I believe that health care is a human right, which is why I have been a long time supporter of health care reform. When the Affordable Care Act (ACA) passed, while I realized it wasn’t going to be the answer to all of our healthcare problems, I also knew that it was a step in the right direction. And now it’s game time! The roll out of the ACA has started and I feel very strongly about being an out and proud fan of the ACA and doing everything I can to help it be as successful as possible. But the problem is, the ACA actually really sucks when it comes to abortion coverage and it’s been making me think, as an abortion supporter, how do I negotiate fully supporting a law that may actually make access to abortion harder?
Before we dive into that, let’s take a look at abortion coverage in the ACA.
1) Abortion cannot be listed as an essential health benefit. The ACA outlines 10 essential benefit categories that must be covered in health insurance plans, and the specific requirements are determined by each state. The ACA prohibits states from including abortion as an essential health benefit.
2) The Hyde Amendment is still in place. The Hyde Amendment, which prohibits the use of federal funding to cover abortions except in the case of rape, incest or endangerment of the life of the pregnant person, still applies. A big part of the ACA is the optional state expansion of Medicaid to persons up to 133% of the federal poverty guideline. While the Medicaid expansion is great for increasing coverage to low income people, with the Hyde Amendment in place Medicaid will continue not to cover elective abortions unless someone lives in one of the 17 states that only uses state money to pay for abortions.
3) No federal funds, including federal subsidies used to buy health insurance, can be used to pay for elective abortions. If a health insurance plan in the healthcare exchanges offers abortion services for cases other than incest, rape or endangerment of the pregnant person, plans have to follow segregation requirements to make sure that no federal money is used to pay for abortion services. This means that individuals have to make two separate premium payments: one for the payment of abortion coverage which they have to use their own money for, and another payment for the remainder of the coverage which can use federal subsidies.
4) All state health insurance exchanges must offer one plan that does not cover abortion. But there is nothing that requires that there is at least one plan that DOES cover abortion.
Put all together, we end up with a system that fails to recognize abortion as an essential health right, expands the Hyde Amendment restrictions to more people, and creates a really complicated system for abortion coverage. Now it’s important to remember that the rules regarding the separate premium payments only applies to insurance bought in the state healthcare exchanges. So for people with private employer based insurance that covers abortion these rules won’t affect them. But considering that the health care exchanges are set up for people who should benefit from federal subsidies and don’t have any other access to health insurance, it continues to make access to abortion harder for people who may need it most. Also, the separate health insurance premium for abortion coverage, could act like an abortion rider that people can choose to purchase. So instead of someone just buying one insurance policy to cover everything, they’d have to choose to buy a separate policy for abortion coverage, and make two separate payments. But that takes away the whole point of having insurance because it’s supposed to protect us from the unexpected and as we all know, no one plans to have an abortion. What’s even worse is that insurance companies may become less willing to provide abortion coverage because of the hassle and red tape they have to go through to collect separate payments. And on top of that, there is also a lot of state variation. Already, 18 states have prohibited abortion coverage in any plans in the state exchanges and nine states have prohibited abortion coverage in the entire private health insurance market.
Basically that’s a lot of bad news. Sure, it’s great that the ACA will cover preventative services and now we can access birth control with no copay, but the problem is that people need access to the full spectrum of sexual and reproductive health care. People will always need abortions and we have a fundamental right to access them just like any other healthcare service. If the purpose of the ACA is to increase access to health insurance and consequently access to healthcare, it feels disingenuous to be perpetuating a system where not all healthcare services are treated equally. Not only does it affect access, but it continues the stigma and shame surrounding abortion.
So where do we go from here? The most important thing is to keep working hard to increase abortion access to those who need it. The ACA will make abortion funds, and sexual and reproductive health clinics as important as ever and they need our support and commitment. On top of that, we need advocates on the ground to help people navigate an ever changing system, and understand what their options are for abortion coverage. It won’t be easy, and at times it will feel really frustrating, which is why we also have to remember to put the situation in perspective. We have a broken health care system that needs to be fixed and the ACA finally offers an opportunity to start fixing the system slowly but surely. Obviously this doesn’t mean that the way the ACA treats abortion is justified, but it’s important to remember that this is just the first step in a long process. I am cautiously optimistic that the goal of the ACA to improve access to insurance and healthcare, will lead to deeper conversations and ideas about what that means and looks like on the ground. That’s why we have to remember that this fight is far from over. We have to keep talking about why abortion is an essential part of healthcare, so that we can grab any opportunity there is in the future to improve access and coverage of abortion services.