Abortion Access: Restrictions on Public Funding and Insurance Coverage

Laws that restrict the use of public funds for abortion can create barriers to women’s abortion access that are as difficult for women to overcome as laws that directly restrict the availability of abortion.  Funding restrictions endanger women’s health and, as some state courts have held, violate women’s privacy and equality rights under state constitutions.

Restrictions on Government Health Care Program Coverage for Abortion

Women who rely on government health insurance programs, like Medicaid, experience significant obstacles as a consequence of restrictions on the use of federal funds to pay for abortions unless a woman’s pregnancy results from rape or incest or endangers her life.  The Hyde Amendment, which restricts the use of federal Medicaid funds for abortion, leaves low-income women without coverage for abortions even when an abortion is necessary to protect a woman’s health.  In 1980, the Supreme Court held that the Hyde Amendment did not violate women’s right to abortion under the federal constitution and did not violate low-income women’s right to equal protection of the law under the federal constitution.  

In the context of Medicaid, which is a federal-state partnership program, states continue to be able to use their own funds to pay for abortion care despite the restrictions imposed on the use of federal funds.  A significant number of states currently provide coverage through Medicaid for medically necessary abortions.  Courts in thirteen of those states have held that restrictions on the use of state funds for abortion violate women’s equality and/or privacy rights under state constitutional law.  Click here for more information about CRR’s use of state constitutions to fight these, and other, attempts to restrict women’s reproductive rightsClick here for more detailed information about the availability of Medicaid funds for women’s abortions.

Women who rely on Medicaid and live in one of the 33 states that do not use state funds to cover abortion are harmed by the exclusion of this essential health service, as the Center for Reproductive Rights documented in a 2010 human rights fact-finding report.  Women interviewed by the Center spoke of having to delay obtaining an abortion for weeks while they tried to cobble together funds, even when funding assistance could be arranged.  The majority of the women interviewed reported having to sell or pawn possessions, borrow money, forgo paying bills, give up their cars (if they were able to afford one in the first place), limit their food intake, or make other arrangements in order to cover the balance of the cost of their abortions, diverting money from other essential household expenditures.  For poor and low-income women, who are already vulnerable to reproductive rights violations and are most affected by legal restrictions on the availability of abortion, the Hyde Amendment is a formidable barrier to obtaining an abortion, and can be a complete obstruction.  Click here to read our report, and the stories of Medicaid-eligible women denied funding for abortion. Click here to learn more about the ways that funding restrictions violate the human rights of low-income and poor women and about CRR’s related work in international human rights forums.

Federal Health Care Reform

In 2010, the United States Congress passed and the President signed the Patient Protection and Affordable Care Act (PPACA), which overhauls the structure of insurance coverage for health care in this country.  The PPACA increases opportunities for health insurance coverage, but is disappointingly limited in coverage for sexual and reproductive health.  For example, the PPACA expanded eligibility for Medicaid, which will increase access to health care by providing public funds for a larger number of low-income and poor women who need health care – unless the health care they need is an abortion.

The PPACA also, for the first time, put federal restrictions on the scope of coverage in the private insurance market in a way that interferes with women’s rights to choose abortion and protect their health.  By 2014, the PPACA requires states to establish health insurance exchanges.  However, a provision called the Nelson Amendment restricts the means by which insurers can offer insurance coverage for abortion within the state exchanges and explicitly allows states to prohibit any insurance coverage for abortion whatsoever.  For more information about the effects of the PPACA on women’s access to sexual and reproductive health care, click here

Insurance Coverage for Abortion in the States

Even before the passage of PPACA, five states legally restricted private insurance coverage for abortions.  In Idaho, Kentucky, Missouri, North Dakota, and Oklahoma, women who wanted health insurance coverage for an abortion would have to buy a policy exclusively for such coverage in addition to buying a policy to cover all other forms of health care.  The laws in those states explicitly prohibit private insurance companies from including in their health insurance plans coverage for abortion, except in the limited circumstances where a woman’s pregnancy endangers her life (and, in Oklahoma, where her pregnancy results from rape or incest).  These laws make no exception for abortions needed to protect a woman’s health.

The Nelson Amendment to the PPACA explicitly invited anti-choice states to restrict insurance coverage for abortion by emphasizing in law that states could prohibit abortion coverage in the new insurance exchanges.  In 2010, five states did just that.  Arizona, Louisiana, Mississippi, Missouri and Tennessee limited the kind of coverage available for abortion to different degrees; the most extreme limitation prohibits any insurance coverage for abortion without exception, and the less extreme allow coverage where a woman’s pregnancy results from rape or incest, and/or endangers her life or health.  Click here for more information about anti-choice legislation passed by the states in 2010.