Denied: Whom the Hyde Amendment HurtsA closer look at the women, the inequity, and the inefficiency

of denied federal funds for abortion

April LambertFall 2009

According to the Guttmacher Institute, nearly fifty percent of all

pregnancies experienced by women in the United States are unintended

and, at current rates, one third of all American women will have had an

abortion by age forty-five (Guttmacher Institute, Facts on Induced Abortion

2008). Abortion is, in fact, one of the most common outpatient medical

procedures in the United States. In 2005, there were 1.21 million abortions

performed (Facts on Induced Abortion 2008). There are not only a large

number of abortions performed each year, the women who demand this

medical procedure is a substantial and diverse cross-section; and yet,

abortion is explicitly singled out—despite its protection by the Roe v. Wade

Supreme Court decision—as a medical procedure that is not covered by

Medicaid. This essay seeks to review the most current data and analysis on

the denial of federal funds for abortion services, its disastrous effects on

women, its perpetuation of classist and racist inequities, and its negative

effects on public health metrics—both fiscal and non-fiscal.

Abortion funding in this country is a complex matter that has long

been subsumed within and highly influenced by political, legal, and cultural

forces. Focusing specifically on denied federal funds for abortions, the legal

history of abortion in the United States provides the best context to frame

this analysis. The first section of this essay will provide this historical

context including a summary of Medicaid, its substantial role in family

planning services, the Hyde Amendment and its effects, the varying state-

by-state scenarios, the unique restrictions applied only to abortion

procedures and funding, and the direct impact Medicaid regulations have

on access.

Once this context is established, this essay will move towards

identifying what these legal decisions and policy restrictions do to women.

This will be accomplished by identifying who the most affected women are

and by identifying some of the common scenarios these women encounter.

In revealing whom the most direly affected women are, the incredible

disparities in abortion access are explicitly apparent. While women are

legally granted the right to choose abortion, they are often denied access to

this right and certain women are denied this right at a much higher rate.

Poor women and women of color are often in greater need of abortion

services and are seriously affected by denied federal funding.1 These

women must either struggle to personally finance their own abortions or

carry an unwanted pregnancy to term. This struggle often leads to delay in

care, significant financial burdens for these women (and their dependents

or families), and—in some cases—dangerous attempts to self-abort. While

options exist, like non-profit abortion funds, state-reimbursement

opportunities, and need-based clinics, they are limited and insufficient.

After establishing the grim individual effects these federal

regulations have on women, these policies’ role in furthering inequitable

access explicitly along class and race lines, and the inadequacy of

alternative funding options, concluding analysis will shift to macro-effects

and policy. What does the denial of federal funding for abortion do for

public health? Is the singling out of abortion as a Medicaid-denied

procedure cost-effective or costly? What are the health and monetary costs

to our social structure? In this final section, research indicating that

abortion-funding restrictions negatively affects public health metrics and

social programs’ bottom-lines will fuel the discussion.

A BRIEF HISTORY OF MEDICAID AND THE HYDE AMENDMENT

1 Unfortunately and not coincidentally, poor women and women-of-color are also most likely to be negatively affected by other restrictive abortion laws, declining provider numbers, inaccessibility due to geographic location of abortion providers, and slashed funding for social programs.

2

Medicaid, enacted in 1965, serves as one of the largest social safety

nets for economically disadvantaged and vulnerable populations. Over fifty-

eight million Americans’ health insurance comes from Medicaid, making

Medicaid spending one sixth of the nation’s overall health care spending (At

A Glance 2008). An individual qualifies for Medicaid by meeting income

requirements and belonging to an eligible group: children, parents of

dependents, pregnant women, people with severe disabilities, and the

elderly (At A Glance 2008). Medicaid is a joint program with state and

federal government sharing expenses, administration, and control.

