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Protecting Abortion Coverage in Health Reform

  • Date: Nov 09 2010
  • Policy Number: 20103

Key Words: Abortion, Health Reform, Womens Health

Related Policies

APHA policy statement 67-18PP: Abortion.1

APHA policy statement 70-25: Standards for abortion services.2

APHA policy statement 81-04: Opposition to constitutional amendments or statutes to prohibit abortion.3

The American Public Health Association (APHA) has a long-standing position in favor of access to abortion and a comprehensive array of reproductive health services.1 Further, APHA has supported the use of public funding to ensure access to abortion services for low-income women who otherwise could not afford this care.2,3 APHA considers the availability of safe, legal, and affordable abortion care to be essential for safeguarding maternal health, reducing maternal mortality and morbidity, and enabling healthy spacing of pregnancies.

APHA is adopting this resolution to address abortion restrictions contained in the federal health reform legislation (the Patient Protection and Affordable Care Act or PPACA)4 signed into law by President Barack Obama on March 23, 2010. Previous APHA policies did not discuss the issue of abortion coverage in health reform, nor did they anticipate the PPACA’s specific restrictions on the availability of abortion coverage in commercial insurance policies to be sold in state insurance exchanges.

APHA supported the adoption of the PPACA because of its potential to promote individual and population health and to improve the ability of millions of Americans to obtain high-quality, affordable health care. APHA took the position that to achieve these goals, health reform should include coverage for comprehensive reproductive health care, which is a foundation for women’s health care across the lifespan. According to leading public health scholars, health reform policy should reflect a “well-woman standard of care” that includes reproductive health, which is a key determinant of women’s overall health. Such a standard of care will enable women to attain good health in their childhood and adolescence, to maintain good health during their reproductive years, and to age well.5

Despite the potential for health reform legislation to improve women’s access to comprehensive reproductive health services, such measures also can provide an opportunity for opponents to seek to establish new obstacles to women’s access to these services. In enacting the PPACA, Congress and the president approved provisions restricting women’s ability to obtain affordable commercial health insurance coverage that includes abortion services in new state insurance exchanges, which will open in 2014. Moreover, the president issued an executive order affirming current congressional restrictions on the use of federal funding for any abortion care, except in the case of rape, incest, or threat to the life of the woman.6

The PPACA’s policies on abortion coverage have the potential to affect a significant number of women. The Henry J. Kaiser Family Foundation has estimated 4.8 million women will qualify for federal subsidy credits to help them purchase health insurance in state exchanges authorized by the PPACA.7 Abortion is one of the most common surgical procedures performed on women in the United States (approximately 1.2 million abortions each year). By the time they reach age 45, approximately one third of US women will have had an abortion.8

Opponents of abortion have argued that abortion should not be considered a legitimate health service and, further, that taxpayers who object to abortion should not be required to help pay for abortion services—either in Medicaid coverage or in the form of federal subsidies for the purchase of commercial insurance. However, public health practitioners have pointed out that when women do not have ready access to safe, affordable abortion care, including publicly funded care, significant health consequences can result. “Unplanned and unwanted pregnancies constitute a serious public health responsibility,” an article in a 2000 World Health Organization (WHO) bulletinp580 declared, warning of the dangers when women are forced to resort to unsafe, delayed, clandestine, or illegal abortions. The economic and social costs of unsafe abortions include not only acute care but also long-term complications from damage to reproductive organs, pelvic inflammatory disease, and secondary infertility, as well as the potential harm to a woman’s existing children when she undergoes an unsafe procedure. Unsafe abortion situations are characterized by a lack of equity in cost, safety, and quality of care.9

Abortion Restrictions in Public Health Insurance Programs
Immediately after the 1973 Roe versus Wade decision by the U.S. Supreme Court legalizing abortion services in the United States, Medicaid provided coverage for abortion services for the low-income women enrolled in Medicaid. However, since the adoption of the Hyde Amendment in 1976, Congress has sharply restricted the use of the federal funding for abortion services through annual appropriations measures limiting abortion coverage to cases of rape, incest, or threat to a woman’s life.10 The primary target of these restrictions has been the Medicaid program, in which more than 7 million women of reproductive health age are now enrolled nationwide. Seventeen states use state Medicaid funds to pay for abortions for poor women, but only four do so voluntarily; the rest do so under a court order. Approximately 13% of all abortions in the United States are paid for with public funds (virtually all from state governments).8

