Reproductive Health: The Third Rail of Health Care

1. Reproductive Health:The Third Rail of Health Care Panna Lossy MD and Norma Jo Waxman MD

2. More than 99% of U.S. women aged 15–44 who have ever had sexual intercourse have used at least one contraceptive method.

3. Nearly 1 in 4 US Women will have an abortion by age 45 (23.7%)

4. Abortion Risks in Perspective Chance of death Risk from terminating pregnancy: per year: Before 9 weeks 1 in 1,000,000 Between 9 and 10 weeks 1 in 500,000 Between 13 and 15 weeks 1 in 60,000 After 20 weeks 1 in 11,000 Risk to persons who participate in: Motorcycling 1 in 1,000 Automobile driving 1 in 5,900 Power-boating 1 in 5,900 Playing football 1 in 25,000 Risk to women aged 15–44 from: Having sexual intercourse (PID) 1 in 50,000 Using tampons 1 in 350,000 Source: Bartlett et al., 2004 (1988–1997 data)

5. Long-Term Safety of Abortion • First trimester abortions pose virtually no risk of: • Infertility • Ectopic pregnancy • Miscarriage • Birth defect • Preterm or low-birth-weight delivery • There is no association between abortion and breast cancer. • Abortion does not pose a hazard to women’s mental health.

7. Unintended Pregnancy and Abortion Rates Dropping

8. The Profound Impacts of Unintended Pregnancy • Increased domestic violence1 • Delayed prenatal care • Among teens: • Decreased high school completion • Increased likelihood of life in poverty • Among infants, higher rates of: • fetal drug and alcohol exposure • developmental deficits • child abuse and life in poverty 1. Pallitto, et al. Trauma, Violence, & Abuse, 2005.

9. SCOTUS Greatest Hits • 1965 – Griswald – Legalized Contraceptives • 1973 – Roe – Legalized abortion • 1980 – Harris– Upheld ban on Federal $ for AB (Hyde) • 1991 – Rust – Upheld the Title X Gag Rule (but on hold) • 1992 – Casey – Allowed many restrictions as long as they are not a “substantial obstacle” • 2014 – Hobby Lobby -Allowed corporations to be exempt due to religious freedoms from Federal rules requiring contraceptive coverage for employees • 2016 – Whole Women’s Health – Struck down restrictions on abortion clinics that pose an “undue burden”

10. Prohibits any Federal spending on abortion except for in cases of rape, incest or life of mother at risk which affects: Women on Medicaid (except 16 states) Women Vets & active Armed Services Women on disability Women in Peace Corps, AmeriCorps, JobCorp Native Americans Women getting care in federally funded hospitals The Hyde Amendment Passed Annually 1976 - Present

11. Few States use Own Funds to Cover Abortion

14. The House Passed H.R. 7 making Hyde Permanent “We are a pro-life Congress.” • --Paul Ryan January 24, 2017

15. New Rules Proposed for Title X in 2018 • Requires financial and physical separation from any organization that provides abortion or referral to abortion • Prohibits referral for abortion • Directs funds to faith based and other organizations that promote fertility awareness and abstinence as means of family planning

16. States increasingly Hostile to Abortion https://www.guttmacher.org/laws-affecting-reproductive-health-and-rights-2013-state-policy-review

17. And in 2018

18. And 50 More Restriction in 2016!

19. 27 States Require Waiting Periods Before Obtaining an Abortion 13 states require two separate visits 23 States No Waiting Period 18-24 Hours 18 States 3 States 48 Hours 6 States 72 Hours SOURCE: Guttmacher Institute. State Laws and Policies, Counseling and Waiting Periods for Abortion. As of July 1, 2016.

20. Many States Require Women to be Counseled on Topics Lacking Medical Consensus or Evidence State Policy Requires Clinicians or Staff to Tell Women Seeking Abortions That: • Abortion raises the risk for breast cancer—AK, KS, MS, OK, TX • Abortion may cause fetal pain—AK, AR, GA, IN, KS, LA, MN, MO, OK, SD, TX, UT • Personhood begins at conception— IN, KS, MO, ND, OK, SD NOTES: States vary in requirements for counseling to be provided verbally or in written materials. SOURCE: Guttmacher Institute. State Laws and Policies, Counseling and Waiting Periods for Abortion. As of July 1, 2016.

21. States Have Enacted Specific Restrictions for Medical Abortions Of the 1.1 million abortions in 2011, 23% were medication abortion SOURCE: Jones RK & Jerman J. (2014) Abortion Incidence and Service Availability in the United States, 2011. Perspectives on Sexual and Reproductive Health; 46(1), pp. 3-14. Guttmacher Institute. State Laws and Policies, Counseling and Waiting Periods for Abortion. As of July 1, 2016. Guttmacher Institute. State Laws and Policies, Targeted Regulation of Abortion Providers. As of July 1, 2016. Guttmacher Institute. State Laws and Policies, Medication Abortion. As of July 1, 2016.

