Expand U.S. Federal Funding for Reproductive Health Choices in Disadvantaged Women

Valerie Bromberg*, Marzia Maliha**, and Christine Ray***
* University of Pennsylvania
** Thomas Jefferson University
*** Southwest Research Institute

Executive Summary:

The Hyde Amendment heavily restricts the usage of federal funds to cover abortion, which unfairly limits access to reproductive health choices in women from disadvantaged backgrounds and leads to worse health outcomes. To address these growing health and safety concerns, the federal government should expand Medicaid funding for reproductive choice to include abortions deemed medically necessary by a healthcare provider, abortions where a deformity or genetic abnormality has been identified in the developing fetus, elective abortions, and other essential reproductive health services.

Key Messages and Recommendations:

• The restricted use of public funding of abortions disproportionately affects low-income women and women of color in the United States, further increasing financial barriers among these groups.
• States that do not offer abortion coverage beyond the conditions outlined in the Hyde Amendment fare worse in multiple indicators of health, including having higher maternal and infant mortality rates, compared to states that have expanded Medicaid funding for abortion.
• The federal government should repeal the Hyde Amendment and expand Medicaid funding to cover one or more of the following: abortions deemed medically necessary by the healthcare provider, abortions where a fetal abnormality has been identified, and/or all abortions including elective abortions.
• The federal government should ensure that all states are providing adequate and accessible reproductive health services to constituents that rely on federal funding for their healthcare.

The Current Landscape of Reproductive Rights

On June 24, 2022, the United States (U.S.) Supreme Court overturned their decision from the 1973 landmark case Roe v. Wade, which affirmed the constitutional right to abortion. With this ruling, federal protection for those seeking and providing abortions, a necessary reproductive health service, was eliminated. It is now up to the individual U.S. states to decide the legality of abortions, and roughly half of them are headed towards abortion bans. Given the current political landscape, it is imperative now more than ever that we familiarize ourselves with existing federal laws regarding reproductive rights to improve upon them and codify them into legislation.

The Hyde Amendment: an Introduction

In 1976, three years after Roe v. Wade, the U.S Congress passed the Hyde Amendment, which originally banned the use of federal funding to pay for abortions through Medicaid. Since then, there have been several amendments to the original bill. Currently, the Hyde Amendment restricts publicly-funded coverage of abortion only to cases of pregnancy arising from rape, incest, and/or when the pregnancy endangers the woman’s life.

Since Medicaid is jointly funded by the federal and state governments, state programs can choose to provide Medicaid coverage for abortion beyond the conditions stipulated by the Hyde Amendment but must use their own funds to do so. While 33 states follow federal regulations and cover abortions only in cases stipulated by the Hyde Amendment, only 16 states have a policy directing the use of state funds to cover abortions under additional circumstances. Additionally, South Dakota has a more restrictive policy in violation of federal regulation, allowing Medicaid coverage of abortions only in cases of life endangerment, and not in cases of rape or incest.

Consequences of Restrictive Public Funding for Abortion

One of the major criticisms of the Hyde Amendment is that it unfairly limits abortion access for women who rely on public funding for their medical care. The majority of these women come from a minority background (Black, Hispanic, Asian, Pacific Islander, and Native American), and 75% of those seeking abortions live at or below 200% of the federal poverty level. Restricting abortion access for disadvantaged women only serves to increase these social and financial barriers: studies have shown that women having to forego a preferred abortion have 4 times greater odds of living in poverty and 3 time greater odds of being unemployed within 6 months of their pregnancy. The psychological stressors resulting from these financial barriers have also contributed to increasing mental distress rates among women of reproductive age across the entire United States in recent years.

