Abortion Remains Contentious Under Obamacare

Abor­tion re­mains one of Obama­care’s most con­ten­tious is­sues, more than five years after it threatened to keep the law from passing.

Ari­zona be­came the 25th state to ap­prove le­gis­la­tion that would re­quire in­sur­ance plans offered in health care ex­changes do not cov­er most abor­tions. And state le­gis­latures in Texas and West Vir­gin­ia, among oth­ers, are con­sid­er­ing bills this spring that would do the same or take re­lated ac­tion.

Al­though the Af­ford­able Care Act re­quires in­surers in ex­changes to se­greg­ate funds used to cov­er abor­tion—a pro­vi­sion ad­ded to the law at the last minute to en­sure fed­er­al funds are not used to cov­er the pro­ced­ures—it also al­lows states to com­pletely ban abor­tion cov­er­age from ex­changes.

In Texas alone, four bills have been in­tro­duced in the state le­gis­lature this ses­sion, all keep­ing abor­tion cov­er­age off the ex­change, ex­cept in cases where the wo­man’s life is en­dangered.

“There’s been tre­mend­ous activ­ity. A big part of that has been states that have en­acted their own lim­it­a­tions to mar­ket­place plan cov­er­age,” which is part of a na­tion­al trend to make cov­er­age for abor­tion lim­ited, said Alina Sal­gan­icoff, vice pres­id­ent and dir­ect­or of wo­men’s health policy at the Kais­er Fam­ily Found­a­tion.

“It’s def­in­itely hap­pen­ing and Texas is next on the list, for sure,” Sal­gan­icoff said.

But in one way, Ari­zona now oc­cu­pies a cat­egory all its own: It bans abor­tion cov­er­age from health in­sur­ance plans in ex­changes ex­cept in spe­cif­ic cases—in­cest, rape, or en­dan­ger­ment of the wo­man’s life—but not from Medi­caid. Ari­zona is un­der court or­der to provide state funds for abor­tion to wo­men covered through Medi­caid, al­though ob­tain­ing re­im­burse­ment for abor­tion from the state Medi­caid pro­gram is dif­fi­cult, ac­cord­ing to an Ibis Re­pro­duct­ive Health re­port.

“The Amer­ic­an people over­whelm­ingly op­pose tax­pay­er fund­ing of abor­tions, and it’s no dif­fer­ent in Ari­zona, where we have long-stand­ing policy against sub­sid­iz­ing them with pub­lic dol­lars,” Gov. Doug Ducey said in a state­ment. “This le­gis­la­tion provides clar­ity to state law.”

The Ari­zona law has sparked out­rage among abor­tion-rights groups and mem­bers of the state le­gis­lature.

“Gov. Ducey ve­toes bill to pre­vent cruelty to cows and chick­ens but signs one that is cruel to wo­men. #AZ­Back­wards,” Demo­crat­ic state Rep. Vic­tor­ia Steele tweeted.

“Deny­ing wo­men the op­por­tun­ity to use private funds for leg­al and safe abor­tion health care is an over­reach. Fur­ther, for­cing wo­men and teens to prove rape or in­cest with in­sur­ance com­pan­ies will only fur­ther trau­mat­ize vic­tims,” Jodi Lig­gett, Planned Par­ent­hood of Ari­zona’s pub­lic policy dir­ect­or, said in a state­ment.

Of the two dozen states ban­ning most abor­tion cov­er­age from plans on ex­changes pri­or to Ari­zona’s de­cision, 10 also have abor­tion cov­er­age lim­it­a­tions on private in­sur­ance plans out­side of ex­changes, and all 24 pro­hib­it most abor­tion cov­er­age un­der Medi­caid, ac­cord­ing to Kais­er.

Cov­er­age de­cisions still are be­ing made across the coun­try, and sev­er­al states have in­tro­duced le­gis­la­tion this ses­sion that would sim­il­arly re­strict ac­cess to abor­tion for wo­men.

Two of the bills in­tro­duced in Texas would re­quire private in­surers to bill en­rollees sep­ar­ately for abor­tion cov­er­age, al­though no fed­er­al funds are used for private in­sur­ance.

West Vir­gin­ia has in­tro­duced a bill to pro­hib­it cov­er­age of most abor­tions on Mar­ket­place plans and, sim­il­ar to Texas, pre­vent oth­er health plans from provid­ing abor­tion cov­er­age ex­cept as sep­ar­ate and sup­ple­ment­al. Mis­sis­sippi in­tro­duced a bill, but it died in com­mit­tee. Montana’s le­gis­lature has in­tro­duced a bill that re­quires in­surers to of­fer a policy without abor­tion cov­er­age if they have a policy that in­cludes abor­tion cov­er­age. Michigan has in­tro­duced a bill that would re­quire in­surers to of­fer a rider for abor­tion cov­er­age.

Vir­gin­ia, break­ing with the dir­ec­tion of pro­posed le­gis­la­tion in oth­er states, in­tro­duced a bill to re­move its ban on most abor­tion cov­er­age in ex­changes, but it died in com­mit­tee.

Even be­fore the Af­ford­able Care Act, it was il­leg­al for fed­er­al money to be used to fund abor­tion un­der the Hyde Amend­ment, with ex­cep­tions for cases of rape, in­cest, or threat to the preg­nant wo­man’s life.

But abor­tion, along with im­mig­ra­tion, was one of the fi­nal hurdles to jump be­fore the pas­sage of the ACA. The fi­nal law in­cluded a com­prom­ise to get the sup­port of Demo­crat­ic Sen. Ben Nel­son of Neb­raska; states are al­lowed to ban abor­tion on their ex­changes, and plans that of­fer abor­tion cov­er­age must se­greg­ate funds to as­sure that no fed­er­al money is used for abor­tion cov­er­age.

Of states that don’t have a ban on abor­tion cov­er­age through ex­changes, sev­en mar­ket­places don’t have plans that in­clude it any­way.

“Not hav­ing abor­tion cov­er­age for wo­men can ef­fect­ively lim­it their ac­cess to abor­tion ser­vices, be­cause the cost is the primary is­sue,” Sal­gan­icoff said.

A clin­ic-based abor­tion at 10 weeks preg­nancy costs between $400 and $550. At 20 to 21 weeks, this jumps from between $1,100 to $1,650 or more. And among un­in­sured wo­men of re­pro­duct­ive age who are in­come eli­gible to re­ceive tax cred­its, 60 per­cent live in states that have banned or do not of­fer abor­tion cov­er­age in mar­ket­place plans, ac­cord­ing to Kais­er.

One reas­on states might not want to al­low abor­tion cov­er­age on ex­changes is be­cause, as a part of the com­prom­ise with Nel­son, se­greg­at­ing the funds for it adds an­oth­er ad­min­is­trat­ive lay­er of work, ac­cord­ing to Kais­er.

But some in­sur­ance com­pan­ies might not fol­low this rule any­ways. Last year, a Gov­ern­ment Ac­count­ab­il­ity Of­fice re­port found that 17 of the 18 pro­viders sur­veyed did not bill en­rollees sep­ar­ately for non-ex­cep­ted abor­tion ser­vices, al­though it was un­clear wheth­er the pro­viders se­greg­ated the funds with­in their fin­an­cial sys­tems. They had, however, es­tim­ated a sep­ar­ate premi­um amount for abor­tion cov­er­age.