first trimester.10 Because of the time and effort needed to scrape together the funds, many low-income women have to postpone their abortion: Fifty-four percent of women in the Turnaway study sample reported that having to raise money for an abortion delayed their obtaining care.11 In addition, the risk of complications from abortion—although exceedingly small at any point—increases with gestational age.20
Although most low-income women who want an abortion manage to obtain one, some do not, and the result is an unplanned and often unwanted birth. A number of studies published over the course of decades have examined how many women are forced to forgo their right to abortion and bear children they did not intend. A 2009 literature review published by the Guttmacher Institute identified studies from five states that compared the ratio of abortions to births before and after coverage ended.18 The review concludes that among women with Medicaid coverage subject to the Hyde Amendment who seek an abortion, one in four are unable to obtain one because of lack of abortion coverage.
The Turnaway study examined the reasons for not obtaining an abortion after being denied one because of provider gestational limits. Among those who considered having an abortion elsewhere, but never obtained one, 85% reported that the reason for not obtaining an abortion was the cost of the procedure and travel.21 The study also found that when a woman who is already struggling to get by is denied an abortion, she is especially likely to fall into poverty.22 Women denied an abortion who subsequently had a child (or another child) were more likely than women who received an abortion to be unemployed, receiving public assistance and living below the federal poverty level one year after their clinic visit—despite the fact that there were no economic differences between the women a year earlier.
Going on the Offensive
Over the last several years, antiabortion legislators have been alarmingly successful at pursuing abortion restrictions at the federal and state levels, which have made it ever more difficult for women who are already struggling economically to access abortion care. Although policymakers who support abortion rights have stood up against these new restrictions, many have been more reticent to take up the fight to repeal the Hyde Amendment. Given a political environment so intensely hostile to abortion rights, many of these elected officials have asserted that this is not the optimal time to force a reopening of the issue of Medicaid coverage for abortion, which has been banned longer than many of them have been in office.
But abortion rights advocates are hoping to change that perception. In 2013, activists with All* Above All—a nationwide network of reproductive rights and justice organizations—launched a series of grassroots and communications campaigns aimed at building support for lifting the Hyde Amendment. "The name All* Above All reflects our positive and powerful belief that each of us, not just some of us, must be able to make the important decision of whether to end a pregnancy," the campaign explains on its website. "For too long, politicians have been allowed to deny a woman’s abortion coverage just because she is poor….We are standing up to say ‘enough.’"23
All* Above All is using several different tactics to bring the Hyde Amendment back into the national conversation. It has developed a social media effort to drum up support for repealing Hyde. Activists have visited college campuses to get young people involved with these efforts. And it launched a "Be Bold" road trip in August 2014 that, after a six-week tour through 12 cities, ended in Washington, DC with a petition urging Congress to repeal the Hyde Amendment.
The centerpiece of this campaign is the Equal Access to Abortion Coverage in Health Insurance (EACH Woman) Act, which was introduced by Reps. Barbara Lee (D-CA) and Jan Schakowsky (D-IL) in 2015, and now has a list of 117 cosponsors. The bill would restore abortion coverage for those insured by the Medicaid program, as well as those who receive their health coverage and care through other federal programs. In addition, it would prohibit states and the federal government from banning or limiting abortion coverage in the private insurance market.
The bill is based on the principle that abortion is basic health care and, therefore, deserving of health insurance coverage, whether public or private. "The EACH Woman Act put the prochoice movement back on the offensive," says Lee. "Politicians shouldn’t be meddling in a woman’s personal healthcare decision just because she’s poor."24
Several other proactive initiatives that address abortion restrictions more broadly are also underway. In 2013 and again in 2015, Sen. Richard Blumenthal (D-CT) and Rep. Judy Chu (D-CA) introduced the Women’s Health Protection Act, in response to the unprecedented number of state-level restrictions on abortion. With 33 cosponsors in the Senate and 144 in the House, the bill is designed to reaffirm women’s right to abortion by making it unlawful for states to enact burdensome requirements—such as previability abortion bans and unwarranted doctor and clinic regulations—that do not advance women’s health and safety and that make abortion services more difficult to access, especially for poor women. The drive to eliminate these types of restrictions received a major boost with the U.S. Supreme Court’s June 2016 decision in Whole Woman’s Health v. Hellerstedt, which struck down several such provisions in Texas.
Another proactive effort, this one aimed at state-level policymakers, kicked off in January 2016, with the release of A Playbook for Abortion Rights.25 The Playbook was launched by the Public Leadership Institute—a nonprofit educational group organized to raise public awareness on key issues of equity and justice—and it provides model state bills for improving women’s access to abortion care. Among those model bills that would particularly affect low-income women is the Abortion Coverage Equity Act, which would require that abortion be covered in all types of health insurance offered, sold or purchased in the state.
In addition, several digital campaigns are underway that encourage women to share their abortion stories as a way to destigmatize the procedure. Some of these efforts (such as The Abortion Diary) are not necessarily political, whereas others (the 1 in 3 Campaign or the #ShoutYourAbortion campaign) have a strong relationship with activism and political organizing. Although not directly targeted at the Hyde Amendment, these campaigns are using storytelling to strengthen support for abortion access, bring the perspectives of low-income women to the debate about reproductive freedom and choice, and "soften the ground" for policy change.
Each of these campaigns endeavors in its own way to raise awareness among the general public and move elected officials to recognize that low-income women deserve the same reproductive rights and access as those who are more fortunate. In many ways, it is "back to the future" for abortion rights advocates. Some 45 years ago, the effort to legalize abortion nationwide that led to Roe v. Wade was driven in large part by a concern with disparities, because low-income women were disproportionately affected by the criminalization of abortion. Even in states where abortion was illegal, women with financial means often had access to a safe albeit clandestine procedure, whereas less-affluent women had few options aside from a dangerous, back-alley abortion. And after the fight to legalize abortion was won, one of the first battlegrounds to follow was over the Hyde Amendment.
The proactive campaigns to heighten attention and call for action to cover abortion care under health insurance—especially for low-income women on Medicaid—seem to be gaining some traction among candidates who support abortion rights. Increasingly, more seem comfortable talking about the issue and fighting for reform. With a new administration and Congress taking office next year, and elections in all 50 states too, advocates are hopeful about rebuilding support—however long it takes—toward achieving true access to abortion care for low-income women, regardless of the state in which they live. This is and should be the heart of the abortion rights struggle in this country.