Eligibility, among other guidelines, is set by the federal government and

cannot be altered by states, but states do have authority to increase their

coverage options (i.e. a state must offer Medicaid to anyone who has met

federal guidelines, but states may choose to expand criteria to allow for

greater enrollment). Medicaid funding in all states is at least fifty percent

federally backed, specifics are determined by per capita income; poorer

states receive a greater percentage of federal Medicaid funding. Medicaid

coverage includes: in/outpatient, lab, and x-ray services; nursing home, in-

home, and long-term care; and family planning services (At A Glance).

Among the recipients of Medicaid, women compose a significant

group making up over seventy percent of the adult beneficiaries. In total,

approximately sixteen million women receive Medicaid benefits (Medicaid’s

Role for Women 2007). Twelve percent of women in the United States of

reproductive age—or 7.3 million women—were enrolled in Medicaid as of

2006 (Medicaid’s Role in Family Planning 2007). Women’s over-

representation in Medicaid beneficiary statistics is, in part, due to their

higher likelihood of being a member of an eligible group, since they might

be either pregnant or the parent of dependent children.

Among the most valuable of services (particularly for women)—and a

highly relevant contextual factor for our exploration of the denied federal

funding for abortion—is Medicaid’s coverage of family planning services.

Medicaid treats family planning services uniquely. As of a 1972

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amendment, when it was explicitly mandated that Medicaid cover family

planning services, state Medicaid spending on family planning services have

been matched at a distinctive ninety percent rate (typically the matching

rate varies from fifty to seventy-seven percent). Additionally, for any family

planning care, beneficiaries are exempt from paying any out-of-pocket

expenses (Medicaid’s Role in Family Planning 2007). This exceptional

treatment of family planning services has led to Medicaid becoming the

largest source of public funding for family planning services. Many services

qualify, including routine and preventative care (like Pap and sexually

transmitted infections tests), contraception options, and sterilization

(Medicaid’s Role for Women 2007). Several large exceptions among these

services stand out, the largest of which is abortion. The history behind this

exception will be explored in further detail in the following paragraphs.2

Medicaid’s coverage of family planning services has been significant for

many women, and now maintains a very important position as the largest

public resource for these types of services; yet—and as the final section of

this paper will explore with greater detail—the efficacy of federal

expenditures on family planning services is severely reduced by the

exclusion of abortion.

Medicaid does not cover abortion, but this has not always been the

case. In fact, in1973—directly following the Roe v. Wade Supreme Court

decision legalizing abortion—“federal Medicaid funds paid for approx

270,000 abortions out of a total of 615,800 performed” (Towey, Poggi, and

Roth 2005: 4). Yet Medicaid only covered abortion until 1976. In that year,

an amendment sponsored by Republican Senator Henry Hyde of Illinois

passed, banning the allocation of any federal funds towards abortion. The

2 It is also important to note that treatment for sexually transmitted infections is not covered under federal guidelines and neither is sterilization for medical conditions (whereas sterilization for contraceptive services is). Both of these exceptions are peculiar and of great interest. An analysis of this would constitute an essay in and of itself. This author would speculatively posit that Medicaid’s emphasis upon family planning services is greatly skewed towards population control—possibly remnants of eugenic politics, policy, and attitude or at least a potential skew due to latent or explicit class/racism—and less concerned with the health and well-being of the beneficiaries. Yet, even this sometimes single-sighted emphasis upon birth control cannot outshine the political firestorm that is abortion.

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original language of this bill included only one exception for federally

funded abortions: the life of the mother. In 1978, the exceptions expanded

to “promptly reported” instances of rape or incest and “severe and long-

lasting physical health damage” as deemed by a physician. This changed

again in 1979 when the health exception language was dropped and, in

1981, when the exceptions for rape or incest were repealed. Ever the

political football, the exceptions changed again under the Clinton

administration to what it remains today: rape, incest, and life endangerment

(Boonstra and Sonfield 2000).

