National Partnership for Women & Families

Monthly Women's Health Research Review

Analysis examines growing effort to overturn harmful Hyde restrictions

Summary of "Abortion in the lives of women struggling financially: Why insurance coverage matters," Heather Boonstra, Guttmacher Policy Review, July 14, 2016.

The Hyde Amendment, enacted in 1977 and upheld by the Supreme Court in 1980, has long "restricted abortion coverage for women insured by Medicaid and, in turn, ... made real reproductive choice a privilege of those who can afford it, rather than a fundamental right," according to Heather Boonstra, director of public policy at the Guttmacher Institute.

Boonstra explained that while reproductive rights advocates have long focused on "stav[ing] 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." However, she wrote, "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

Boonstra wrote that while "substantial progress has been made toward enabling American women and their partners to control their childbearing," including improved contraceptive access, "not all women are sharing equally in this progress."

Boonstra explained that "[a]lthough the rate of unintended pregnancy among low-income women declined between 2008 and 2011 ... the unintended pregnancy rate among women living under the federal poverty level in [2011] ... was more than five times that among women with an income at or above 200% of poverty." According to Boonstra, "[B]ecause of this high rate of unintended pregnancy, women who are struggling financially experience high levels of abortion."

She noted that that "over the last few decades, abortion has become increasingly concentrated among [low-income individuals]," with about "75% of abortions in 2014 [occurring] among low-income patients." Moreover, Boonstra cited research showing that "[t]he reasons women give for having an abortion underscore their understanding of the economic impact [unintended] childbearing would have on themselves and their families," including the cost of another child or their responsibility to others in their care.

However, according to Boonstra, "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." She cited a study that "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." Moreover, "[o]ther studies show that many Americans do not have adequate savings to cover a financial emergency of any kind," Boonstra wrote.

Enter Hyde

According to Boonstra, the Hyde Amendment, from fiscal year 1994 onward, "has limited federal reimbursement for abortions under Medicaid to cases of rape, incest or when a woman's life is threatened."

Further, Boonstra noted that while 17 states have policies that mitigate the harmful effects of Hyde by "requiring the use of state funds to cover abortions for low-income women enrolled in Medicaid," only "15 states appear to be doing so in practice." She wrote, "In states where Medicaid covers abortion services, 89% of abortion patients with Medicaid used their insurance to access abortion care."

Boonstra also cited the multiple laws enacted by Congress "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." According to Boonstra, all of these restrictions currently "mirror the Hyde Amendment, in that they include exceptions in cases of rape, incest or when a woman's life is endangered."

Demonstrated impact

Boonstra highlighted the potential effect of the Hyde Amendment, noting that 60 percent of reproductive-age women currently enrolled in Medicaid "live in the 35 states and the District of Columbia that do not cover abortion, except in limited circumstances." Moreover, she wrote that the Hyde Amendment disproportionately affects women of color, who are more likely than white women to be covered under Medicaid. Specifically, 30 percent "of black women and 24% of Hispanic women aged 15-44 are enrolled in Medicaid, compared with 14% of white women."

Further, Boonstra explained that many low-income women who do not have abortion coverage "delay or forgo paying utility bills or rent, or buying food for themselves and their children" to access abortion care, while "others rely on family members for financial help, receive financial assistance from clinics or sell their personal belongings." Boonstra also cited research showing how "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."

Citing another study, Boonstra noted 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." She pointed to research showing that "[w]omen 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

According to Boonstra, abortion-rights advocates are now encouraging lawmakers to combat the Hyde Amendment, which many had previously avoided because of continued hostility toward abortion rights and the policy's longstanding presence.

For example, Boonstra highlighted the "centerpiece" of the All* Above All campaign: The "Equal Access to Abortion Coverage in Health Insurance (EACH Woman) Act [HR 2972], which was introduced by Reps. Barbara Lee (D-CA) and Jan Schakowsky (D-IL) in 2015, and now has a list of 117 cosponsors." According to Boonstra, the measure "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" and "would prohibit states and the federal government from banning or limiting abortion coverage in the private insurance market."

Boonstra also pointed to a measure, proposed by Sen. Richard Blumenthal (D-Conn.) and Rep. Judy Chu (D-Calif.) in 2013 and 2015, that would "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 [low-income] women." Boonstra wrote that the effort "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."

Boonstra also highlighted the Playbook for Abortion Rights, which "provides model state bills for improving women's access to abortion care." For example, one of the model bills, called the Abortion Coverage Equity Act, would facilitate abortion access for low-income women by "requir[ing] that abortion be covered in all types of health insurance offered, sold or purchased in the state." Among other proactive efforts, Boonstra cited "several digital campaigns ... that encourage women to share their abortion stories as a way to destigmatize the procedure ... 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."

According to Boonstra, "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." She concluded, "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."