Restricting access to reproductive choice has numerous health and safety consequences, often worsening the health of both the mother and developing infant. A 2018 report by USA Today shows that, on average, maternal mortality rates in states that allow only the Hyde Amendment conditions for Medicaid coverage of abortions have higher maternal mortality rates than states that offer more expanded coverage options (Figure 1). While there are multiple factors that may contribute to these high rates, such as limited medicaid funding overall in more restricted states, numerous studies have linked restricted abortion access to rising maternal deaths. A 2017 research report prepared by Ibis Reproductive Health connected abortion restrictions with poorer health outcomes for women and children. A 2021 study published in Demography explored the maternal mortality consequences of a national abortion ban. Another 2021 study published in the American Journal of Public Health examined state-level differences in maternal mortality, and found that the lack of federal funds for abortion is one of the two most important abortion restrictions contributing to maternal mortality risk. Although the Hyde Amendment stipulates that federal funds may cover abortions when the mother’s life is in danger, healthcare providers may hesitate to terminate pregnancies due to fear of legal ramifications; this, along with an overall lack of legal abortion providers and pursuit of illegal and unsafe termination options, all threaten maternal health and may increase mortality risk in states with restrictive abortion outlook.

Figure 1: Maternal mortality rates by state, compared to the national average (~21 maternal deaths per 100,000 live births). In general, states that impose the Hyde Amendment restrictions on abortion coverage (orange) or, in the case of South Dakota, even stricter restrictions (red), fare worse in maternal mortality. While multiple factors influence these rates, clear links have been demonstrated between restricted abortion access and increased maternal mortality.

Policy Options: What Reproductive Choices Should States Be Allowed to Cover with Federal Funds?

Among the 16 states that have opted to use state funds to cover abortions in circumstances beyond those specified in the Hyde Amendment, additional coverage falls into several categories. Seven states– Montana, Alaska, Minnesota, New Mexico, Massachusetts, Connecticut, and Maryland– cover all abortions deemed “medically necessary” by a healthcare provider to prevent serious health consequences for the pregnant woman beyond immediate life endangerment, including mental health conditions. Maryland also allows state funds to cover abortions when there is a serious genetic defect or abnormality in the developing fetus. An additional nine states– Washington, Oregon, California, Hawaii, Illinois, Maine, New York, Vermont and New Jersey– allow Medicaid to cover all abortions, both elective or deemed medically necessary.

To combat the social and financial discrimination inherent in the Hyde Amendment, as well as the higher average maternal and infant mortality rates seen in states that provide Medicaid coverage of abortions according to the Hyde Amendment, we propose discussion of the following policy options that have already been successfully implemented in the 16 states mentioned above:

1. Congress could repeal the Hyde Amendment, allowing all states to use federal funds to cover abortions deemed “medically necessary” by the healthcare provider. This would allow medical professionals to determine whether carrying a pregnancy to term would pose a serious risk to the physical or mental health of the pregnant woman and empower them to make the best decision for their patient’s health.
2. The federal government could allow states to use federal Medicaid funds to cover abortions where a fetal abnormality or defect has been identified. This would ensure that pregnancies that the healthcare provider has determined would result in infant mortality or other serious health complications would not be forcibly brought to term, putting undue financial and mental health burdens on the parents.
3. The federal government could expand federal Medicaid to include all abortions, including elective abortions. This would eliminate discrimination in reproductive choice options for disadvantaged women that rely on Medicaid funding for their healthcare.
4. The federal government could ensure that all states are providing adequate and accessible reproductive health services to constituents that rely on federal funding for their healthcare. In addition to expanding federal abortion coverage, in accordance with the decision from Doe v Bolton (1973) the government can ensure that states do not pose undue financial and geographical constraints on abortion for those who rely on Medicaid and other federal funds for healthcare. Current healthcare facilities can be expanded to include a complete range of essential reproductive health services, eg. obstetrics and gynecology, and family planning programs, depending on the demographic needs of a given area.

Disclaimer: Throughout this brief, we use the term ‘women’ to refer to people affected by restrictive reproductive measures, but we recognize that all pregnant individuals and individuals with the capacity for pregnancy are equally affected by these measures, including transgender men and nonbinary individuals.