Days after the Women's March on Washington, the Trump administration and Republicans in Congress launched attacks on public funding for women's health care.

On Monday, President Trump reinstated the global gag rule, which strips all US funding from foreign aid groups that counsel patients on abortion. Rather than decrease abortion rates, the move is likely to increase them, devastate the global health system in the process, and leave millions of women across the globe without access to either safe abortion or contraception.

And on Tuesday afternoon, House Republicans voted 238-183 to permanently ban US women, too, from receiving any federal financial assistance for abortion — whether they are insured through public programs like Medicaid or if they purchase private health insurance on the Affordable Care Act exchanges.

The bill would codify existing restrictions that make abortion harder for poor women to get

The text of the bill, HR 7, introduced by Rep. Christopher Smith (R-NJ), states that its purpose is to “prohibit taxpayer-funded abortions.”

But federal tax dollars are already not allowed to pay for abortion, either in the US or overseas.

The Hyde Amendment currently bans federal funding for abortion in the US. It makes exceptions for women who become pregnant through rape or incest, or whose lives would be endangered by the pregnancy — but not for women who have any other maternal health issues or fetal abnormalities.

The Hyde Amendment is a budget rider that has passed every year since 1976, not a permanent law. Congress always technically has the option to pass a budget without Hyde, but it’s never actually done so in the 40 years since Hyde was first introduced.

Republicans in Congress want to take that option away. Passing HR 7 would codify the language of the Hyde Amendment into permanent law. (Passing the law through the Senate would require 60 votes to break a Democratic filibuster — which would be possible, but seems unlikely.)

Pushing to make Hyde permanent is “doubling down on harmful policy, and disregarding the health of low-income women and other women who receive health insurance coverage and care through the federal government,” said Megan Donovan, senior policy manager at the Guttmacher Institute.

As it turns out, a lot of people get their health insurance through the federal government — federal employees, military service members, incarcerated people, Native Americans who use Indian health service facilities, and people who are insured through Medicaid.

The Medicaid ban in particular means that abortion is already disproportionately unaffordable for poor women, young women, and women of color — all of whom are more likely to need abortions in the first place.

About one in six women of reproductive age rely on Medicaid for their health insurance. Currently, 17 states have a policy to use their own state Medicaid funds to pay for abortion services — but 60 percent of women on Medicaid don’t live in those states, so they can’t get any insurance coverage for abortion at all.

More than half of those women who can’t get any coverage are women of color.

The bill could also effectively eliminate private insurance coverage of abortion

If HR 7 were passed into law, it could “effectively ban” private insurers from covering abortion through plans on the Affordable Care Act exchanges, Jamila Taylor, a senior fellow in women’s health at the Center for American Progress, told Vox.

To be clear, HR 7 doesn’t ban abortion coverage directly. Instead, it gives insurers almost no other choice but to stop offering plans on the ACA exchanges that cover abortion.

Under HR 7, women who buy an insurance plan that covers abortion through the ACA exchanges won’t be able to receive government subsidies. And without those subsidies, buying insurance through the Affordable Care Act is a lot less affordable.

If insurance that covers abortion is much more expensive than insurance that doesn’t, most people will choose the cheaper option. That wouldn’t leave insurance companies much incentive to offer abortion coverage at all, even if it’s technically not prohibited by law.

About half of all US states already restrict abortion coverage on their ACA exchanges. HR 7 would extend similar restrictions to the other half of the country.

“It’s clear the goal is to try to eliminate private coverage of abortion entirely,” Donovan said.

Despite these impacts, private insurance coverage isn’t getting as much focus as the specter of “taxpayer-funded abortions” in debate over the bill.

That may be because HR 7 isn’t a new bill. The House has passed versions of it before, when repealing the ACA wasn’t a realistic possibility and gutting it through indirect means was a better approach.

Now, of course, Republicans in Congress are actually pursuing a full ACA repeal. So from a rhetorical standpoint, it’s less important for them to talk about the ACA than it is to rally their anti-abortion base with talk of “taxpayer-funded abortions” in advance of the March for Life that’s coming up on Friday.

Grassroots advocates have been trying to overturn the Hyde Amendment for years — and they’ve made significant headway

Passing HR 7 would make it a lot harder to get rid of the Hyde Amendment in the future — and that would be a significant blow to the reproductive justice movement.

It’s hard to overstate the impact the Hyde Amendment has had on women’s access to abortion, even compared with the slew of state restrictions on abortion that have passed in the last five years. While some of those laws closed abortion clinics by the dozen, the Hyde Amendment is even more sweeping: It has made abortion completely unaffordable for millions of women for 40 years.

Somewhere along the line, Hyde became a point of consensus between pro-choice and pro-life politicians — a sort of third rail in abortion politics that neither side would touch. It became status quo to consider abortion so controversial that, at the very least, there should be “no taxpayer funding” for it. Even pro-choice lawmakers, when fighting against efforts to defund Planned Parenthood, may quickly point out that the organization can’t use tax dollars for abortion because Hyde is “the law of the land.”

In recent years, however, grassroots activists have been pushing hard to repeal Hyde. Organizing efforts led by women of color have started to shift the conversation around Hyde from being about tax dollars and shame to being about basic fairness and dignity.

That’s a big reason why the Democratic Party platform included a call to repeal the Hyde Amendment for the first time in 2016, and why a bill to repeal Hyde was introduced in Congress for the first time in 2015.