While the Hyde Amendment limits the federal arm of Medicaid from

covering abortions, it does not affect state coverage besides mandating that

the states “must contract separately with their participating managed care

plans” (Boostra and Sonfield 2000: 9). So, states may continue to use their

Medicaid dollars to cover abortion; however, it becomes a much more

expensive proposition, especially relative to the very high matching-rate for

other family planning services under Medicaid. It also places further

administrative burdens upon the state Medicaid system, as it must organize

separate contracts for abortion services. And finally, the Hyde Amendment

carried with it a certain social and cultural message. The country’s budding

social conservativism, most active during the Reagan Era, certainly had its

effects on public and political perceptions of abortion and this restrictive,

conservative trend began with Hyde. The 1980s and early 90s were marked

with very active, visible, and—at times--violence anti-choice activism and

particularly restrictive federal and state abortion law. As of 2009, thirty-

three states mirror the federal policy and do not cover abortion; this has

been true for most of these states since very soon after the enactment of the

Hyde Amendment (Boonstra and Sonfield 2000). In those thirty-three

states, economically disadvantaged Medicaid-eligible women seeking

abortions must find ways to finance the procedure out-of-pocket.

The other seventeen states fund “medically necessary” abortions

generally following a broad definition (a far cry from the “life

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endangerment” language of Hyde). The remaining states and the District of

Columbia follow standards set by the Hyde Amendment with three states

allowing for abortions in cases of “fetal abnormality.” South Dakota

actually limits funding of abortion even more than the current Hyde

Amendment language—offering coverage only in the case of life

endangerment and disregarding the rape or incest exceptions. They are

currently in violation of federal law (State Funding of Abortion Under

Medicaid 2009). Five states have additional legislation that prohibits

private health insurance from covering abortions (outside of rape, incest, or

mother’s life exceptions) on regular plans. In those states, private insurers

may only cover abortions in separate, rider plans (Boostra and Sonfield

2000; NARAL Press Release 7 Nov 2009). Overall, studies show that only

thirteen percent of all abortions are financed through Medicaid, nearly all of

that thirteen percent is through Medicaid-funding states (Henshaw and

Finer 2003).

THE WOMEN MOST HARMED: DEMOGRAPHY & ANECDOTE

Stanley Henshaw and Lawrence Finer of the Alan Guttmacher

Institute look specifically at the denial of federal funding for abortions in

their report: “The Accessibility of Abortion Services in the United States”

(2003). Relying upon research done by P. J. Cook for an article published in

Journal of Health Economics, Henshaw and Finer note that “between 18%

and 35% of Medicaid-eligible women who would have abortions instead

continue their pregnancies if public funding is unavailable” (23). Henshaw

and Finer go on to conclude that, “the lack of Medicaid coverage may be the

public policy that has the greatest impact on the number of women who

want an abortion but are not able to obtain one” (23).

Shawn Towey, Stephanie Poggi, and Rachel Roth find, in their

comprehensive report on abortion funding for the National Network of

Abortion Funds (NNAF), that—in the non-Medicaid states—Medicaid pays

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for less than one percent of abortions3; yet—in the other seventeen states—

Medicaid pays for twenty-seven percent of abortions (2005). The vast

difference between less than one percent and twenty-seven percent suggest

that there are many Medicaid beneficiaries in non-Medicaid funding states

that are either not having abortions or paying out-of-pocket for abortions.

In one final comparison—as mentioned previously—in 1973, 270,000 of the

615,800 abortions performed were financed through Medicaid (Towey et al

2005). That is nearly half of all abortions, compared to only thirteen

percent today (Henshaw and Finer 2001). Considering these statistics, it is

obvious that the Hyde Amendment has significant and real effects on many

women, if not forcing many women to carry unwanted pregnancies to term

then at least requiring them to personally finance a costly procedure. In the

following paragraphs, the characteristics of the women most harmed by

Hyde will be revealed. Unfortunately, in investigating who is most harmed,

certain groups of women are disproportionately represented: poor women

and women-of-color. Restrictions to Medicaid funding creates and

perpetuates inaccessibility along entrenched race and class lines, often

harming women who are already marginalized at various intersections and

disempowered in many sectors of their lives.

