In The Fight for Reproductive Rights, Don’t Forget the Medicaid Gap

Originally published in The Intercept on October 1, 2021.
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IN ONE OF the grimmest periods ever for reproductive rights, advocates are scrambling to react to a spate of new restrictions on abortion. The Biden Justice Department filed a lawsuit against Texas in the wake of S.B. 8, the state’s new law that invites private citizens to enforce abortion bans through civil litigation. House Democrats passed the Women’s Health Protection Act, a bill that would protect abortion providers and remove barriers for patients. And some advocates see hope in medication abortion, a combination of two drugs — mifepristone and misoprostol — which people can take to safely end pregnancies.

But many states still restrict where providers can mail drugs, and most groups still only service states with relatively friendly abortion laws. Last week, a Republican state representative in Florida introduced a bill that mirrors S.B. 8, and lawmakers in other GOP-controlled states have signaled interest in following suit. The U.S. Supreme Court has refused thus far to block Texas’s notorious statute, and the Women’s Health Protection Act stands little chance of passage in the Senate.

As long as the Senate filibuster remains in place, and the U.S. Supreme Court maintains its anti-abortion majority, advocates in the South say there’s little that Washington can really do to aid their plight. There is one crucial method, though, which often falls off the radar: Medicaid expansion.

“What people have forgotten is [in] this entire swath of the southeast, from Texas and Georgia and Florida, we never got Medicaid expansion, so there’s a lot of people, especially people capable of becoming pregnant, unable to access any sort of insurance,” said Robin Marty, a journalist, activist, and head of operations for West Alabama Women’s Center, an independent abortion clinic in Tuscaloosa. “We need national organizations to remember that we’re still five steps behind. While they’re trying to get new medication abortion programs standing, we’d like to even use the [Affordable Care Act] birth control mandate.”

As Congress considers proposals to include in the upcoming reconciliation bill — a $3.5 trillion social spending package that Sens. Kyrsten Sinema, D-Ariz., and Joe Manchin, D-W.Va., are threatening to derail — Democrats are weighing at least two measures that would expand Medicaid access in the 12 states that have refused. One pathway, led by Democratic Sens. Raphael Warnock and Jon Ossoff of Georgia and Tammy Baldwin of Wisconsin, would create a program that’s like Medicaid but administered by the federal government rather than by individual states. Their proposal would require the Centers for Medicare and Medicaid Services to offer coverage to those eligible in the 12 holdout states. Texas Democratic Rep. Lloyd Doggett also has a bill that would allow cities and counties to expand Medicaid in states that have refused. And some powerful lawmakers, including House Majority Whip Jim Clyburn, D-S.C., have cited Medicaid expansion as a top priority for inclusion.

Sen. Jon Ossoff, D-Ga., speaks on Medicaid expansion and the reconciliation package during a press conference with fellow lawmakers at the Capitol in Washington, D.C., on Sept. 23, 2021.

The cost for expansion so far is estimated at potentially $250 to $300 billion, but the price could shrink if legislators put an expiration date on their plans. Clyburn suggested last week that he would back a few years of Medicaid expansion, which he said could be harder to strip away once it’s in place.

Lawmakers are under pressure to reduce the cost of the reconciliation package — despite the fact that the $3.5 trillion price tag would be spread over 10 years and partially covered by raising taxes on the wealthy — and several health care priorities are competing for space. These include expanding Medicare, bolstering Obamacare subsidies, and ensuring access to in-home care for the elderly. A Washington Post report on Thursday made the chances for a permanent Medicaid expansion look less likely: Some advocates and Democratic senators expressed concern that it might reward recalcitrant GOP lawmakers, or even incentivize states that have expanded Medicaid to reverse course, potentially forcing the federal government to pick up the tab for states that had previously expanded Medicaid.

