What if public health insurance paid for abortion? More and more people are beginning to ask that question.

With support for Roe v. Wade stronger than ever before, reproductive rights advocates have moved the “Overton window” of what policy ideas are considered feasible. Now, instead of simply defending the right to abortion, they’re talking about securing access.

Advocates have been trying to get public insurance to cover abortion for some time now, and they’re beginning to see victories in legislation and lawsuits. The work is manifold: ensuring that the federal government provides abortion coverage in the limited circumstances it says it will, trying to lift these coverage restrictions altogether, and most recently, demanding abortion be part of Democrat’s reforms to health care.

Co-director of All* Above All Destiny Lopez expects the newest version of the House’s Medicare-for-All bill, legislation sponsored by Rep. Pramila Jayapal (D-WA) that implements a single-payer national health insurance program, will include abortion care when it is introduced later this month. The original bill, sponsored by former Reps. John Conyers (D-MI) and Keith Ellison (D-MN), didn’t mention reproductive health care, much less abortion. ThinkProgress reached out to Jayapal’s office for comment, but did not immediately hear back.


“We believe that continuing to exclude abortion services from any federal plans interferes with reproductive health decisions and ultimately disproportionately affects low-income people and people of color, and so really that’s the education we’ve had to do: what’s the impact if you decide to leave abortion, specifically, or reproductive health, more broadly, out of these bills,” Lopez told ThinkProgress.

The campaign to get the public more comfortable with abortion coverage began in 2013 when reproductive rights and justice organizations united to build support for lifting restrictions in Medicaid, government-run insurance for low-income residents or individuals with disabilities. The All* Above All campaign, as it’s known, has concentrated on repealing the Hyde Amendment, a federal amendment first introduced in 1976 and passed annually in appropriation bills that blocks federal Medicaid dollars from paying for abortion services except in cases of life endangerment and rape or incest.

So far, the All* Above All campaign has got Rep. Barbara Lee (D-CA) to introduce legislation to formally put an end to Hyde in 2017, which she plans to reintroduce in February.

Change isn’t just coming at the federal level, as advocates have also been working on state-based initiatives.

Tangible wins over the years came when advocates worked with city councils and local boards, passing resolutions to condemn Hyde. But a major victory came in 2017, when Illinois Gov. Bruce Rauner (R) signed legislation to let state Medicaid dollars pay for abortions — no exemptions needed.


States can use local Medicaid dollars to pay for abortion care beyond Hyde, but only 15 states do. In fact, some states are even skirting federal law, which requires coverage in the cases of rape, incest, and life endangerment. Fourteen states don’t cover medication abortion even though it’s eligible for federal funding, and South Dakota only covers abortions in cases of life endangerment, according to a new Government Accountability Office report. The Centers for Medicare & Medicaid Services told ThinkProgress by email the agency “will examine this issue further and to the extent that states may not be accurately reporting Medicaid expenditures correctly, we will work with them to ensure full compliance.”

When state Medicaid dollars don’t cover abortion services, people earning below or near the poverty level might have to pay upwards of $3,500 for the procedure themselves or apply for non-profit funds, usually a combination of both. While the reasons to have an abortion vary, financial constraints are a frequently-cited reason; a majority of abortion seekers are already parents.

That’s why advocates need to secure abortion coverage in any public health plan — whether it’s offered in Medicaid or in a single-payer health care program, said executive director of the National Network of Abortion Funds Yamani Hernandez.

“Our network of abortion funds gets 150,000 calls and is able to support about 30,000 of those people. While we are looking for a visionary solution that is many, many years down the line, in the meantime, we are very much focused on how to get people the care they need today,” Hernandez told ThinkProgress. There are not many groups providing this direct support, she added.

Photo of late Rep. Henry Hyde (R-IL). Led by Hyde, Congress first barred Medicaid from paying for abortion care in 1976.

Even minor victories prove vital to the movement, as it keeps morale up. Advocates were thrilled when Texas Rep. Sheryl Cole (D) recently introduced a bill that would let state Medicaid dollars pay for abortions. It’s a notable feat given that no Texas lawmaker, Democrats included, wanted to introduce House Bill 895 last session, said executive director of the Lilith Fund Amanda Williams. HB 895, dubbed “Rosie’s Law,” was written in memory of 27-year-old Rosie Jimenez who died after trying to get an illegal abortion in Mexico; advocates refer to her as the Hyde amendment’s first victim. Cole, a newly elected representative, has shifted the conversation, making it clear it’s not enough for lawmakers who say they support abortion access to simply oppose restrictions introduced by Republicans.


“We have to be proactive and look further back at our history, and [ask], ‘What are the real logistical barriers?’ It doesn’t just stop with abortion coverage,” Williams told ThinkProgress.

Groups are also getting states to cover abortion beyond Hyde by filing lawsuits. On Friday, the Alaska Supreme Court handed advocates their latest victory by striking down a local law and regulation that limited Medicaid coverage for abortion, saying if the state elects to pay for a person to carry the pregnancy to term then the state must also pay for a person who decides to terminate the pregnancy. Litigation to lift Medicaid abortion coverage bans also exist in Pennsylvania and Maine.

Advocates argue the needle moved on abortion coverage more broadly only after lawmakers really began to understand how the Hyde amendment affects people. The federal conversation shifted in 2016, when the Democratic party included Hyde repeal in its 2016 presidential platform. Sen. Bernie Sanders (I-VT), who’s running for president again in 2020, repealed coverage restrictions in his Medicare-for-all bill.

“When you are thinking of revising the system, you have to make sure that you are not thinking just about reproductive health care but also abortion… because it’s not necessarily what comes top of mind when they are thinking about health care expansion,” said Lopez. “Unless you are explicit, abortion ends up being on the chopping blocks.”

This is true of the last time Democrats tackled health care with the Affordable Care Act. The 2010 law reinforces Hyde, and the Trump administration is working to further restrict abortion coverage in private plans offered on the ACA marketplaces.