Largely, abortion services are paid out-of-pocket. Seventy-four

percent of women who obtain abortions pay for the service themselves. In

2005, the average cost of a first-trimester abortion was $468, between

twelve and sixteen weeks was $774, and between sixteen weeks and twenty

weeks was $1,179 (Towey et al 2005: 6). Women who can personally bear

this financial burden or are located within supportive families, partnerships,

or communities which can comfortably afford this procedure will be

generally unaffected by the accessibility barriers created by Hyde.4 Other

3 Presumably these are the Medicaid beneficiaries in need of abortions due to rape, incest, or life-endangerment—this percentage might remain low due to the antagonist bureaucracy that women must navigate to procure abortions even when they ought to be eligible given the Hyde Amendment restrictions4 There are numerous other factors affecting accessibility including declining provider numbers, stigma and anti-choice activity, other legislative restrictions such as mandatory waiting-periods or spousal/parental consent forms, and geographic proximity to clinics or private providers.

7

women have private insurance plans that cover abortion and, assuming

these women have safe access to these benefits (i.e. their insurance is not

contingent upon an abusive partner or unsupportive parents), they too will

remain significantly less affected by federal funding restrictions. Yet, for

many other insured and uninsured women abortion funding restrictions

have real consequences. Many insured women find that their insurance

does not cover abortion, many women are uninsured and ineligible for

Medicaid—including very poor women, and many women are eligible for

Medicaid but are uninsured for their abortions.

Women who find themselves inadequately insured by private insurers

when they seek abortion coverage are also experiencing the impact of the

Hyde Amendment. The Hyde Amendment set a cultural tone and political

precedent that has led to fewer private insurers covering abortions.

According to the 2005 NNAF report on abortion accessibility, private

insurance covered nineteen percent of abortion in Medicaid states and only

eight percent in non-Medicaid states (Towey et al 2005: 6). There is a

correlation between the state’s abortion-funding guidelines and private

insurance coverage. Whether this occurs because the state guidelines

actually prohibit regular private insurance coverage (as it does outright in

five states and in eleven states abortion coverage by private insurance is

severely limited for public employees (Towey et al 2005)) or because state

guidelines reflect and create cultural attitudes and expectations regarding

abortion, it is clear that private insurance coverage decisions are impacted

by Hyde guidelines.

Yet, the women who are most blatantly affected by Hyde are

Medicaid beneficiaries. As a social safety net, Medicaid serves only those

who are at or below 100-200% the Federal Poverty Level (depending upon

their categorical eligibility). The beneficiaries are poor. Therefore,

coverage restrictions that just affect what Medicaid can or cannot cover will

mostly affect the most economically disadvantaged of American women.

Since women of color are over-represented among America’s poor, they are

8

also disproportionately represented among Medicaid recipients. As of 2008,

42.8% of non-elderly Medicaid beneficiaries were white, 22.2% black, and

27.9% Hispanic (Distribution of the Nonelderly with Medicaid by

Race/Ethnicity 2008). For comparison, both black Americans and Hispanic

Americans are less than fifteen percent of the population (American

Community Survey 2006). The average rate of unintended births for

American women is thirty-one percent, for black women it is fifty-one

percent. Towey, Poggi, and Roth speculate that this is, at least in part, due

to the Medicaid funding restrictions (2005: 5).

While federal policy makes abortion most restricted for these women,

it is precisely these women who are most often having abortions. A 2001

Guttmacher Institute report found that “women with incomes below 200%

of poverty made up 30% of all women of reproductive age, but accounted

for 57% of all women having abortions in 2000.” Even more interestingly,

“the concentration of economically disadvantaged women among those

having abortions was greater in 2000 than in 1994” (Jones, Darroch, and

Henshaw 2001: 231). In fact, abortions, on whole, declined eleven percent

between 1994 and 2000 but rose for economically disadvantaged women

(Jones et al 2001: 226).

