Single-Payer Health Care Must Come With Reproductive Coverage

If a single-payer plan doesn’t protect abortion, we cannot call it universal.

I n the wake of the GOP’s recent and unflagging attempts to repeal the Affordable Care Act — an unpopular move by multiple measures — a handful of Democrats are fighting back with a push in the opposite direction. Rather than try to tape the ACA back together, candidates and lawmakers are pushing for a health-care revolution in the form of a single-payer system. Last week, the idea got its most high-profile boost yet, when Sanders unveiled a Medicare-for-All bill with a record 15 Democratic co-sponsors in the Senate.

The legislation, of course, doesn’t stand a chance of passing in the current GOP-controlled political climate (Trump has even gone so far as to call the plan, ludicrously, a “a curse”) — but there’s reason to believe it has potential, especially if Democrats soon take back political power. A recent Pew poll, for instance, found that support for single-payer health care has grown 12 points since 2014.

This push for universal or single-payer health care — which aren’t exactly the same, but are similar enough that they’re largely used interchangeably — is undoubtedly promising. But there is also good reason to believe that a single-payer plan could potentially leave many pregnant people without a way to pay for a necessary medical procedure that hundreds of thousands seek each year.

A recent Pew poll found that support for single-payer health care has grown 12 points since 2014.

That’s because in the United States — a country where erectile dysfunction medication, cosmetic surgery, and numerous other pills and procedures are covered by insurance — abortion has largely been funded out of the pockets of the people who pursue it. Since the 1970s, Medicaid funds have been barred from paying for abortion services, and Targeted Regulation of Abortion Providers (TRAP) laws have restricted the ways in which even private insurance can pay for the procedure and aftercare. If restrictions like these aren’t expressly confronted and dismantled in a single-payer health-care plan, many reproductive-rights organizations believe that universal health care will not expand access to coverage for pregnant people in need, and could even further hinder access.

At a time when basic abortion services are in peril — when states are rolling back abortion rights with little resistance, and when Democratic organizations and lawmakers have made it clear that abortion is an area of potential compromise — how can we be sure that any attempt at single-payer health care will hold strong and ensure that everyone truly is covered?

Even as we fight back against the GOP’s latest last-gasp effort to get rid of Obamacare — and it’s crucial that we do — it’s also important that we open up a pro-choice dialogue around single-payer. Because no plan can be universal if it doesn’t support those seeking reproductive care.

The Power Of Hyde

It would be easy to assume that pro-choice advocates and single-payer advocates are one in the same — they are united in their interest in expanding health-care access, and both tend to come from more progressive camps. However, many reproductive-health organizers are skeptical that single-payer plans will truly be inclusive, while single-payer supporters view pro-choice groups as being too incremental.

The schism lies partially — but not entirely — in concerns over the budget appropriation known as the Hyde amendment, which bars most public money from paying for abortion services. Because of Hyde, for the 17% of non-elderly adult women who are on Medicaid (many of whom are members of marginalized populations), abortion services — which can run up to $1,500 — must be paid out of pocket except in very specific instances. That’s in addition to the cost of traveling over state lines and potential hotel stays in states that require 24-hour waiting periods, which only increase the chance that an unwanted pregnancy becomes financially ruinous.

However, there’s little political will to change the rule; since its passage in 1976, the Hyde amendment has been renewed every single year. And support has come not just from conservatives — but, in more subtle ways, from pro-choice organizations like Planned Parenthood.

This isn’t because Planned Parenthood is against reproductive justice for the less privileged, of course. But as the organization has clawed its way to remain funded in the wake of relentless GOP attacks, it’s often distanced itself rhetorically from abortion services. As a result, as Kylie Cheung wrote for Mediaite in July:

“Instead of fighting the Hyde amendment, which prevents thousands of low-income women from being able to access safe and legal abortion, [Planned Parenthood] routinely affirms the Hyde amendment’s legitimacy by reminding conservatives that they don’t use federal funding to pay for abortion.”

Still, there’s reason to be hopeful that getting rid of Hyde could be part of a push for universal health care. Despite Planned Parenthood’s rhetoric, the organization has in action fought the Hyde amendment in some key ways — it lobbied aggressively against HR 7 in January, which would have made Hyde permanent, and has supported numerous candidates who have listed rescinding Hyde as a major campaign promise. The organization also recently hosted a rally with Sanders, patron saint of single-payer, who has himself strongly backed repealing Hyde.

Rescinding Hyde as part of the push for single-payer is possible, then — but there’s also reason to believe it could be entirely ignored. And this would ensure many pregnant people would continue to struggle to access abortion services, even in the wake of “universal” care.

