As accusations that "Barack Obama is the most extreme pro-abortion candidate ever on a national ticket" reverberate around the conservative and anti-choice blogosphere, the Senator's pro-prevention, pro-education policies get scant attention - while his support for the Freedom of Choice Act and his opposition to the Hyde Amendment come in for fierce derision.

Last week, Amie explained that the proposed federal Freedom of Choice Act (FOCA) would do nothing more radical than codify the holdings of Roe - the right of a woman to seek pre-viability abortion, and post-viability abortion in the case of threat to her health - for women around the country whose access to abortion has been steadily eroded by anti-choice laws mandating waiting periods, biased counseling, coerced ultrasounds, TRAP laws and parental notification laws, even a federal ban on certain abortion procedures without an exception for women's health.  In affirmatively guaranteeing abortion rights to women, FOCA pushes anti-choice buttons, yes, but it's hardly extreme.

Roe was perhaps most significantly compromised by the Hyde Amendment, which passed three years after Roe was decided and all but invalidated Roe for low-income women. Hyde outlawed the use of federal funding for abortion care except in cases of rape, incest, and life endangerment, meaning women on Medicaid, women in the military, disabled women and women receiving care through the Indian Health Services cannot access funded abortion through their health insurance.   Prior to Hyde, Medicaid paid for nearly one-third of all abortions.  Since Hyde, federal Medicaid has paid for less than one percent of all abortions, and thirty-three states have enacted funding bans.  "The Hyde Amendment," Toni Bond Leonard and Marlene Gerber Friend have written, "makes reproductive decisions privileges instead of rights." Barack Obama opposes the Hyde Amendment. Obama's campaign staff told RH Reality Check last December, "He believes that the federal government should not use its dollars to intrude on a poor woman's decision whether to carry to term or to terminate her pregnancy and selectively withhold benefits because she seeks to exercise her right of reproductive choice in a manner the government disfavors."

While many anti-choice activists credit Hyde for protecting their tax dollars from supporting a procedure they find morally repugnant, Hyde's impact, in fact, is far less neat, and it is hardly confined to the realm of moral judgment.  The number of women of reproductive age on Medicaid is far from negligible: more than seven million women of reproductive age - 12% of all U.S. women in that age-group-are enrolled in Medicaid. (Most women on Medicaid are already mothers, as childless adults are typically ineligible.)  Studies have repeatedly shown that Hyde pushes women to have later, less safe and more expensive abortions rather than to forego abortion altogether; poor women take up to three weeks longer than other women to access abortion care. "[T]he risk of complications increases exponentially at higher gestations, so many poor women become trapped in a vicious cycle in which their difficulties are exacerbated and their health risks increased," writes Heather Boonstra in a Guttmacher Institute policy review.  Guttmacher studies show that 22% of Medicaid-eligible women having second-trimester abortions would have terminated their pregnancies in the first trimester if Medicaid had covered abortion care. Researchers Stanley K. Henshaw and Lawrence B. Finer concluded that "the lack of Medicaid coverage may be the public policy that has the greatest impact on the number of women who want an abortion but are unable to get one."

Being unable to cover the cost of an abortion means women may forego food, rent or bills to pay for the procedure.  (Even a 10-week abortion costs an average of $372.)  And some women in the end carry a pregnancy to term they intended to terminate.  Two decades of studies found that 18-35% of women who would have had an abortion continued their pregnancies after Medicaid funding was cut off. "This is not about the morality of abortion," says Liza Fuentes, recent board member of the National Network of Abortion Funds. "It's undercutting the health and well-being of women with the least amount of money. The effect is to steal women's dignity away because they are poor." 

"Hyde targets people with the smallest voice in politics," says Fuentes. Chilling remarks made by the amendment's sponsor, the late Rep. Henry J. Hyde, during a congressional debate over Medicaid funding in 1977, bear out Fuentes's argument. "I certainly would like to prevent, if I could legally, anybody having an abortion, a rich woman, a middle-class woman, or a poor woman," Hyde said. "Unfortunately, the only vehicle available is the...Medicaid bill."

Compromises after Hyde removed the limited physical health exception, and rape and incest exceptions were later dropped.  Boonstra reports that the current version of the Hyde Amendment allows federal funding for abortion in cases of rape and incest, as well as life endangerment, but "tightens the life exception to permit payment only when the woman's life is threatened by ‘physical disorder, physical injury, or physical illness, including a life-endangering physical condition caused by or arising from the pregnancy itself.'"

Fuentes emphasizes that denial of Medicaid coverage for abortion can only be fully understood as one of many denials of services that plague women's attempts to access adequate health care.  As our nation's health care "system" fails to insure millions, disproportionately female, as birth control pricing skyrockets, as new Department of Health and Human Services provider right-of-refusal laws would protect providers from dispensing even contraception if they opposed it on religious grounds, and as Title X funding stagnates - it's clear that women's access to a wide spectrum of reproductive health services is compromised. The Hyde Amendment may offer a particularly politically potent instance of health care refusal, but it is just one of many examples of a health care system that fails to address women's needs.

For Boonstra, however, the lack of public funding for abortion is an aberration.  Boonstra points out that other programs do attempt to fill the gaps in access for low-income people - including Title X and other pregnancy-related programs.  "Abortion care is the one arena in which the government is abdicating its responsibility to women," she says.

Overturning Hyde will be an uphill battle whether Obama becomes president or not.  Pro-choice advocates have long struggled to put progressive legislation that would expand abortion access on the national stage; it's unlikely that poor women's reproductive health care will find congressional sponsors ready to take on the fight.  The National Network of Abortion Funds and a diverse group of supporters working on the "Hyde - 30 Years Is Enough!" campaign attempted to introduce a resolution in opposition to Hyde in the last Congress and will try again next year.

"Legal abortion was supposed to level the playing field," says Boonstra, so that both low-income and economically comfortable women would have access to abortion care.  "But by taking away government funding, you just build the inequality back into the system."

For more, watch "Our Reality": Access to Reproductive Health Care Services:
Our Reality: Helping Women Find Reproductive Health Information and Services from RH Reality Check on Vimeo.