22. Additional State Restrictions • Parental involvement – 37 states • Must be performed by MD – 42 states • Institutional refusal allowed – 42 states • Partial birth abortion ban - 20 states

23. What did we learn from the last Health Care Battle?

24. ACA 101: the BIG wins • Maternity and newborn care essential benefit • Contraceptive Coverage Guarantee • Direct access to Ob-Gyns (qualify as a medical home) • Ends pre-existing exclusion- pregnancy, h/oc-section, IPV history, breast mass

26. Birth Control=Preventative Health

29. The Impact of the ACA on Abortion • The Stupak-Obama Compromise • Executive Order (3/24/10) • No federal subsidies for abortion coverage beyond Hyde • Applies to exchanges, Medicaid, Community Health Center Fund • State health insurance exchanges • At least 1 plan that covers + 1 does not cover abortion • No plan required to offer abortion • States may ban abortion coverage in exchange

30. The Impact of the ACA on Abortion • Extends Hyde Amendment to middle class individuals using state health insurance exchanges • Sends message that abortion not “health care” • Further institutionalizes the moral view of some members ofCongress • Unlikely that many women will write the “separate check…will not have coverage when they need it

31. Half of States Limit ACA or Private Insurance Coverage of Abortions Some states ban coverage in all cases. Other states allow coverage in cases of rape, incest or life threat. WA VT ME MT ND NH MN OR MA NY WI ID SD RI MI CT WY PA NJ IA OH NE DE IN NV IL MD WV UT CO VA CA DC MO KS KY NC TN OK SC AZ AR NM GA AL MS LA TX FL AK Private and ACA Marketplace Restrictions (10 states) HI ACA Marketplace Restrictions (15 states) No Private Insurance Restrictions (25 states & DC) NOTES: Private Insurance Coverage Limitations - State has a law that prohibits coverage of abortions from being included in private insurance policies sold in the state (with certain exceptions). Private insurance includes individual, small group, and large group. Some states may allow abortion coverage to be purchased as a rider. State Marketplace Coverage Limitations - State has a law that prohibits plans sold on state Marketplaces from covering abortion (with certain exceptions). No Private Insurance Limitations - State does not limit coverage of abortion in private insurance or the state Marketplace. SOURCE: Kaiser Family Foundation. Interactive: How State Policies Shape Access to Abortion. 2016.

32. Availability of Abortion Coverage for Tax Credit Eligible Uninsured Women

33. Where are we now?

34. Outrage and Mass Protest over Repro Rights after 2016 Election

35. The Supreme Court dramatically impacts Reproductive Rights Liberal Justices Ruth Bader Ginsburg Elena Kagan Sonia Sotomayor Stephen Breyer Conservative Justices Clarence Thomas Samuel Alito Neil Gorsuch Brett Kavanaugh John Roberts

36. What happens if Roe is overturned • 16 states have laws that could be used to restrict the legal status of abortion. • 4 states have laws that automatically ban abortion if Roe were to be overturned. • 9 states retain their unenforced, pre-Roe abortion bans. • 7 states have laws that express their intent to restrict the right to legal abortion to the maximum extent permitted by the U.S. Supreme Court in the absence of Roe. • 9 states have laws that protect the right to choose abortion prior to viability or when necessary to protect the life or health of the woman.

38. What do Single Payer Plans Propose?

39. HR 676 • Does not specifically mention reproductive care or abortion. • Conyers says he thinks Hyde will be repealed before his bill is passed so it is not necessary

40. Medicare for All • Comprehensive reproductive, maternity, and newborn care" in the benefits section (sec.201(a)(7)) • Trust Fund section says "Restrictions shall not apply- Any other provision of law in effect on the date of enactment of this Act restricting the use of Federal funds for any reproductive health service shall not apply to monies in the Trust Fund" (sec. 701(b)(3)) – • (Overriding Hyde) Beyond the Rhetoric: The Real-World Impact of Attacks on Planned Parenthood and Title X

41. PHNP Reproductive Health Stance • “Physicians for a National Health Program supports full coverage of women's health care services in the single payer plan that we advocate. This should include coverage for counseling regarding all family planning options, and free access to contraception, abortion and preventive cancer services for all residents of the United States”.

42. Universal Health Care Decreases Rate of Abortion • Canada - 15.2 abortions per 1,000 women • Denmark - 14.3 • Germany - 7.8 • Japan - 12.3 • Britain - 17.0 • United States - 20.8.

43. Public opinion on women’s health Poll findings from 2017-2018 KFF Health Tracking Polls

44. Vast Majorities Support Policies that Include Maternity Care of the public originally support the ACA’s requirement that private health plans must include maternity care coverage of the public support the requirement after those who originally opposed hear that, without it, policies that include maternity care would become very expensive SOURCE: KFF Health Tracking Poll (conducted March 6-12, 2017)

45. say it is important to them that the federal government funds reproductive health services for lower-income women 80% say the federal government should continue paying Planned Parenthood for non-abortion services provided to people on Medicaid 73% SOURCE: KFF Health Tracking Polls (conducted April 17-23, 2017 and June 11-20, 2018)

46. 68%of Americans support the ACA’s requirement that, with the exception of certain religious objections, private health insurance plans cover the full cost of birth control SOURCE: KFF Health Tracking Poll (conducted June 14-19, 2017)

47. 59% of US Adults believe abortion should be legal

48. Large Majorities of Independents and Democrats Believe Abortion should be Legal

49. Hispanic Adults are Divided about if Abortion should be Legal

50. By Religion, only White Evangelicals have a majority who say Abortion should be Illegal