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In 2017, Sen. Bernie Sanders introduced the Medicare for All Act in the United States Senate. Medicare for All is what many refer to as single-payer, where citizens pay for publicly funded health insurance through taxes rather than paying for private insurance. In the midst of Democratic Party backtracking on abortion rights, the bill came as a breath of fresh air to the reproductive justice movement. Sanders’s Medicare for All bill mandates “comprehensive reproductive care,” including abortion. Mandated equal access to abortion care in federal legislation would mean nullifying the Hyde Amendment, which is the legislation that gets passed yearly preventing Medicaid programs from providing federal funds for abortions except in dire circumstances. There would then be no basis for Hyde’s annual passage, since preventing federally mandated abortion access is the reason Hyde exists. Defeating Hyde means abandoning the defensive, legalistic way of interpreting reproductive justice solely through the lens of privacy, which mainstream nonprofits and reproductive rights advocates have clung to under Roe v Wade. Roe is the Supreme Court decision that legalized abortion on the basis of the Fourteenth Amendment’s due process clause. It affirmed that the state cannot interfere in a person’s decision to terminate a pregnancy without due process of law. Fundamentally, Roe affirms a pregnant person’s right to privacy. It does not, however, affirm the state’s responsibility to ensure abortion access. Sanders’s approach means, instead, creating a class-wide basis for deepening reproductive justice. By tying abortion access into a health system that addresses all of women’s needs, it affirms a more expansive sense of reproductive justice: both the right to reproduce and the right not to in a safe and healthy environment. And the promise of fully funded health care for all takes the edge off the GOP’s specter of “taxpayer-funded abortions” used to pass Hyde every year. With Medicare for all, the Right’s zero-sum logic about who does and doesn’t deserve “scarce” healthcare resources loses its relevance. In all these ways, the struggle for Medicare for All provides a powerful context in which to fight for reproductive rights. However, winning reproductive justice won’t be as simple as including a provision in the Medicare for All bill. This is because a staunch defense of the right to abortion is not a given in the Democratic Party, even in its most progressive corners. The backtrack on abortion has spanned the Democratic spectrum, from House Speaker Nancy Pelosi and DNC head Tom Perez to Bernie Sanders himself. In 2017, Pelosi argued that the Democratic Party should ease up on abortion as any kind of litmus test for party candidates. Likewise, Sanders and Perez went on a “unity tour” in which Sanders claimed that stumping for anti-abortion candidates is the sort of thing that the Democrats need to do “if we’re going to be a fifty-state party.” In this context, building the political will needed to win Sanders’s mandated funding provision, let alone extending reproductive justice beyond this indispensable floor, won’t be automatic. Socialists will have to lead the way on this issue. And to do so, they’ll need to understand the political landscape that more than forty years of assault on reproductive rights has produced.

The Left Debates Abortion The right and access to abortion is, fundamentally, a working-class demand. Working-class women are the most vulnerable to restrictions on abortion access and the least capable of going around those restrictions, with fewer resources to pay for abortion care out of pocket or travel to out-of-state providers. For these women, the 1970s women’s liberation slogan of “free abortion on demand” seems increasingly out of reach. To put it bluntly, the Right is winning. A well-funded and top-down, yet militant and activist, anti-abortion movement has put enough pressure on the political system to cause concession after concession in state after state. A snapshot of abortion access in the United States shows a dire picture: Only sixteen states use public funding for all or most abortion, eleven states restrict abortion coverage even in private insurance plans, forty-two states allow health care institutions to refuse to participate in an abortion, eighteen states mandate counseling before having an abortion, twenty-seven states require waiting periods, thirty-seven states require parental involvement in a minor’s decision to have an abortion. Seven states have only one remaining abortion clinic: Kentucky, West Virginia, Missouri, Wyoming, South Dakota, North Dakota, and Mississippi. The public debate about abortion has been pushed so far to the right that adding “and without apology” to the original slogan seems outside of our current moral universe. Women seeking health care are regularly met with hundreds protesting their medical decisions during the so-called bi-annual 40 Days for Life Campaign. Across the country, women are harassed and intimidated at every turn. From “peaceful prayer” to physical harassment to sidewalk counseling, the moral ground has literally been turned over to the Right. Trump’s election and Kavanaugh’s confirmation to the Supreme Court have only emboldened the anti-abortion movement. They know that they are winning: this Supreme Court may finally overturn Roe v Wade, handing over abortion legislation to the states. Four states already have “trigger laws” on the books which would make abortion illegal as soon as Roe is defeated. Meanwhile, with Roe on the chopping block, liberal organizations are still clinging to the strategy which brought them to this conjuncture. They seek to preserve the tenuous legality of abortion under Roe, rather than entrenching it as a right within the health care system. In this way, the procedure has become technically permissible but far from accessible. Now, it’s in danger of becoming neither. The demand for Medicare for All is broader than these defensive, narrow strategies. However, there is a temptation on the Left to overstate Medicare for All’s power to win greater abortion rights by itself. In this perspective, Medicare for All’s unifying power will simply transfer to its specific provisions for reproductive health funding. Emphasizing these provisions, on the other hand, could invite divisions within its potential base. This perspective underestimates the political challenge ahead of us in winning the moral ground back from the Right on this issue. It also misunderstands the extent to which, thanks to the legal framework Hyde inspired, Sanders’s provision is only a starting point in winning true reproductive justice.