Over the years, restrictions on providing abortion coverage using federal funds have been gradually extended beyond the Medicaid program. Also now affected is the Federal Employees Health Benefit Program, which insures 9 million federal employees and their dependents. The abortion coverage restrictions also apply to more than 200,000 active duty women in the military and 1.6 million female veterans (most of whom are of reproductive health age), 12,000 female inmates in federal prisons, 5,000 women who are Peace Corps volunteers, and nearly 1 million American Indian and Alaska Native women who are recipients of Indian Health Service health care.8 The restrictions on use of federal funding for abortion coverage are voted on annually by Congress as part of federal budget appropriations bills. A coalition of women’s health and reproductive justice organizations have been working in recent years to get those restrictions lifted, arguing that the Hyde restrictions effectively deprive the most vulnerable women in the United States of access to a legal health service and cause low-income women to delay having abortion procedures while they try to raise the necessary funds.11

The PPACA failed to lift current restrictions on the use of federal funds for abortion coverage in public insurance programs. As a result, the estimated 6.7 million American women of reproductive health age (15 to 44) who will become newly eligible for Medicaid through the PPACA will be unable to use this coverage for abortion services except in cases of rape, incest, or life endangerment, according to analysis by the Kaiser Family Foundation.7

Abortion Restrictions in Commercial Health Insurance 
By contrast to the situation with public health insurance, most commercial health insurance policies have routinely included abortion coverage. A 2002 study, for example, found that 87% of typical employer-based insurance policies cover medically necessary or appropriate abortions.12 Only five states (Idaho, Kentucky, Missouri, North Dakota, and Oklahoma) have taken the step of barring abortion coverage in private insurance policies sold within their boundaries.13

Inclusion of abortion restrictions within the new federal health reform law (PPACA) represents unprecedented federal intrusion into the offering of abortion coverage in the private insurance marketplace. This expansion is a significant setback in abortion policy in the United States.

In language included to satisfy the concerns of Senator Ben Nelson, a Nebraska Democrat who opposes abortion services, the PPACA gives states the option to prohibit abortion coverage in the commercial insurance plans that will be offered in state insurance exchanges established through health reform.14 Although states theoretically already have that option, as demonstrated by the five states that previously banned abortion coverage in private health insurance, the Nelson language specifically invites states to take on this issue and has set off state-by-state battles over whether abortion coverage should be allowed.15 By September 2010, five states (Arizona, Louisiana, Mississippi, Missouri, and Tennessee) had already acted to approve bans on abortion coverage in their state insurance exchanges, and several more state legislatures and governors were considering such actions.16

Moreover, in those states that do choose to allow abortion coverage to be offered in their state insurance exchanges, the Nelson language adds burdensome conditions on both the insurer offering the coverage and the consumer purchasing it. People purchasing the coverage would have to make two premium payments—one for abortion coverage and one for every other aspect of the coverage. Insurers providing the coverage would have to process those two payments from the individual and a third payment from the federal government for any subsidies to which the enrollee would be entitled. The federal subsidy money would have to be segregated from the private abortion premium payment by the insurer. An analysis by professors at the George Washington University School of Public Health concluded that insurance companies would simply drop abortion coverage in policies offered inside the state exchanges rather than comply with these requirements, and insurers could consider doing the same in policies sold outside the exchanges in the interest of uniformity and efficiency.17

Analysis by the Guttmacher Institute warned that “insurance companies would have to jump through numerous, unprecedented hoops to estimate the cost of abortion coverage and ensure that the abortion payments never mix with other funds; they also are likely to face extensive public scrutiny and protest around their action.”18 A further Guttmacher policy review concluded that because of the PPACA payment provisions, “the extent to which abortion coverage actually will be available to people will largely depend on what insurance companies perceive to be practical, efficient and in their business interests.”16p4 Arguing that even these restrictions do not go far enough, abortion opponents have signaled their intention to pass new legislation eliminating any abortion coverage under health reform—whether in the expanded Medicaid program or in the private insurance plans that will be offered through state exchanges.16

APHA deplores the politicization of abortion coverage in the enactment of the PPACA and in the state legislative debates concerning the establishment of state insurance exchanges. Decisions about which services should be covered in health insurance policies should be made on the basis of medical standards of care and sound public health principles, not politics or ideology. Health reform should ensure that all women, regardless of their income status or source of health insurance, have coverage for comprehensive women’s health care services, including abortion.

Policy Recommendations
APHA takes the position that current restrictions on use of federal funds for abortion coverage in the Medicaid program and other federally funded health insurance programs are unjust and effectively deny access to legal abortion services to the country’s most vulnerable women. Extending that kind of restricted coverage to millions more US women through health reform is contrary to the goals of health reform and squanders an important opportunity to improve the lives and health of low-income women and the families that depend on them.