THERE ARE MORE than 2 million poor, uninsured adults in the so-called Medicaid gap. Of those, roughly 800,000 are women of reproductive age. Most people who fall into the gap are unlikely to afford insurance on the individual marketplace because they’re ineligible for premium subsidies, which help offset high monthly costs. And while the Affordable Care Act applies to most private insurance plans, according to the Guttmacher Institute, 13 percent of workers in 2019 were enrolled in “grandfathered” plans exempt from the ACA’s protections — including the mandate for contraception coverage.

In Washington, D.C., and 38 states that have expanded Medicaid since 2014, public health researchers found an immediate and large increase in insurance coverage for low-income women of reproductive age. Health and economics researchers also found that low-income women in expansion states were more likely to use effective birth control methods during their postpartum period than their counterparts in holdout states, and were more likely to use long-acting reversible contraception, considered among the best methods for preventing unwanted pregnancies. The proposed Medicaid expansion plans would increase access to birth control and reproductive services in the remaining 12 states.

On Tuesday, Planned Parenthood Federation of America issued new fact sheets detailing what Medicaid expansion would mean for each state that has until now resisted broadening coverage. In Alabama, for example, Planned Parenthood says 51,000 women of reproductive age would gain access to affordable health insurance, including more than 20,000 Black women. In Texas, more than 324,000 women of reproductive age would gain affordable health insurance and access to services, including 48,000 Black women and 1930,000 Latina women.

“I can’t tell you how many people I’ve seen who wanted birth control and were not able to get it,” said Marty. “The county health departments are booked two to three months in advance, so by the time they get there it’s too late; and then we have patients who do have private doctors, but the doctors are denying them the coverage.”

Jamila Taylor, the director of health care reform and a senior fellow at the Century Foundation, said expanding Medicaid could definitely help support women who fall into the coverage gap, who lack insurance or access to comprehensive maternal services. “We know this affects people not ready to be parents, and those who are ready to have children,” she said.

So if either the Ossoff-Warnock-Baldwin plan or the Doggett proposal passes, the changes could expand access to contraception for thousands of currently uninsured people. But would they allow Medicaid to cover solutions like medication abortion? Thanks to the Hyde Amendment — a prohibition on using federal funds to cover abortions outside of the exceptions of rape, incest, and endangerment to a woman’s life, which Congress has reauthorized every year since 1976 — the answer is still no.

There is legislation pending in the House and Senate, called the Equal Access to Abortion Coverage in Health Insurance Act of 2021, or EACH Act, that would overturn the Hyde Amendment — but like the Women’s Health Protection Act, it stands little chance of passage with the filibuster in place. On Wednesday, Manchin told the conservative National Review that he was open to considering Medicaid expansion as part of reconciliation — but only if the package includes the Hyde Amendment. States can, however, still opt to use their own Medicaid funding to cover abortions, and 16 primarily blue states already do.

As long as the Hyde Amendment remains in place, those living in regions at odds with reproductive health access will have to rely on more difficult and sometimes risky measures to terminate their pregnancies. If the amendment were repealed, Medicaid funds could potentially be used to prescribe medication abortion, offering an alternative in places where clinics are closed. But many hostile states have broadened their anti-abortion measures to cover mifepristone and misoprostol. Since April, lawmakers in Republican-led states, working closely with anti-abortion groups like the Susan B. Anthony List, have moved to pass even more restrictions on medication abortion.

Marty, who authored “Handbook for a Post-Roe America” in 2019, said for now people should consider obtaining medication abortion pills before they are pregnant, a process known as advanced provision. Some are are already doing this in Texas through Aid Access, an organization based in Europe that a Dutch doctor started in April 2018.

“At this point [activists] do not believe that someone who takes this step is under threat of a lawsuit because pregnant people are explicitly excluded from [SB8], but it could be a potential lawsuit if that person who ordered it gave it to someone else,” said Marty.

But shipping pills from Europe can result in delays. “Hypothetically, there might be people who try get ahold of medication abortion from one of these online retailers despite living in a different city,” said Marty, referring to U.S.-based telehealth organizations like Abortion on Demand. In those cases, which could also present legal risk, women might ask contacts they know living in more abortion-friendly states to obtain the medication and then quietly mail them the pills.

