Rep. John Conyers (D-MI) began introducing Medicare for All bills in 2003—more than a decade before Democrats cast off Hyde as the cost of doing business on Capitol Hill and coalesced around the Equal Access to Abortion Coverage in Health Insurance (EACH Woman) Act.

Alex Wong/Getty Images

When Sen. Bernie Sanders (I-VT) and Rep. John Conyers (D-MI) partnered for an overflowing health-care town hall in Michigan over the August recess, they shared more than a stage. The veteran lawmakers are leading the charge in Washington for universal health coverage.

More than 1,000 people packed the meeting that turned into a “rallying cry for progressives,” according to a Detroit Free Press report. Progressives recognize that health care is a human right. But do they recognize abortion care as health care, or will they sacrifice it for the sake of the quote-unquote greater good?

On Capitol Hill, Democrats have increasingly signaled their support for single-payer proposals in which the federal government covers health-care costs, regardless of income, job status, or health status.

I intend to co-sponsor the Medicare for All bill because it’s just the right thing to do. Sex. Abortion. Parenthood. Power. The latest news, delivered straight to your inbox. SUBSCRIBE — Kamala Harris (@KamalaHarris) August 30, 2017

The most popular ones propose expanding Medicare, the federal insurance program for people age 65 and older, to all. Conyers introduced his eighth iteration of a Medicare for All bill in the U.S. House of Representatives at the start of the current 115th Congress, and Sanders plans to unveil a U.S. Senate version after lawmakers return to Washington in early September, Rewire reported in July.

Sen. Brian Schatz (D-HI) recently sat down with Vox’s Sarah Kliff and Jeff Stein to discuss his forthcoming bill that would allow anyone to buy into Medicaid, the joint state-federal insurance program for people with low incomes, on the Affordable Care Act (ACA) exchanges.

A policy goal pursued by generations of progressive organizations and lawmakers, a nationalized health care system for all Americans, regardless of age or income, now receives the support of 33 percent of the country across party lines, according to a Pew Research Center poll from June. A full 60 percent broadly believes health care for all is the federal government’s responsibility. Of course, with a GOP-controlled Congress and White House committed to undermining coverage, single-payer health care will remain a dream for now. What proposals from Sanders, Conyers, and Schatz can do is show voters how the world should look when Washington emerges from unilateral rule by a Republican Party fiercely opposed to expanding quality health-care coverage.

There’s one hitch in these best-laid plans: Thanks to the Hyde Amendment, a congressional appropriations rider enacted into law every year since 1976, no federal funds—including the Medicaid and Medicare reimbursements that a doctor receives for providing various health-care services—can cover abortion care except in rare circumstances. Hyde today disproportionately affects people with low incomes and people of color.

Under Medicare for All or another single-payer system, the discriminatory ban could apply to every person who moves off their private insurance into a public option that’s supposed to be more equitable. (Many women with private insurance still pay out of pocket for abortion care, according to a 2013 study co-authored by the Guttmacher Institute’s Rachel K. Jones. The pro-choice research institute maintains a list of states that restrict private insurance from covering abortion. Vox’s Kliff published a story Thursday about how patients with private insurance that covers abortion “often have to fight for coverage.”)

Sanders is the only lawmaker whose bill addresses Hyde. Conyers is aware of the issue but is banking on Hyde being gone before Medicare for All becomes a reality. He’s involved in a separate effort to put an end to Hyde. Schatz represents the great unknown.

Three Bills, Three Different Approaches

Sanders’ Medicare for All bill will preempt the discriminatory Hyde Amendment, according to an aide.

“It will cover ‘comprehensive reproductive, maternity and newborn care.’ Abortion falls into that bucket,” the aide said in an email. “We are also taking steps to ensure the government could not refuse to accredit an abortion provider as a participating provider simply because they provide abortions.”

Conyers’ version does not.

“I just can’t envision a world where we have the votes to pass Medicare for All but we haven’t repealed the Hyde Amendment yet,” Dan Riffle, Conyers’ senior legislative assistant for health care, told Rewire.

“We agree that that’s important,” Riffle said in a phone interview. “I just don’t think it’s something we should slow down progress on Medicare for All now, today, based on a concern that is almost certainly not likely to be present when the bill is passed.”

Conyers began introducing Medicare for All bills in 2003—more than a decade before Democrats cast off Hyde as the cost of doing business on Capitol Hill and coalesced around the Equal Access to Abortion Coverage in Health Insurance (EACH Woman) Act. The EACH Woman Act replaces Hyde with explicit guaranteed abortion coverage under Medicaid, Medicare, and other health-care plans obtained through the federal government. The legislation protects private insurance companies that cover abortion care from political interference at the federal, state, and local levels.

More than two-thirds of House Democrats, including Conyers, signed on to the 2015 and 2017 versions of the legislation embodying the #BeBoldEndHyde movement. More than half of the chamber’s Democrats have co-sponsored Conyers’ vision for universal coverage.

Conyers’ office considered amending this year’s Medicare for All bill to address Hyde but faced a “tight timeline” prior to introduction, according to Riffle. Although the office is open to amending a future version, the “easiest way” to get co-sponsors to sign onto a bill is to tell co-sponsors from prior years that it’s the same.

