Americans are overwhelmingly in favor of national health care reform. But would the type of reform proposed by presidential candidate Barack Obama have any impact on the options for economically disadvantaged women facing unwanted pregnancies?

Without a repeal of the Hyde Amendment, which bans federal funding for abortion care, the likely answer to that question is no. Two years after health care reform in Massachusetts -- a reform that strongly resembles Obama's proposal -- was signed into law, hundreds of women in Massachusetts are still unable to afford the reproductive health care they seek.

Abortion Funding in Massachusetts, Pre- and Post-Reform 

In 1981, the Supreme Judicial Court of Massachusetts determined that, as a matter of Massachusetts constitutional law, MassHealth (the Massachusetts Medicaid program) must cover medically necessary abortions. In 1986, Massachusetts voters rejected a referendum (58% to 42%) that would have amended the state constitution and permitted the legislature to cut off public funding for abortion. Thus, by the time then-Governor Mitt Romney signed Massachusetts's health care reform system into law in 2006, it was firmly established that public health care plans in Massachusetts would cover abortion services for the low-income women who qualified for these plans. With the Hyde Amendment blocking federal money from paying for Medicaid abortions, the state has paid for this particular service for the past thirty years.

The goal of the Massachusetts health care reform law was to ensure near-universal coverage for the Massachusetts population. In simple terms: through a set of rules that approach Byzantine complexity, the reform law created a mid-level, sliding-scale public health care system, Commonwealth Care, which provides services to low-income legal residents who do not qualify for MassHealth, the state Medicaid system. In theory (and by mandate), every adult in Massachusetts ought to be covered through MassHealth, Commonwealth Care, or one of the bevy of private insurance options.

As with many bureaucratic systems, though, there is a forgotten population, one that is incapable of doing exactly what the government is compelling it to do. This population includes, among others, undocumented immigrants who do not qualify for public health care due to immigration status, individuals who do not meet income requirements for public health care but who nonetheless cannot afford private health insurance, individuals who have private insurance with co-pays and deductibles so high that they cannot afford to seek health care services, and individuals who have recently changed jobs and are within the 30- or 60-day waiting periods for employer-offered insurance required by many private insurers. When seeking to end an unwanted pregnancy, the women of this forgotten population often have the fewest resources.

Even insured women find themselves in need of abortion funding. Private insurers are not required to cover abortion procedures, and not all women's health clinics and doctors accept public health plans. Young women insured through a parent's family policy and married women insured through a spouse's policy cannot obtain abortions without the policyholders knowing, a fact that can compromise the safety of these women. MassHealth and Commonwealth Care will not follow women who must leave the state to obtain their abortions, due either to the parental consent law for minors or advanced pregnancy. Lastly, federal copycats of the Hyde Amendment operate to prevent the health care plans of military personnel, participants in the Indian Health Services, persons on disability insurance, and federal employees in Massachusetts from covering abortion services. (Narrow exceptions for rape, incest, and the life of the pregnant woman exist.)

All this in a state compelled by its constitution to provide public funding for abortion.

If Massachusetts-Style Health Reform Went National

Were the nation to see a new federal public health insurance plan similar to the one proposed by Senator Barack Obama, nothing would change in Massachusetts. As regards public funding for abortion, it seems likely that very little would change in the rest of the nation either.

Senator Obama's plan includes a menu similar to that in Massachusetts: Medicaid (albeit with extended eligibility), a public health insurance plan "similar to that offered through the Federal Employees Health Benefits Program (FEHBP)" for small businesses and individuals who do not have private group insurance available to them, and private insurance, overseen by a newly created National Health Insurance Exchange watchdog group. Under the plan, lower-income individuals who do not qualify for Medicaid will be eligible for federal subsidies toward either the public health insurance plan or a private plan of their choice. The plan does not contain an individual mandate.

Under Senator Obama's health plan, more women would be covered by Medicaid -- yet the Hyde Amendment prevents federal Medicaid money from covering abortions (except in the cases of rape, incest, or life endangerment).

And a significant number of women would be covered by a FEHBP-lookalike -- yet the FEHBP is prohibited by federal law from covering abortion services (except in the cases of rape, incest, or life endangerment).

So what changes for poor women seeking abortions? Not much. If Senator Obama's plan were to go into effect while the Hyde Amendment were still standing, the onus to cover abortions for Medicaid recipients would continue to rest on the states. Currently, only 17 states cover abortion as part of their state-administered Medicaid plans (the vast majority due to court order). Thus, while Obama is on record as opposing the Hyde Amendment, the Amendment would nonetheless limit the effects of his plan.

Were the new public health insurance plan -- the FEHBP-lookalike -- to survive Congress with coverage of abortion services intact (the likelihood of which is certainly debatable), it would be a triumph -- ideologically and practically -- for reproductive health advocates and the middle class. And yet, it would still reinforce the status quo and abandon the women with the fewest resources.

Abortion services in Massachusetts, for example, range from $400-500 for first trimester procedures to more than $3,000 for second trimester procedures. Even with the financial assistance of abortion funds in the state, women must miss utility payments, skip necessities such as food and childcare, sell personal belongings, borrow money from friends and employers, attempt to increase credit limits on high-interest and already overburdened credit cards, and take on additional jobs such as yard work and house cleaning to pay for abortion care. Poor women are more likely to lose time between choosing to have an abortion and actually obtaining one, due to the steps necessary to collect funds from these various sources. This lost time often results in more expensive and more complicated abortions.

Of course, funding is only one of the many obstacles to abortion access for these women, many of whom must travel long distances, lose wages for time off, petition for judicial bypass of the parental consent law, locate translation services, and keep the entire process a secret from friends or family members.

In the 33 states where Medicaid does not pay for abortions, the need is much greater and the situation more dire. And so, as is often the case, the women who bear the brunt of restrictive abortion laws such as the Hyde Amendment are our nation's youngest women, poorest women, immigrant women, indigenous women, and, disproportionately, women of color.

No matter how many campaign promises are made, no matter how many options are proposed in health care reform plans -- none of this changes so long as Hyde stands.

To join the effort to repeal the Hyde Amendment, visit the Hyde -- 30 Years is Enough! Campaign.

Thanks to Amy Katzen of Massachusetts's Health Care For All for her assistance.

Related Posts 

• Toni Bond Leonard and Marlene Gerber Fried, 30 Years of the Hyde Amendment Is Enough!
• Mike Lillis, Extra Abortion Limitation for Native Americans Only
• Andrea Lych, Abortion Funds: Putting Women's Needs at the Center