Polling also suggests that most Americans would be just fine with repealing Hyde. A survey conducted by Hart Research for All Above All, the grassroots coalition pushing to repeal Hyde, is striking. Large majorities of voters, even Republicans, in battleground states agree with the statement, “However we feel about abortion, politicians should not be allowed to deny a woman's health coverage for it just because she's poor.” Black voters are by far the most supportive of this sentiment. And a majority of those polled, 54 percent, say they would support a law requiring Medicaid to cover abortions.

The Hyde Amendment leaves many poor women with no “choice” at all

The Hyde Amendment makes it incredibly difficult, if not impossible, for a low-income woman to actually exercise her right to an abortion. Hyde means that women on Medicaid have to pay a median out-of-pocket cost of $575 for an abortion — which is about a third of monthly income for most of these women.

“Of the women who report that Medicaid isn’t paying for their abortion, most are already food- or housing-insecure,” said Sarah Roberts, a public health social scientist at Advancing New Standards in Reproductive Health (ANSIRH). “They skip meals, or they’re unable to pay their rent or mortgage.”

“Women will go to great lengths to get an abortion,” said Diane Horvath-Cosper, an abortion provider and an advocacy fellow with Physicians for Reproductive Health. “But you can’t get blood from a stone. If somebody doesn’t have the money, they don’t have the money.”

That’s why many advocates see the Hyde Amendment as “discrimination, pure and simple,” Horvath-Cosper said. “It’s discrimination against women who are poor, against people who are already struggling to survive and make ends meet.”

The human costs of banning public abortion funding can be devastating

Horvath-Cosper provides abortions in both Maryland, where Medicaid can cover abortions, and the District of Columbia, where it can’t. The difference between the two, she says, is “night and day.”

“A lot of people don’t even know,” she said. “They’re shocked, they’re floored, to find out that Medicaid doesn’t cover abortion. Because it covers everything else, and their friends in Maryland can use their Medicaid. They’re blown away.”

Sometimes women delay the procedure in order to have enough time to scrape the money together. But if they delay long enough, they might need to have a more expensive and riskier procedure.

“From a purely public health perspective, it makes sense to help women get the abortion as early as possible,” said Dan Grossman, director of ANSIRH. “Funding restrictions can end up having a negative health impact.”

And women who become pregnant by an abusive partner and can’t get an abortion will often find themselves even further trapped in the cycle of abuse.

So it’s no wonder that not being able to afford the procedure might drive some women to desperation, including trying to give themselves an abortion at home. When researchers interview women who have tried to self-induce an abortion, many of them mention cost as a reason for doing so.

Women who become pregnant by an abusive partner and can’t get an abortion will often find themselves even further trapped in the cycle of abuse

That’s why shortly after the Hyde Amendment passed, grassroots abortion rights advocates started creating abortion funds — organizations that raise funds, give rides, watch children (60 percent of women who have abortions are already mothers), and provide other services for women who need abortions but can’t afford them. Today, 70 of these groups in 38 states are organized under the banner of the National Network of Abortion Funds (NNAF).

But abortion funds, while they provide a lifeline for many women in need, can’t come close to filling the funding gap. NNAF gets about 100,000 calls a year from women seeking financial assistance for an abortion, executive director Yamani Hernandez said — and can only fulfill about a third of those requests, with an average grant of $200 per woman. Meanwhile, there are 29 million women who are subject to Hyde and other funding restrictions in America.

“Thank goodness abortion access funds are there, but they’ve got limited resources and they’re unable to help all the clients who call them,” Horvath-Cosper said. “We shouldn’t have to crowdfund somebody’s medical care. That shouldn’t be a thing.”

Low-income women aren’t the only ones who suffer from Hyde, Horvath-Cosper said. She provides abortions in a hospital, and several times a week she sees patients who have “devastating” prenatal diagnoses, where the pregnancy is wanted but the fetus will likely not survive — and where insurance won’t cover a termination because of the Hyde Amendment. These tend to be later procedures, which can cost $10,000 to $15,000. Abortion funding organizations usually can’t cover expenses that high.

“We shouldn’t have to crowdfund somebody’s medical care”

Some of these patients are attorneys or analysts who have good-paying government jobs — but because they are federal employees, Hyde affects them.

“These are people who have fantastic insurance, or so they thought,” Horvath-Cosper said. “And they come in and say, ‘Well, what do you mean, my insurance won't cover this? My baby will die, are they saying I just have to continue the pregnancy and wait for that to happen?’ And I have to say, yeah, that's exactly what that means. It feels heartless. It feels uncaring.

“To put somebody through a doomed pregnancy when they don't want to continue it, and worry about the baby being born and experiencing pain — it's devastating for everybody involved. And it makes you feel really angry at the people in the offices who are making these laws, who don't sit with these families and know what it feels like.”

There are exceptions to the Hyde Amendment, but they are extremely limited and don’t cover fetal anomalies. They also don’t cover risks to a woman’s health that fall short of death — and that puts doctors in a terrible position.

“How do you decide when someone is close enough to death to say that they deserve to have a pregnancy termination?” Horvath-Cosper said. “From a clinician’s point of view, there’s no ‘death checklist,’ where we say, well, if you have this and this but not this, then you're not close enough. ... You want to catch things before things get really bad and someone is at death’s door.”

All of this — the health impacts, the economic impacts, the social justice impacts — is why activists have been pushing so hard to repeal Hyde.

In just the three years since the All Above All campaign went public, repealing Hyde has gone from a taboo subject to a mainstream pro-choice position officially embraced by the Democratic Party. It’s an issue that’s unlikely to go away quietly, even under an anti-abortion Trump-Pence administration and a Republican Congress.

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