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A Case We Can’t Afford Not to Make

Regaining lost ground on funding abortion care

Recently, I received a phone call that elicited equal parts pride and dread for a prochoice spokesperson like me. The call was from the editor of this magazine asking me to pen a piece about the Hyde Amendment and public funding for abortion, a topic that has become a “third rail” issue—something electrified that most people don’t want to touch, both inside and outside our movement.

Why would this topic cause dread in someone with an unwavering personal and professional commitment to supporting public funding to help make the right to choose a reality, and who firmly believes that the prochoice community shares that view? When I think about public funding for abortion, two competing voices whisper in my ear: one reminds me that public funding is a political nonstarter because conventional wisdom says we have neither the votes nor the public on our side. This voice insists that focusing on public funding will hurt our prochoice allies and our movement by creating a storyline of loss. The other voice, though, tells me that this is gut-check time: we can’t ignore our core value of justice for all women. This is especially true given that the lack of public funding renders the right to choose virtually meaningless for some of the most vulnerable women among us.

I am writing this because, ultimately, both whispers are true and should be respected. They tell a complex, but not competing, story which need not prevent us from moving ahead with an agenda that includes a passionate defense of public funding for abortion care, an agenda that lets our whispers about reproductive justice become roars. That’s because I believe that our movement—and the public—are at a crossroads. More conversations than ever are taking place at every level of society about how abortions are paid for, the role of government in ensuring coverage for healthcare (including abortion), as well as the role of insurers in making care more or less accessible. Initially, this conversation opened the floodgates to new attacks on abortion coverage in the private marketplace, which our movement is working valiantly to hold back. And current political realities make it difficult—if not impossible—for us not to be tempted to pivot by stating that public funding is not the issue at hand. We feel backed into a corner, forced to tacitly accept the panoply of restrictions on public funding at the federal, state and local levels in hopes of mitigating further damage to women’s access to abortion care.

Yet, tellingly, prochoicers are still losing ground—even in the area of public funding’s presumably more popular sister, private insurance coverage for abortion. And the definition of public funding for abortion itself keeps changing. Our opposition keeps shifting the goalposts.

So let me ask you: Would you consider funding for medical training that includes education on abortion provision to be public funding for abortion? What about family planning funding for any entity that also provides abortion care, even though the dollars spent on abortion care are segregated from the family planning dollars? Or government subsidies to purchase health insurance if that insurance adheres to the industry standards for providing abortion coverage? Is it public funding for abortion if you spend funds in your personal health savings account for abortion care? Or if a charitable organization that provides or refers for abortion care gets a state tax credit? In 2011, antichoice lawmakers in Congress and state houses throughout the country classified all of the above, and more, as public funding for abortion.

So what exactly is public funding of abortion? I’d say that maybe the answer shouldn’t matter to us. Today, when antichoice lawmakers talk about stopping public funding for abortion, they are not just talking about enshrining the Hyde Amendment, that decades-old restriction on using federal dollars to cover a woman’s abortion care (except if her life is endangered or she was sexually assaulted) if she relies on Medicaid for her healthcare. Nor are they referring only to the Hyde Amendment and its many iterations affecting public employees, women in the military, women living in the District of Columbia, women who get care through Indian Health Services and more. They are also not simply seeking to expand that list by increasing the number of states that have adopted similar provisions.

Our opposition is looking far beyond what we in the prochoice movement have traditionally considered to be public funding for abortion. They have set their sights on making abortion as inaccessible and stigmatized as possible. And they hope that we tie ourselves up in knots, trying to parse out what is public funding and what is not.

I propose that instead, we should embrace the nuance and seize on the opportunity presented by a nascent blurring of the distinctions between public and private, thanks to the national dialogue on health reform. At the risk of sounding like a Pollyanna, I believe that we can use this moment to create a new conversation and forge a path—albeit a long one with some rockslides likely along the way—for support of abortion coverage, regardless of who foots the insurance bill.

In the summer of 2010, the National Institute for Reproductive Health (NIRH) conducted opinion research to better understand attitudes about private insurance coverage for abortion among prochoice supporters and those who could, hopefully, be persuaded to support our position. The timing was critical because, as I could already attest from my recent tenure as executive director of NARAL Pro-Choice Massachusetts, passage of a healthcare law—even one that maintains (if not expands) coverage for reproductive healthcare, including abortion—is not the end of the debate over the state’s health policy. As the last year has shown, the vitriolic debate over abortion coverage in the Patient Protection and Affordable Care Act only signaled the beginning of the contention between policymakers and the public over how abortion is paid for and if it is covered by insurance. (While this was originally written in January 2012, these words ring even truer in light of the fight over whether the no-copays for preventive care will extend to contraceptives, regardless of where a woman works.)