“As an author and activist, I firmly believe that all people need to be [ready] for when abortion is completely illegal and inaccessible,” said Marty. “It’s become clear to me that abortion will mostly disappear in red states.”

Arkansas’ Medication Abortion Ban Was Hit With a Temporary Restraining Order. Here’s What’s Next.

Originally published in Rewire News on June 20th, 2018.
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A federal judge on Monday granted a brief reprieve from an Arkansas law that dramatically restricts abortion access in the state by effectively banning medication abortion.

The first-of-its-kind statute would limit abortion access at all but one Arkansas health center. The law had been in effect since May 29, when the U.S. Supreme Court declined Planned Parenthood’s request to hear the case. The plaintiffs filed for emergency relief following the high court’s dismissal, and U.S. District Judge Kristine Baker agreed to grant them a two-week restraining order, which will expire at 5 p.m. on July 2.

But the battle to stop the law is far from over.

This fight began in the spring of 2015, when the GOP-majority Arkansas legislature passed Act 577, requiring physicians who prescribe drugs for non-surgical abortions to secure contracts with a second doctor who has hospital-admitting privileges. The American College of Obstetricians and Gynecologists and the American Medical Association have both said there is “no medical basis” for such requirements, and abortion providers, especially those in conservative states, typically struggle to find hospitals willing to partner with them.

The law was set to take effect at the start of 2016, but on December 28, 2015, Planned Parenthood sued to block it. A temporary restraining order was issued on December 31 of that year, and three months later, Judge Baker issued a preliminary injunction as Planned Parenthood Great Plains continued with their lawsuit against the state.

An Eighth Circuit Court of Appeals panel in July 2017 lifted Baker’s injunction, asserting she would need to more concretely show how Arkansas women would be harmed by the admitting privileges law. A year earlier the Supreme Court overturned a package of abortion restrictions that included requirements for admitting privileges. The justices determined the rules posed an unconstitutional burden on Texan women seeking to end their pregnancies.

Planned Parenthood says that if the law were to take effect, its two abortion facilities in Little Rock and Fayetteville would no longer be able to provide medication abortion. Neither of those facilities provide surgical abortions.

The health care provider requested the Eighth Circuit’s full bench of judges review the panel’s July ruling, but in late September, the appellate court declined the request. The Eighth Circuit is one of the most conservative appellate courts in the country; two years earlier its judges recommended that the U.S. Supreme Court “re-evaluate its jurisprudence” on abortion, urging for greater state power over reproductive health.

The next step for the plaintiffs was petitioning the Supreme Court to review the Eighth Circuit’s decision. The appellate court agreed to keep the preliminary injunction in place in the meantime, which meant the law has not been enforced all year. But at the end of May, the Supreme Court finally responded to Planned Parenthood’s petition and declined to intervene. This set the law into immediate effect.

Planned Parenthood quickly filed for a temporary restraining order, a request which was finally granted this week. In a press statement, Planned Parenthood said that beginning on May 29, “health center staff were forced to immediately call patients to inform them they would no longer be able to access their medication abortion.”

Some patients, according to Planned Parenthood, were already en route to their appointments, and others were “left scrambling to alter their work and child care schedules, and to secure additional funds required to undergo the state-mandated counseling process over again for a surgical abortion or to travel out of state, further delaying care.”

Emily Miller, director of communications for Planned Parenthood Great Plains, told Rewire.News that the next steps are not clear, though at least until July 2, when the temporary restraining order lifts, providers will again be able to provide medication abortion.

“We’re approaching it like we have a temporary restraining order that will run for fourteen days, and then we’ll focus on our next step which is the preliminary injunction,” Miller explained. “But we don’t know exactly what course the state will choose to take.” The state might try to skip the preliminary injunction step and go straight to a full hearing. Miller says if that does happen, the two-week restraining order could be extended.

Ever since the Eighth Circuit demanded the plaintiffs more clearly show how the admitting privileges law would affect patients, Planned Parenthood has worked to collect and document that information, Miller said.

