Republicans are proceeding, as promised during election season, with one of their top priorities: reducing access to vital reproductive health care. Their multipronged plan has taken shape over the past six weeks through budget talks, confirmation of department heads, proposed and passed legislation, and the unveiling of the American Health Care Act, aka "Trumpcare."
Patients who utilize Medicaid or the Title X program -- which provides preventative care like pregnancy prevention and education, breast and cervical cancer screening, infertility services, and sexually transmitted infection (STI) testing, counseling, education and referral -- are at particular risk of losing access to affordable reproductive health care. Republican representatives are attacking Title X on all sides. The House voted to rescind it altogether last month, and GOP leaders along with the president are attempting to disqualify Planned Parenthood from serving Medicaid patients because they use non-public funds for abortion care. While the Hyde Amendment already prevents federal funds for being used for abortion, Republicans disingenuously continue to claim that the fact that 3 percent of Planned Parenthood's patients receive separately funded support in terminating pregnancies should prevent all Planned Parenthood clinics from having access to Medicaid payments for the non-abortion-related preventative care they provide for the vast majority of their patients.
"It's appalling, but not surprising, that congressional Republicans are doubling down on their assault on basic family planning services," Rep. Barbara Lee (D-California) said in a statement following the House vote. "Their actions will hurt those who need help the most: low-income women, women of color and young people. Undermining Title X will limit families' access to trusted, qualified health care providers. Republicans' ideological agenda will undoubtedly leave some women with no reproductive health care options at all."
While Planned Parenthood does not provide the majority of abortion care (between 60 percent and 80 percent is provided by independent clinics/providers), its 56 affiliates around the country provide a substantial percentage of preventative care to low-income patients, including Medicaid recipients. Medicaid provides approximately 75 percent of public family planning expenditures, with Planned Parenthood serving around one quarter of those clients. Title X provides approximately 10 percent of public family planning expenditures annually, with Planned Parenthood serving around one-third of those clients.
If Access to Contraception Is Cut Off, Unwanted Pregnancies Will Soar
Analysis by the Guttmacher Institute, a sexual and reproductive health research and advocacy group, indicates that Planned Parenthood simply isn't replaceable should Trumpcare disqualify its clinics from federal funds; there are not enough clinics to absorb its patients. Thus far, there is no word on whether GOP leadership or the president has plans to address the gap Trumpcare would create.
In addition to being willing to accept patients insured through Medicaid and utilizing Title X funding to provide preventative care to low-income people, undocumented people, youth and more, Planned Parenthood clinics are also, in general, more accessible than others to those who need same-day or late-in-the-day appointments due to work or child care responsibilities. Disallowing Planned Parenthood from seeing its 2.5 million patients per year would put preventative care out of reach for the marginalized communities who disproportionately rely on its 650 health centers.
The Congressional Budget Office estimates that the American Health Care Act's provision blocking Planned Parenthood-affiliated clinics from receiving any federal funds would result in at least 15 percent of low-income people losing access to contraception, leading to thousands more unwanted pregnancies brought to term. Many of these pregnancies would require prenatal care paid for by Medicaid -- so not only does Trumpcare take control of their reproductive health away from millions of people, it also would be expensive for the federal government. Guttmacher estimates that unintended pregnancy cost taxpayers $11 billion annually before the Affordable Care Act, and every dollar invested in family planning saved states $3.74 in Medicaid and other pregnancy costs.
Dr. Diane Horvath-Cosper, a reproductive health advocacy fellow at Physicians for Reproductive Health, said in a statement that the Affordable Care Act, in combination with Medicaid, has been "life-changing" for her patients.
"There are 12.9 million women of reproductive age insured by Medicaid who are in danger of losing their coverage if the ACA is repealed," said Horvath-Cosper, citing the CBO report. "Even one person losing coverage is too many -- but this drastic number indicates that under the proposed ACA repeal bill, access to affordable health insurance will be eliminated for millions of families.... We implore Congress to do better for our patients."
Rep. Lee appealed to her colleagues in Congress as well.
"The politically motivated attempts to undermine basic health care for women living on the edge are nothing short of shameful," she said. "As a member of the House Appropriations Subcommittee on Labor, Health and Human Services and Education, I've seen Republicans attack these lifesaving programs far too many times. Last year, Republicans tried to completely eliminate funding for Title X. This legislation is yet another attempt by politicians to control women's bodies. I strongly condemn this effort and call on Republicans in Congress to keep their hands off of family planning services."
Attacks on Title X Health Care
Though Planned Parenthood has long been a very publicized target of Republican attempts to dismantle reproductive health care, the attacks on Title X -- which serves 4 million annually -- are happening largely under the radar.
Title X, which President Richard Nixon signed in 1970, was created through the Public Health Service Act. Administered through the Office of Population Affairs in the Department of Health and Human Services, its funding now requires annual appropriations bills from Congress. Even if there isn't the will in the Senate to eliminate Title X forever via legislation, a program without funding might as well not exist.
A group of 46 senators lead by Patty Murray (D-Washington), Catherine Cortez Masto (D-Nevada) and Richard Blumenthal (D-Connecticut) are calling on Republican leader Mitch McConnell (R-Kentucky) not to bring the legislation passed by the House to the Senate floor.
"For women in every U.S. state and especially in rural and struggling communities, Title X health centers are a vital resource for preventive and primary care," the senators wrote in a letter to McConnell. "It is critical that you take a stand and protect women's health against efforts to undermine reproductive health care and roll back women's health advances."
The letter also cites a group of health care providers who have come out against efforts to overturn Title X, including the American Academy of Pediatrics; American College of Nurse-Midwives; American Congress of Obstetricians and Gynecologists; Association of Women's Health, Obstetrics and Neonatal Nurses and the American Academy of Family Physicians.
"In their statement, these providers note the danger of permitting such discrimination between different health care providers, noting, 'the move would further reduce, and in many cases eliminate, low-income and adolescent patient's access to essential health care by discriminating against providers for reasons unrelated to medical evidence or best practices.'"
Broader Dangers Posed by Trumpcare
By repealing the Affordable Care Act, Trumpcare could impede reproductive health care even for those who don't use Medicaid or Title X. The new head of Health and Human Services, Tom Price, could reinstate pre-ACA discrimination and allow all insurers to disallow contraception coverage. According to reproductive health outlet Rewire News, all Price needs is the promised ACA repeal:
HHS has always had the power to unilaterally ax the birth control benefit: They could simply declassify contraceptives as preventive care before the ink dries on ACA repeal. Rep. Diane Black (R-TN), interim chair of the House Budget Committee, said Republicans won't replace the popular birth control benefit.
While the votes to repeal in the Senate are no guarantee, thanks to mixed-choice Senators Susan Collins (R-Maine) and Lisa Murkowski (R-Alaska), Vice President Mike Pence is poised to cast a tie-breaking vote. If either avenue is successful, the effect on reproductive health will be devastating.