The Political Legacy of the Hyde Amendment The Hyde Amendment has political consequences that have played out over the course of the four decades since Roe v. Wade. These consequences, described below, complicate the issue of abortion in a fight for single-payer. The immediate effects of Hyde are that poor women who rely on Medicaid, which is a federal program, cannot use those funds for abortion care. One in five women of reproductive age uses Medicaid and thus have to pay for abortions out of pocket. These women are disproportionately women of color, disabled people, and young people. This redefinition of working-class women’s relationship to the state was foreseen and tolerated by the Amendment’s creators. As Representative Henry Hyde explained, “I certainly would like to prevent if I could legally, anybody having an abortion, a rich woman, a middle-class women, or a poor woman. Unfortunately, the only vehicle available is the HEW Medicaid bill.” The Right needed a scapegoat that would allow them to embed private religious objection into public law. Working-class women, and their dependence on state benefits, provided it. Hyde has generated a political strategy by the Right that has since gone far beyond its initial parameters. Now, it is the ostensible religious beliefs of legislators or institutions that determine abortion policy. Even health care personnel and institutions can refuse to provide reproductive services based on religious or moral objections. In some places this applies not only to religious, private institutions but also to public institutions. Only thirteen of the forty-four states that allow health care institutions to refuse to provide abortion services limit the exemption to private or religious health care institutions. Hyde made state constitutions a moral battleground for securing abortion rights one way or the other. Moralizing abortion on religious grounds created a situation in which a medical procedure to end a pregnancy became an act that individual states can restrict based on arbitrary “moral” motivations. Did they make bad choices that lead to the pregnancy? Were they responsible for it? A whole network of obstacles has thus been set up on a state-by-state constitutional basis. Fetal homicide laws are the outgrowth of this state-by-state constitutional movement. If there is a moral offense committed, like doing drugs, negligence, self-induced abortion, even attempted suicide, that harms the embryo or fetus, the state can declare this behavior a crime. Currently, thirty-eight states have fetal homicide laws. Feticide laws make lack of public funding for abortion the tip of the iceberg for the kind of state intervention that a woman may be subject to during their pregnancy. In sum, any legislation for public funding for abortions at a federal level will face a constitutional landscape on the state level that is quite different from when the Hyde Amendment first passed. The consequences are not only legal. They are institutional. One of the most peculiar features of reproductive health care in the United States is that abortions are sidelined from the mainstream health care system. 59 percent of all abortions are obtained at abortion clinics, but abortion clinics make up only 16 percent of abortion facilities — 31 percent of facilities are nonspecialized clinics, 38 percent are hospitals, and 15 percent are private physicians’ offices. A full 86 percent of abortions are done in freestanding clinics of some kind. When Roe v Wade passed, hospital administrations either worried about overcrowding or were unwilling to perform abortions. In response, the reproductive rights movement spearheaded the efforts to create freestanding clinics. Unfortunately, freestanding clinics have proven to be more vulnerable to attack than hospitals. Not only are clinics easier to harass, intimidate, and in some cases, terrorize violently due to their physical isolation, they are also the targets of special legal regulations. Targeted regulation of abortion providers (TRAP laws) insist that abortion clinics outfit themselves as “ambulatory surgical centers.” These are expensive obstacles to running free-standing abortion clinics. Further, TRAP laws require that abortion doctors have admitting privileges at local hospitals, which may not allow them to obtain. The isolation, balkanization, and privatization of abortion services born of the Hyde Amendment make obtaining an abortion a special problem even if it’s covered by public insurance plans. Beyond TRAP laws, in some places in the country, the only hospitals within 150 miles are Catholic hospitals. Without Hyde, they still won’t be compelled to offer the service. What is needed is to repeal all restrictions on abortion at the state level and to reintegrate abortion care into the central organs of the health care system. The waiting periods, the counseling, the religious exemptions, the feticide laws, all have to go.