Both this Guttmacher Institute report and the NNAF report account

for this rise in abortions among poor women in the late 1990s to 1996

welfare reform (the Personal Responsibility and Work Opportunity Act

including the Temporary Assistance for Needy Families block program)

which made it very difficult, if not punitive, for economically disadvantaged

women to carry out a pregnancy or care for young children. These reforms

included stricter required work laws, limits on assistance (a two-year limit

and a lifetime limit of five years) and “family caps” which denied further

coverage for families having additional children (Towey et al., 2005).

Additionally, the welfare reform laws led to fewer Medicaid enrollees (and

more uninsured Americans). Since Medicaid accounts for most publicly

funded family planning services, losing coverage leads to less access to

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contraceptive methods. In the mean time, other publicly funded programs,

like Title X, did not increase to compensate for greater numbers of

uninsured individuals seeking contraceptive options. Economically

disadvantaged women found themselves with few, if any, options for

affordable contraception (Towey et al, 2005; Jones et al 2001).

Economically disadvantaged women and, disproportionately, women

of color are the least able to afford abortions, the most likely to be

uncovered, and the most likely to experience unintended pregnancies.

Federal regulations, like the Hyde Amendment, insure that these women

will not have the same opportunities to procure abortions as their privileged

counterparts. Other federal policies and actions, such as the 1996 welfare

reform act and the inadequately funded Title X program, have left these

women unable to obtain appropriate contraception and facing dire financial

strain and potentially lost aid if they do carry pregnancies to term. All these

factors create a scenario within which “real reproductive choice [becomes]

a privilege of those who can afford it, rather than a fundamental right”

(Boonstra and Sonfield 2000: 11). What are these women left to do? They

must attempt to finance their own abortions and, if they fail, they may

either dangerously attempt to self-abort of carry the unwanted pregnancy to

term.

Struggling to scrape together $500 or more for an abortion poses a

serious financial burden for economically disadvantaged women. In one

study, sixty percent of Medicaid-eligible respondents said that an abortion

would cause “serious hardship” compared to only twenty-five percent of

non-eligible women (Boonstra and Sonfield 2000: 10). Many of these

women have to forgo other necessities—like food, rent, utility, or clothing

for their children or themselves—to finance an abortion. Furthermore, on

average, women who do not have simple access to money for an abortion

wait two to three weeks longer than other women before having the

procedure (Boonstra and Sonfield 2000). The difference between an

abortion at fourteen weeks and sixteen weeks could be $300. The

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difference between eighteen weeks and twenty might be nearly $500

(Towey et al 2005). Additionally, the longer women must wait the higher

the likelihood that there will not be a local provider willing to perform the

procedure. The cost of an average abortion given earlier ($468, $774, and

$1,179) does not take into account travel expenses, overnight stays,

childcare, or time away from work.

One funding option that some women may use is abortion funds, many

of which are affiliated with NNAF. These organizations rely predominately

on individual donors and work to provide women with the amount of money

they need for their abortion. The NNAF report includes several case

studies of member funds; through case study data and anecdotes a fuller

picture emerges of these women and their struggles. It is important to note

that many of the women these funds serve are Medicaid beneficiaries.

While the funds also help women who are ineligible for Medicaid, a

significant percent—two-thirds at the Women’s Medical Fund in

Philadelphia, for example—are eligible when they seek aid. At the Women’s

Reproductive Rights Assistance Project (WRAPP) in Los Angeles, many of

the women are from out-of-state. They are Medicaid-eligible but have been

denied coverage, and—further along in their pregnancies—are attempting

to find funding for a later-term abortion. These women, if it were not for

their state’s policies and the Hyde Amendment, would receive funding from

Medicaid. In fact, in Pennsylvania the state covered one in three abortions

through Medicaid prior to 1985 at which time the state banned funding

(Towey et al 2005).