The Power Of State Control

Hyde isn’t the only thing standing in the way of universal health care covering abortion services. The United States prizes its ability to let states govern themselves in many ways, including how they distribute grant money and when and where they allow their medical professionals to practice. Without express federal protections for abortion that actively require states to expand access and coverage, the question remains: Even if we pass comprehensive universal health care, could it be whittled away by states looking to curb coverage and access?

There’s an example of precisely that just north. In Canada — where many in the United States look to see a shining example of single-payer at work — there’s a clear example of what happens when reproductive health is not at the center of the health-care conversation. In spite of the country’s reputation for progressive values, abortion rights have been whittled away, one province at a time.

Writing for Jacobin, Gerard Di Trolio explains what’s happening.

“Though there is no law regulating abortion in Canada, all provinces have varying restrictions on government-funded abortions. Women seeking an abortion have to meet a particularly high bar in New Brunswick. There, abortions are only covered when: performed before the 16-week mark, carried out by an obstetrician or gynecologist in a hospital, and after two doctors have signed off on the procedure.
Prince Edward Island (PEI) is even worse. The province doesn’t have a single medical facility that can perform abortions. This has led to instances in which women have harmed themselves because they didn’t have abortion access. Pro-choice activists have long argued these regional variations violate the Canada Health Act. Still, PEI Premier Robert Ghiz said this spring, ‘I believe the status quo is working.’ He can get away with such comments and policy positions because the federal government has never intervened to ensure equitable access.”

To see how state regulations could complicate abortion access under a single-payer system, one need look no further than Colorado. In 2016, voters from the state rejected a bill that would have achieved universal health care. And from the beginning, reproductive-rights organizations expressed concerns about one very specific legal hurdle: a state amendment passed in 1984 which prohibited public funds from being used to fund abortion services.

Even states like California — where health care access is greater than many others and abortion services are potentially more in-reach — still present significant barriers to accessing abortion. For instance, Medi-Cal, California’s Medicaid program, has a massive access problem; a 2011 report found that 45% of California counties don’t have a Medi-Cal abortion provider. Which means that even if the state were to pass a single-payer plan (without additional stipulations to provide more clinics or locations which offer abortion service), the coverage would still be just as limited, if not more so.

Sans federally mandated abortion protections within a single-payer plan, it’s easy to see how states could severely limit access to reproductive services.

The Power Of The Democratic Party

Perhaps the biggest threat to abortion services, though, is the current ideology of the Democratic party. Regardless of a person’s moral beliefs about abortion, there is an inalienable case to be made that abortion on demand is an economic imperative. Yet the party has made it clear in recent months that it views abortion services as an optional or superfluous part of the left’s agenda.

As such, the most important way to move forward on single-payer is to make this message crystal-clear: Interjecting mentions about Hyde and abortion and reproductive care into conversations about single-payer is not derailing — it is essential.

It’s possible to do, too — and when it’s done correctly, the desired effect of fewer abortions can be achieved. In Massachusetts, where statewide health care was used as a model (kind of) for the ACA, abortion rates declined significantly “despite public and private funding of abortion that is substantially more liberal than the provisions of the federal legislation currently under consideration by Congress,” according to a 2010 article by Patrick Whelan, M.D., Ph.D. in the New England Journal of Medicine.

Perhaps the biggest threat to abortion services is the current ideology of the Democratic party.

However, in the current climate, where the GOP seems more certain than ever that the only way to preserve their legacy to repeal the ACA, it seems exceedingly difficult to imagine that, as a nation, we could both a.) build and implement a functional universal health care system that truly works for everyone and b.) repeal the numerous state and federal bans on public dollars for abortions.

In the United States, where the GOP is so passionate about states’ rights, it’s easy to see how a situation like the one in Canada could unfold. States like Texas and Missouri are already attempting to reduce access at every turn. What happens if we do push so hard for single-payer that we forget how many in the country still desperately want to not only strengthen Hyde, but repeal Roe v. Wade?

What happens if we stop bringing up the existing barriers to abortion and as a result, they are never removed when new health-care policies are put into place?

What happens if the fervor for single-payer becomes so great that compromising on abortion becomes fair game?

There is a surging current of support for universal health care in some ways — perhaps even universal Medicaid or Medicare, as the Dem-backed new bill is pushing for. But if access to necessary medical procedures and reproductive health care aren’t part of the policy (if clinics aren’t added, waiting periods aren’t repealed, and requirements that trans-vaginal ultrasounds aren’t removed), it will necessarily be a half-measure achieved at the expense of millions.

What if the fervor for single-payer becomes so great that compromising on abortion becomes fair game?

Even if Hyde is repealed and universal health insurance can pay for abortions, if there’s nowhere to go, it’s not really a right.

Supporters of single-payer ought to be on the front lawn, in the streets, and on the phones with their representatives. They must be turning out at the ballots and holding town halls and pressing their lawmakers. But they also must do so with an eye on the very real, very scary potential that single-payer which doesn’t cover abortion is nowhere near universal.

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