“That’s why we try to do it the same every year,” Riffle said. “But, you know, there comes a point where you do have to update it,” whether that’s by eliminating Hyde or “moving away from a fee-for-service to [an] outcome-based payments model.”

“It’s something that we’ll look at, I don’t know if it’s something that we would put in on the first draft, but again, we’re never going to pass a Medicare for All bill that doesn’t cover abortion services.”

Schatz’s Medicaid expansion bill may or may not take Hyde into consideration. A spokesperson, Mike Inacay, asked Rewire to send questions via email but ignored repeated follow-up requests for answers.

The Senate does not have any Hyde-ending legislation comparable to the House’s EACH Woman Act.

#BeBoldEndHyde From the Start

Advocates agree that single-payer bills must tackle Hyde, even as they concurrently work to end the provision.

Destiny Lopez is the co-director of All* Above All, a reproductive justice coalition dedicated to eliminating Hyde, partly through spearheading support for the EACH Woman Act. She maintains that any universal coverage that doesn’t include abortion among the full range of reproductive health services “falls short of accomplishing what the purpose of the law actually is—that everyone can get the health care that they need.”

“Anything that somehow carves out or doesn’t address existing abortion coverage bans is not good enough for us,” Lopez said in a phone interview.

Prominent members of the All* Above All coalition have had positive discussions with Sanders’ office. “The proof will be in the pudding, right, so we’ll see kind of what mechanisms they’re going to use to do that, and we’ll hold our breath until we see the bill,” Lopez said.

As for Conyers’ version, “our wish for that bill would be the same.”

“I think there’s some work we still need to do on the House side to ensure that that bill, again, is a bill that’s putting out our vision.”

Lopez acknowledged that work is a little easier on the House side because of the 122 EACH Woman Act co-sponsors, including Conyers, who have “put their values on this out there.”

Whether Hyde-type restrictions would automatically carry over into a single-payer universe depends on how the bills are written, according to the National Women’s Law Center’s Rachel Easter. Would the bills, for instance, fund health care through mechanisms subject to Hyde?

“What we do know is that members of Congress who are opposed to abortion are constantly trying to eliminate insurance coverage of abortion altogether,” Easter, counsel for reproductive rights and health, told Rewire.

Easter pointed to congressional Republicans’ push to end private insurance coverage of abortion care through their Obamacare repeal bill and sundry legislative attempts to expand and codify Hyde. Anti-choice lawmakers will try to hold single-payer proposals hostage as well, she warned in a phone interview.

That’s why the lawmakers behind single-payer bills need to take aim at Hyde from the start.

Abortion Access for All

And just as importantly, they need to be proactive in specifying abortion care within the scope of covered services.

“How does a piece of legislation determine what is and isn’t covered?” Easter asked. “Does it refer to what the ACA requires coverage for? Because if so, that’s not automatically going to include abortion coverage.”

It’s not at all. President Obama in 2010 signed an executive order applying the Hyde Amendment to the ACA. Obama’s executive order followed the unsuccessful Stupak-Pitts Amendment’s attempt to bar the ACA’s tax credits from subsidizing health insurance plans that covers abortion.

Although the Stupak-Pitts amendment ultimately failed, it initially passed the House with the help of 64 Democrats. Only a handful of those Democrats remain in the House. But even vocally pro-choice members of the party have rejected a litmus test on abortion, inviting anti-choice Democrats into the fold. Sanders, a progressive icon and former presidential candidate who ran on ending Hyde prior to its inclusion in the Democratic Party platform, told NPR that “you just can’t exclude people who disagree with us on one issue.”

Democrats’ and progressives’ fealty to abortion rights, then, isn’t a given in the upcoming single-payer debates.

“It’s a concern for me at a time when the Democrats are talking about candidates and saying, ‘We’re not too worried about your litmus test here,’” Karen Middleton, NARAL Pro-Choice Colorado’s executive director and a former state legislator, said in a phone interview.

Middleton and other Colorado-based reproductive rights advocates breathed a sigh of relief when a 2016 ballot initiative to add universal health coverage to the state’s constitution failed. The proposal didn’t override Colorado’s pre-existing constitutional ban on state funds for abortion care. “It’s likely that universal health care advocates left out any protections for abortion coverage to ease the initiative’s passage in a somewhat conservative state,” Slate’s Christina Cauterucci reported at the time.

Single-payer advocates in Congress can confront Hyde head-on because it’s part of a statute; were Democrats who support the EACH Woman Act in power, they’d likely choose to stop attaching the ban in the form of riders to the various appropriations bills (and the continuing resolutions that fund the government in the absence of viable appropriations bills), unlike their Republican counterparts.

Middleton encouraged those lawmakers to “at least start with the best version of the bill, not start with the bill where we need to advocate” to override Hyde and cover abortion. Reproductive rights advocates didn’t accept that tradeoff for the supposed greater good in Colorado, and they won’t now.

“The cautionary tale of Colorado was that we had well-meaning allies and advocates who we work with closely all the time who were so committed to wanting to provide universal health care that they missed nuance,” Middleton said. “They were happy to throw this issue [of abortion] under the bus.”

“It was really sad to get into that fight, which is why the idea that they’re even thinking about it [in Congress] ahead of time … would make so much more sense, and it would bring all of us to the table to help fight to support the bill,” she added. “You’re much happier having us as friends than enemies, trust me.”