Multiple funds reported a significant percentage of women pregnant

as a result of rape. At the Fund in Philadelphia the incidence of pregnancy

as a result from rape was eleven percent, at WRRAP in Los Angeles the

incidence of rape was nine percent, at the Community Abortion Information

and Resource Project (CAIR) in Seattle the incidence of rape was eight

percent. All states’ Medicaid programs should cover an abortion in the case

or rape, but these women are still seeking assistance because they have

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either encountered too many bureaucratic barriers or are not eligible for

Medicaid (at the Fund in Philadelphia just less than 50 percent of the

women pregnant as a result of rape were Medicaid recipients). For these

women, many of the rapes were not reported and, therefore, would not be

accepted by Medicaid insurance plans as an eligible abortion (Towey et al

2005). Another important theme among women seeking assistance

funding from abortion funds, is the occurrence of domestic violence. At the

Fund in Philadelphia, forty-three percent of the women reported feeling like

their lives were or had been “at-risk,” half of those women feared “extreme

violence,” fourteen percent of the women were currently in an abusive

relationship. The other funds also attempted to keep track of the numbers

of women reporting abuse. At CAIR—although the question was less

frequently asked—five percent of women reported some form of current

abuse. Some women feared violence as a result of getting an abortion, while

others feared violence as a result of not getting one. (Towey et al 2005)

Yet another striking statistic offered by the Fund in Philadelphia

indicates that black women make up eighty-three percent of women seeking

aid while they are only forty-one percent of the adult female population of

Philadelphia (Towey et al 2005). This again highlights the race dynamic

inherent in the issue of inequitable abortion accessibility. The staggering

numbers of black women seeking aid is, in part, due to the disproportionate

number of poor women of color, but might also be explained by another

phenomenon. Economically disadvantaged women of color often have fewer

financial resources among friends and family than their white counterparts.5

Since many women report borrowing money from friends and family to

5 A recent study of single mothers, for example, shows that white women report a 4.2 on a social support/safety scale, where black women report 3.55 and Hispanic women 3.69. And upon further examination, this tracks more along race/ethnicity lines than class lines: “Among Hispanics and Blacks, financial vulnerability, measured by low education levels, low incomes, and few assets, was related to weak safety nets. However, among Whites, financial vulnerability was not related to safety net strength.” (Society for Social Work and Research). This is an example of when just looking at just class might mask other active factors. Historical institutional racism has led to certain communities having fewer internal social safety nets than others—despite one’s personal economic status—these dissimilarities in the availability and resourcefulness of social safety nets further perpetuates a racialized poverty.

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finance their abortions, this is certainly a potential explanation for more

black women needing to seek external aid (Boonstra and Sonfield 2001).

Looking closely at the women most harmed, their situations, and their

options reveals demographic patterns, unsettling themes, and inadequate

choices and opportunities. These women are at multiple intersections

experiencing institutional oppression most palpably along race and class

lines. The high incidence of rape, domestic abuse, bureaucratic obstacles,

and system failures highlight the disempowered position many women find

themselves in as they attempt to navigate—often alone—the financing of

their own abortion. It is through these women’s stories that one most sees

the real affects of the Hyde Amendment. It has created and cemented a

scenario within which the rights protected under Roe are available to

privileged women and denied or made significantly more difficult to obtain

for economically disadvantaged women, women-of-color, and otherwise at-

risk or vulnerable women.

THE BOTTOM-LINE: PUBLIC HEALTH RESULTS AND SPENDING

We’ve seen ample evidence that restrictions on federal funding of

abortion harms women, particularly those in already vulnerable groups.

Even women who have been raped and who are meant to be afforded

protection by current federal and state restrictions are, all too often, those

struggling with the financial inaccessibility of abortion. But the denial of

federal funds for abortions also has negative effects on greater public health

numbers, fiscal and non-fiscal. Research indicates that when women are

actually granted their right to choose, health results for women and

children improve, as does the efficiency and efficacy of certain social-

program spending.