The NIRH research findings caused a real “aha” moment for me. Something interesting surfaced in the focus groups conducted in Raleigh, NC; Minneapolis; Denver; Pittsburgh and Kansas City, Mo.; among prochoice women and men and those who agreed with some prochoice positions, described as “mixed choice.” The healthcare debate—the Stupak amendment; the Nelson “compromise,” a public option versus government subsidies for purchasing private insurance; the relationship between coverage and access to care; and the challenges so many face getting either or both—had trickled down in such a way that these pro- and mixed-choicers were seeing less of a distinction between private insurance coverage and public insurance coverage of abortion services.

This changing sensibility was echoed in the responses to the companion national online poll, which surveyed 1,211 voters who believe: (a) abortion should be legal and generally available (group 1); (b) regulation of abortion may sometimes be necessary although it should remain legal in most circumstances (group 2); or (c) abortion should be legal in only the most extreme cases, i.e., life, rape and incest (group 3). To be clear, voters who believe all abortions should be illegal, who we typically assume comprise roughly 15 percent of the population, were excluded from the research because the goal was to assess what might motivate voters to support protecting private insurance coverage of abortion. (We don’t ever expect to garner support from those who believe abortion should be completely illegal in all circumstances.) But among all of those polled, 62 percent agreed that both private health insurance and insurance paid for with government funding should cover abortion, including a majority of women who lean toward being antichoice. (For full disclosure, the question provided 4 options, the others being: private insurance [20 percent], health insurance should not cover [16 percent] and “health insurance paid for with government funding” [2 percent].)

I won’t pretend that a national poll with the wording “taxpayer funding for abortion” would be likely to show widespread public support. But that’s because this phrasing is the opposition’s clarion call, not ours. What matters is that, when asked to choose between agreeing that “it’s wrong to deny women coverage for a legal medical procedure like abortion just because some people do not approve of it” or agreeing that “taxpayer money should not be used to pay for health plans that cover abortion,” 60 percent of ones, twos, and threes agreed with the statement that reflects our values.

I believe that the focus group participants and poll respondents were picking up on a phenomenon that will become much more pronounced in a post-Affordable Care Act world: people’s health insurance status is not static. In the coming years, they will be moving back and forth even more often between utilizing employer-sponsored insurance; purchasing private insurance (in the future this may be on an exchange); receiving subsidies for insurance; and using public insurance. This will depend on myriad other factors in their lives: job status, marital and family status, income level, residence and more.

A Latina participating in the Denver focus group expressed her point of view thus:

“Who has the right to tell people that they can’t have insurance that covers abortions? Because they’re low-income or because they’re not getting insurance through a job like I am? I just don’t think people have that right.”

This sentiment may be indicative of a public that has become less invested in using demarcations of where a person’s insurance comes from to determine what kinds of services are covered. This is probably because they are more aware now that, if they are on one side of that line today, they could be on the other side of it tomorrow. So, it becomes a matter of fairness: if abortion coverage is available to some, it should be available to all.

Women, historically, have been especially susceptible to what is known as insurance “churning,” meaning that their insurance status is highly unstable as they move between types of coverage (employer vs. government) or between being covered and not. This is one of the many reasons that so many of us saw health reform as a woman’s issue. We will see major changes in the insurance market trends in coverage over the next several years, along with the increased involvement and responsibility of consumers related to their insurance coverage. I believe this creates a new opportunity to begin building support for abortion coverage, including ultimately removing the restrictions on both public and private insurance.

How can the prochoice movement capitalize on this new landscape, where the public better understands the shifting source of one’s insurance coverage? We can do so by consistently and forcefully maintaining that a woman deserves coverage for the care she needs, including abortion care, no matter where her insurance comes from. From this position, we can legitimately argue for abortion access for all women, with coverage for abortion care playing a vital role in making those services available. (If I may aim really high, this will also allow us to speak about abortion in a way that brings it back into the context of healthcare.)