Accordingly, APHA

  1. Calls on the president and the US Department of Health and Human Services to ensure that PPACA implementation regulations do not create roadblocks to insurers’ ability to offer abortion coverage in plans sold through state insurance exchanges nor impose unnecessary burdens on consumers seeking to purchase plans that include abortion coverage.
  2. Calls on governors and state legislative leaders to ensure that abortion coverage is available in commercial insurance policies made available to consumers through state insurance exchanges.
  3. Urges insurers to include and advertise the availability of abortion coverage within commercial insurance policies offered to consumers through state insurance exchanges, where permitted.
  4. Urges Congress and the president to reject any proposals to further restrict or eliminate abortion coverage, either in expanded Medicaid or in private insurance policies that will be offered in state insurance exchanges.
  5. Further calls on Congress and the president to repeal the Hyde amendment restrictions on use of federal funds for abortions coverage, thereby enabling the offering of abortion care in public insurance plans and lifting the restrictions on use of federal subsidies for the purchase of commercial insurance policies in state insurance exchanges.


  1. American Public Health Association. APHA policy statement 67-18PP: Abortion. Washington, DC: American Public Health Association; 1967. Available at: www.apha.org/advocacy/policy/policysearch/default.htm?id=592. Accessed November 30, 2009.
  2. American Public Health Association. APHA policy statement 70-25: Standards for abortion services. Washington, DC: American Public Health Association; 1970. Available at: www.apha.org/advocacy/policy/policysearch/default.htm?id=661. Accessed November 30, 2009.
  3. American Public Health Association. APHA policy statement 81-04: Opposition to constitutional amendments or statutes to prohibit abortion. Washington, DC: American Public Health Association; 1981. Available at: www.apha.org/advocacy/policy/policysearch/default.htm?id=976. Accessed Nov. 30, 2009.
  4. Pub L No. 111-148.
  5. Chavkin W, Rosenbaum S, Jones J, et al. Women’s Health and Health Care Reform: The Key Role of Comprehensive Reproductive Health Care. New York, NY: Columbia University, Mailman School of Public Health; 2008. Available at: www.mailmanschool.org/facultypubs/womenshealthcarereform.pdf. Accessed November 30, 2009.
  6. Werner E. Obama signs order blocking abortion funding. The Boston Globe. March 25, 2010. Available at: www.boston.com/news/nation/washington/articles/2010/03/25/obama_signs_order_blocking_abortion_funding/. Accessed June 16, 2010.
  7. Ranji U, Salginicoff A. Access to abortion coverage and health reform (in the series, Focus on Health Reform). Menlo Park, Calif: The Henry J. Kaiser Family Foundation; 2010, Available at: www.kff.org/healthreform/upload/8021.pdf. Accessed February 16, 2010.
  8. Boonstra H. The heart of the matter: public funding for abortion for poor women in the United States. Guttmacher Policy Review. 2007;10(1). Available at: www.guttmacher.org/pubs/gpr/10/1/gpr100112.html. Accessed December 31, 2010.
  9. Berer M. Making abortions safe: a matter of good public health policy and practice. Bull World Health Organ. 2000;78(5):580–592.
  10. Consolidated Appropriations Act, 2008. Pub L No. 110-161, §§ 507–508, 121 Stat 1844, 2208–2209 [2007].
  11. Hyde–30 years is Enough! Campaign. Available at: www.hyde30years.nnaf.org/more_hyde.html. Accessed February 16, 2010
  12. Guttmacher Institute Memo on Insurance Coverage of Abortion, July 22, 2009. Available at: www.guttmacher.org/media/inthenews/2009/07/22/index.html. Accessed February 16, 2010.
  13. State Policies in Brief: Restricting Insurance Coverage of Abortion. New York, NY: Guttmacher Institute; 2010. Available at: www.guttmacher.org/statecenter/spibs/spib_RICA.pdf. Accessed February 16, 2010.
  14. Sonfield A. The new health reform legislation: pros and cons for reproductive health. Guttmacher Policy Review. 2010;13(2):25–28.
  15. Leland J. Abortion foes advance cause at state level. The New York Times. June 2, 2010. Available at: www.nytimes.com/2010/06/03/health/policy/03abortion.html. Accessed June 15, 2010.
  16. Cohen SA. Insurance coverage of abortion: the battle to date and the battle to come. Guttmacher Policy Review. 2010;13(4):2–6. Available at: www.guttmacher.org/pubs/gpr/13/4/gpr130402.html. Accessed Nov. 8, 2010.
  17. Lillis M. Nelson amendment would “chill” access to abortion coverage, quoting professor Sara Rosenbaum. Washington Independent, December 21, 2009. Available at: http://washingtonindependent.com/71637/expert-nelson-amendment-would-chill-access-to-abortion-coverage. Accessed February 16, 2010.
  18. The Guttmacher Institute. The new health reform legislation: pros and cons for reproductive health care. March 29, 2010, Available at: www.guttmacher.org/media/inthenews/2010/03/29/index.html. Accessed June 15, 2010.

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