Last month, research was released that sought to systematically evaluate the availability of abortion care and distance from all major U.S. cities. The study’s objective was to describe abortion facilities and services available in the country from the perspective of a potential patient searching online, and to find out which cities are farthest from available abortion care.

Alice Cartwright, project director at Advancing New Standards in Reproductive Health and co-author of the study, told Rewire.News that their research is exactly the kind of data plaintiffs could refer to if they returned to court.

“We found that abortion access is better in the northeast and western part of the country and one reason is they were more likely to have a higher proportion of clinics that were only providing medication abortion,” said Cartwright.

The organization’s research team worked to determine the number of cities with at least 50,000 people where patients would have to travel 100 miles or more to reach the closest abortion provider. As of spring 2017, they found 27 such cities in the US. Cartwright says if this Arkansas law were to take effect the number of cities could increase much more.

The rate of medication abortion has increased in popularity since the Food and Drug Administration first approved Mifeprex in 2000. The procedure typically involves using both Mifeprex—often referred to as “the abortion pill”—and a second drug, misoprostol. With access to surgical abortion diminishing at a rapid clip, medication abortion is recognized as a safe, much-needed health care alternative, especially for those living in rural and medically underserved parts of the US.

Arkansas and Hawaii Lawsuits Present Challenges and Opportunities For Medication Abortion

Originally published in The American Prospect on November 3, 2017.
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The U.S. abortion rate recently hit its lowest level since Roe v. Wade, but medication abortion—non-surgical abortions induced through drugs—has increased in popularity since the Food and Drug Administration first approved Mifeprex in 2000. (Medication abortions typically involve using both Mifeprex—colloquially known as “the abortion pill”—and another drug, misoprostol.)

Yet despite the proven efficacy of medication abortion for safely terminating early-stage pregnancies, a series of regulatory and statutory restrictions have prevented many women from being able to use this abortion option. Two different legal battles taking place right now—in Arkansas and Hawaii—illustrate why.

In 2015, Arkansas passed a law requiring physicians who prescribe drugs for non-surgical abortions to secure contracts with a second doctor who has hospital-admitting privileges. The American College of Obstetricians and Gynecologists and the American Medical Association have both said that there is “no medical basis” for such mandates.

It can be difficult for abortion providers—especially ones in conservative states like Arkansas—to obtain admitting privileges, because hospitals tend to avoid partnerships that could produce a backlash from anti-choice groups. When Texas passed a law in 2013 requiring all abortion clinics to obtain hospital-admitting privileges and to meet ambulatory surgical center building standards, nearly half of the state’s clinics shut down soon afterward. The U.S. Supreme Court overturned the package of restrictions in 2016, concluding they posed an unconstitutional burden on Texan women seeking to end their pregnancies.

In March 2016, U.S. District Judge Kristine Baker issued a preliminary injunctionblocking the Arkansas admitting-privileges law from taking effect while Planned Parenthood Great Plains sued the state. But this past July, an Eighth Circuit Court of Appeals panel lifted Baker’s injunction, concluding that she would need to show more specifically how Arkansas women would be harmed by the law. Planned Parenthood maintains that its two abortion facilities in Little Rock and Fayetteville would no longer be able to provide medication abortion if this law were to take effect, and that neither of those centers provide surgical abortions.

Following the July decision, Planned Parenthood requested that the Eighth Circuit’s full bench of judges review the panel’s ruling. But in late September, the Eighth Circuit declined to do so. “The extremists who put this law into place will now be responsible for the lives they’ve put in harm’s way,” said Aaron Samuleck, the interim president and CEO of Planned Parenthood Great Plains, after the September decision.

The Eighth Circuit is one of the most conservative appellate courts in the country. In 2015, its judges recommended that the U.S. Supreme Court “reevaluate its jurisprudence” on abortion, urging the high court to return greater reproductive decision-making power to the states.