K. J. Meier and D. R. McFarlane in their article “State family planning

and abortion expenditures” outline a series of studies that show the varying

positive affects of funded abortions on public health numbers (1994). Meier

13

and McFarlane use a data period from 1982 to 1988 to explore varying

public health results between states who fund abortions through Medicaid

and states that do not (states needed to only publicly fund abortions for one

year during the data period to be included among the states with federal

funding). They found that abortion funding had positive public health

results across the board, and in some cases affected public health results

that other social programs had failed to affect.

Largely, Meier and McFarlane found that abortion funding had similar

public health affects to family planning funding. Both led to fewer

incidences of low birth weight, late or lacking prenatal care, infant

mortality, premature births, and neonatal mortality. There was one public

health result, in particular, that was not similar for abortion funding and

family planning services funding. Funding of abortion has a large impact on

teenage birth rates, compared to family planning services’ minor effects on

teen pregnancy rates. Meier and McFarlane identify mothers younger than

twenty as “risk factors for premature and low-birthrate births”; so a

significant decrease in teen birth rates positively affects those public health

numbers (1994: 1471). In examining maternal, infant, birth, and natal care

health results for a diverse group of women, there was no health result that

was negatively impacted by abortion funding. Meier and McFarlane

conclude that family planning funding and abortion funding both address

“unwanted fertility” but do so with “different clientele, delivery systems,

and funding mechanisms” thus leading to “distinctly different…public health

outcomes” (1994: 1471). This diversity is positive for public health—as it

means more women and infants will be affected. (Meier and McFarlane

1994)

States that fund abortions in addition to family planning services, are

not necessarily just adding social program expenses to their budget. In

fact, further spending for abortion leads to less spending on other social

programs. Boonstra and Sonfield summarize these statistics simply: “the

cost to the taxpayer subsidizing a first-trimester nonhospital abortion will

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always be far less than the cost of subsidizing prenatal and delivery services

not to mention the secondary costs of an unwanted birth” (2000: 10). In

2003, forty-one percent of all births in the US were Medicaid-funded births

(Kaiser 2003). Meier and McFarlane cite one 1984 study that indicates that

states without Medicaid funding for abortions paid more money for

“maternity care, medical care for the infant, Aid to Families with Dependent

Children, and nutritional assistance to women on Medicaid. For every

dollar used to pay for abortions for poor women…more than $4 was saved in

medical and social welfare costs over the next two years” (1994: 1468).

Overall, considering positive public health results particularly for infant and

maternal health and greater fiscal efficiency in dollars spent, the argument

to keep federal money away from abortion appears economically unsound

and under-informed.

WHAT’S CURRENT & WHAT NOW? CONCLUDING NOTES

The Hyde Amendment has recently experienced more media airtime

than ever. As the US Congress debated health care reform, several anti-

choice Democrats and Republicans began to worry about health care reform

and the possibility of federal funds going towards abortions. While the

health care reform bill (HR 3962: Affordable Health Care for America Act)

would not have altered the status quo set by the Hyde Amendment, some

Congresspeople—led by Representative Bart Stupak (Democrat of

Michigan) and Republican Representative Joe Pitts (Republican of

Pennsylvania)—spearheaded a debate regarding abortion and health care

reform. This over-politicized, highly contested health care debate presented

a ripe political scenario for certain politicians with anti-choice agendas.

Because Speaker of the House Nancy Pelosi needed Democrats to vote in

favor of the bill, to insure enough numbers, Stupak and others became an

important negotiating block. Using their votes as leverage, they secured a

roll call vote for the Stupak-Pitts Amendment (Herszenhorn and Calmes

2009). This Amendment included far stricter language than Hyde, going so

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far as to prevent any private insurance company from covering abortion on

regular plans if they accept even one subsidized customer (NARAL Press

Release 7 Nov 2009; MacGillis 2009). Just like those four states mentioned

earlier, private insurance plans would need to create abortion riders that

individuals would purchase separately from their basic insurance plan.6

On November 7, the Stupak-Pitts Amendment passed, 290-194, with

sixty-four Democrats and became part of the landmark health care reform

bill. Later that evening, the health care reform bill went on to pass by just

five votes, with thirty-nine of the Democrats who had voted for the Stupak-

Pitts Amendment still not voting for the reform bill (HR 3962, Roll Call 884).