From here, I believe, we can begin to reclaim the ground lost on the Hyde Amendment and its many insidious incarnations in federal and state laws. This would steer us away from implying—even inadvertently—that public funding of abortion is a completely lost cause. We could argue against public funding bans as an unacceptable compromise in the abortion debate. After all, as we’ve been reminded so powerfully of late, if the antichoice lobby had their way in defining “public funding,” any alleged “compromise” would create a slippery slope—and a whole new set of policies that undermine a woman’s access to abortion care.

Advocates for abortion rights are working on the front lines every day to stem the tide of antichoice legislation sweeping the nation. In a Congress that barely supports family planning funding, and in state houses that enacted 69 antichoice measures in 2011, prochoice organizations are battling mandatory delays, unnecessary ultrasound requirements, pre-viability abortion bans, attacks on family planning and onerous regulations on abortion providers. Bans on private insurance coverage for abortion have now joined the list. So how can we and our allies be asked to fight for public insurance coverage of abortion? The real question, though, is how can we not fight for it?

If the health reform fight and the losses we saw in 2011 can teach us something, it may be that sidelining public funding of abortion from other abortion-rights efforts has forced us to play by rules we did not create in a game we cannot win. What if we started to create new rules—a new discourse where women are not divided by their insurance coverage status, where we proudly declare support for abortion coverage as a matter of fairness and justice? I believe this is the way we can begin to change the conversation.

As much as we might want to sidestep discussions of abortion coverage in the hopes of avoiding a public fight, antichoice forces simply won’t let us. As tempting as it might be to think that throwing them a “bone” (like the Hyde Amendment) could help us at least maintain the status quo, it will not satisfy them. The drumbeat to “stop taxpayer funding of abortion” (which the polling shows is a line that still resonates powerfully with the public) only grows stronger, more expansive and harder to fight. We can’t ignore it. Nor can we rewind and erase the past. But we can move forward, together, with a renewed commitment to understanding how talking about abortion coverage without distinctions can better pave the way for future efforts to restore public funding for abortion.

I’m not going to claim that there is a single, silver bullet message that will protect our prochoice elected allies, persuade the mixed-choice public and reorient the debate over abortion in the United States. But I have learned two critical lessons over the years. First, you don’t use polling and messaging to determine your values; you use them to figure out how to best convey your values to those you need to reach. Second, you need to know where people are in order to know how to get them to where you want them to be. We know what our values are, and the post-healthcare reform landscape has put the public in a place to be able to move toward us. Research has taught me that people can be prochoice and also believe that life begins at conception or that abortion ends it. Similarly, I believe that we need not get the public to embrace “taxpayer funded abortions” in order to get their support for abortion coverage writ large, private and public.

There is power—philosophical and political—in speaking consistently about the importance of abortion coverage for all women. We can capitalize on women’s unwillingness to buy into the divisions that have been created for us—those with private insurance and those without—because we don’t have to just talk about protecting what a woman can do with her own private money when purchasing insurance on an exchange. We can instead choose to talk about our underlying core values that all women deserve the same peace of mind that they can obtain the healthcare they need, regardless of where their insurance comes from.

Abortion has always been accessible for women of means. To truly be prochoice means fully embracing what has sadly become clear for so many more among us of late: you cannot underestimate the power of economic status and its relationship to access to healthcare. Surely, promoting a prochoice agenda that asks for the complete repeal of funding bans on abortion is an uphill battle. But we’re no strangers to hills, and this one is critical. We must defend all kinds of coverage of abortion care in order to defend any kind of coverage for abortion care, and we must start now before we lose any more ground.

Those in the movement who count the votes know we don’t have them right now. Those in the movement who talk to elected officials and candidates know that speaking out against the Hyde Amendment can hurt politicians. But I am hopeful that if we begin to operate within a new framework, we can begin to say “no” to the choice our opponents want to create for us, which is really no choice at all. We can find ways to better reconcile our short-term goals with our long-term vision of overturning the Hyde Amendment in all of its forms.

I know in my head and my heart that all of us in the prochoice movement want the same thing: we want a woman to be able to make personal, private decisions about her reproductive health and have access to the services she needs, including abortion care, no matter her income, insurance status, employment status, geography, citizenship status or race. Maligning coverage of abortion care in public plans has worked for the antichoice movement for decades. Now it’s our time to use the public’s sensitivity to issues related to healthcare access created by the health reform debate to advance our core values and support abortion coverage for all.