Now Planned Parenthood Great Plains has notified the U.S Supreme Court that it intends to file what’s known as a petition for a writ of certiorari, which essentially means that the organization plans to ask the high court to review their case. When they do file their petition, Planned Parenthood also plans to also ask the Supreme Court to issue a preliminary injunction to block the admitting-privileges law from taking effect. Planned Parenthood has also gone back to the Eighth Circuit to ask that the appellate court refrain from enforcing the law while they petition the Supreme Court—a request the Eighth Circuit granted in mid-October. So for now, the law remains on hold.

Meanwhile, a very different sort of medication abortion challenge is under way in Hawaii. The FDA has Mifeprex (mifepristone) on its Risk Evaluation and Mitigation Strategies list (REMS), a designation the government uses when it determines that increased restrictions are necessary for a drug’s benefit to outweigh its risks. Because the abortion pill is on the REMS list, the FDA can require that only certified medical professionals in hospitals, medical offices, or clinics administer it. In other words, women can’t fill a prescription for Mifeprex at their local pharmacy. But just as it can be difficult for abortion clinics to obtain hospital-admitting privileges because of political objections, many medical centers also encounter political resistance to stocking and distributing Mifeprex.

In early October, the American Civil Liberties Union filed a lawsuit against the FDA, charging that the agency was both violating its own statutory authority, as well as the Constitution’s due process protections, by preventing commercial pharmacies from filling Mifeprex prescriptions. The lawsuit was filed on behalf of a Hawaiian doctor on Kauai, who cannot stock Mifeprex in his office or direct women to nearby abortion clinics since there are none on the island. If patients come to him seeking early-stage abortions, he has to tell them to fly to another island for the procedure—something that can both increase a patient’s costs, as well as delay it for weeks, if not entirely.

Reproductive rights advocates say there’s no reason for the FDA to put Mifeprex on the agency’s list of particularly risky drugs. In 2016, the American Congress of Obstetricians and Gynecologists stated that putting the abortion pill on the REMS list “is inconsistent with requirements for other drugs with similar or greater risks, especially in light of the significant benefit that mifepristone provides to patients.” In their new lawsuit, the ACLU argues that the restrictions are unscientific and onerous. They note that blood thinners, Viagra, and other drugs carry greater risks than Mifeprex, yet local pharmacies can fill prescriptions for these medications.

In an interview with The American Prospect, Julia Kaye, a staff attorney with the ACLU’s Reproductive Freedom Project, says the Arkansas and Hawaii cases target different issues, but ultimately revolve around the same core problems: “unconstitutional and unjustified” restrictions on reproductive health care.

Moreover, despite the FDA’s stated concern about possible risks, the agency does not even require patients to take Mifeprex at a designated health-care setting; they only must obtain it there. “There is simply no safety benefit to requiring that a patient be handed a pill at a clinic to then swallow it home, rather than [receiving it] at a pharmacy,” says Kaye. (Some health-care facilities prefer patients to take the medication on site, but the FDA doesn’t require it.) The FDA’s own research also concludes that medication abortion “has been increasingly used as its efficacy and safety have become well-established by both research and experience, and serious complications have proven to be extremely rare.”

“Often health-care providers are unable to stock the abortion pill because of bureaucratic hurdles, or because of opposition to abortion by co-workers,” explains Kaye, who adds that health-care providers must navigate multiple layers of institutional approval before they can administer the drug. “The process is not only complicated and time-consuming, but because there are so many individuals who need to sign off on procurement, even a single individual who objects to abortion can significantly delay or even derail stocking this medication,” she says.

While research suggests that women generally prefer surgical abortions (which tend to be faster procedures that involve less bleeding) over medication ones, many women are unable to access surgical abortions, due to the diminishing number of abortion clinics, as well as restrictions such as mandatory waiting periods. Medication abortion provides women with much-needed reproductive health-care alternatives—especially low-income women, and women living in conservative, rural, and medically underserved parts of the country.

An ACLU win in the Hawaii case would affect FDA restrictions on Mifeprex nationwide.