Now the bill goes to the Senate. Many speculate that this amendment will

not make it into the Senate-endorsed bill especially after vocal outcry from

pro-choice constituents and activists across the country (NARAL Press

Release 19 Nov 2009). If this amendment did stand, it would be the single

most restrictive abortion legislation since Hyde itself. Private insurers

would be mandated to remove abortion coverage if they wished to

participate in any significant way on the public exchange (i.e. for any plan

available to any subsidized customers, abortion could not be covered).

Choosing to remain excluded from the public exchange would be financially

imprudent, so abortion coverage would be dropped and all women—insured,

uninsured, Medicaid-eligible—would have no option but to privately finance

their own abortion or pay the additional costs for a separate plan. The

Stupak-Pitts Amendment is a clear continuation and escalation of the Hyde

Amendment, reflecting the restrictive nature of Hyde, a disregard for Roe’s

intent, and an implementation of legislation that explicitly perpetuates race,

class, and gender oppressions.

Truly, the denial of federal funding for abortion and its effects upon

Medicaid-eligible women is just part of the story. Disparity and inequity in

abortion accessibility is a complex tangle of factors including a national

6 Interestingly, in the five states that institute this rider policy, private insurance plans have not created riders—seeing this legal barrier as an obstacle not worth the trouble (NARAL Press Release 7 Nov 2009).

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decline in providers, a whole host of state abortion restrictions, anti-choice

activists and politicians, geographic distribution of providers, and cultural

and social attitudes regarding abortion. In fact, this essay cannot even tell

the whole story regarding the hardship and inequities the Hyde Amendment

has upon Medicaid-enrolled women. Although mentioned briefly, the

bureaucratic obstacles inherent in Medicaid and wrapped up with Hyde are

boundless. When does a woman’s life become at-risk and therefore qualify

that woman for a Medicaid funded abortion? Who has to call it rape for it to

be rape in a Medicaid HMO’s eyes? Even in Medicaid-funding states, what

is “medically necessary?” Which providers are eligible for Medicaid-

funding? Must a woman travel to a clinic eighty miles away to procure a

Medicaid-funded abortion? What are the other state restrictions she will

encounter? Once she has driven to the clinic outside her county, will she

have to stay overnight in compliance with a waiting period or a mandatory

counseling law? Once out-of-state, what will Medicaid cover?

Obviously, many of these questions were merely alluded to or even

ignored over the course of this essay. This essay attempted to broadly

overview the state of abortion in the context of federal funding and

Medicaid, the general effects this has on which women and why, and

relevant public health and policy statistics that indicate that denied public

funding for abortion has negative effects on women, maternal, and infant

health; the efficacy and efficiency of social programs; and state and federal

government spending. It would be impossible to address many of the issues

and questions I mention now, but I mention them because it is necessary

that we keep in mind the complexity of these issues, the massive

accessibility issues our country currently faces with regard to abortion, and

that these accessibility issues translate to a world not in which choosing

abortion is every woman’s right, but only a right for some. Only the woman

who is wealthy enough, geographically well placed, and in an empowered

enough societal and personal scenario can safely choose abortion.

17

As revealed though this essay though, the Hyde Amendment

represents the largest and most powerful institutional player in this

inequitable distribution of choice. The repeal of Hyde would significantly

decrease the racial and classed inequities currently affecting many women’s

options. It would also signify a political and cultural shift that might result

in rippling effects among state policies and political opinions—just as its

enactment did. Instead of facing a potential appeal of this amendment,

however, we are facing further restriction in the Stupak-Pitts Amendment.

An amendment that could easily overtake the Hyde Amendment as the most

harmful, inequity-perpetuating piece of abortion restriction legislation thus

far—signifying the largest step backwards for reproductive justice since

1976.

18

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21

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23