Originally published on Health Affairs Blog.

Earlier this month, House Republicans introduced their first draft of legislation to repeal and replace large portions of the Affordable Care Act (ACA). While they found themselves divided on a wide range of important issues, from the ACA’s Medicaid expansion and subsidies in the form of tax credits, in one area they were united. The new legislation, titled the American Health Care Act (AHCA), includes language barring federal money from being used to support any private insurance plan that covers abortion. These efforts are an extension of a long-term campaign to isolate abortion from the rest of the health care system and are one facet of a broader agenda to undermine access to sexual and reproductive health care

The AHCA is designed to make private insurance plans drop coverage for abortion

Four decades ago, antiabortion members of Congress succeeded in passing the Hyde Amendment, which bars federal dollars from supporting abortion coverage under Medicaid, except in the most limited circumstances. In the years since, they have repeatedly looked for opportunities to do something similar in private insurance. That determination almost prevented Congress from enacting the ACA in 2010, when antiabortion Democratic members in the House initially insisted on including a provision that would bar any of the ACA’s insurance subsidies from going to any plan that includes coverage of abortion. Instead, the ACA was enacted with a lesser but still burdensome provision that allows plans to cover abortion but imposes strict measures to ensure that private dollars, not federal ones, are used to pay for abortion coverage and care.

Antiabortion advocates have never given up on the idea of an abortion coverage ban, and current efforts to repeal and replace the ACA appear to be their best opportunity yet. The American Health Care Act, as introduced, included no less than four abortion coverage restrictions that, combined, would effectively end abortion coverage in the individual health insurance market and would undermine abortion coverage in employer-sponsored insurance plans.

Each of the restrictions bars a specific pot of federal subsidies or grants from being used to purchase a health plan that covers abortion. Abortion restrictions would apply to:

• existing ACA subsidies to help low- and middle-income individuals purchase health plans on their own (which the legislation phases out and replaces);
• existing ACA subsidies to help small employers purchase health plans for their employees (which are also phased out under this bill);
• new subsidies (in place of the ACA’s) that could be used by individuals in all but the highest-income brackets to purchase insurance on their own in the individual insurance market or to purchase so-called COBRA plans (continuing on an employer-sponsored plan after leaving that job); and,
• a new fund for states that they could use in a wide variety of ways to stabilize their insurance markets, including through direct payments to insurance companies to keep them in the markets and additional subsidies to individuals buying any type of health insurance.

Placing abortion restrictions on the existing and new subsidies to help people buy individual market health insurance plans would have a clear and direct impact. Because almost everyone purchasing a plan in the individual insurance market would be eligible for several thousand dollars in federal tax credits, the end result would be that insurance companies would be no longer be able to offer plans in the individual market that include abortion coverage.

The impact of these restrictions on employer-sponsored coverage is less clear. However, by placing restrictions on the small employer subsidies, on subsidies for COBRA plans, and on the state stabilization fund, this legislation could have a chilling effect on some employers’ willingness to include abortion coverage in the plans they sponsor.

Like most other current federal abortion restrictions, this legislation includes exceptions only in rare cases when the woman’s life is endangered or the pregnancy is the result of rape or incest. And like many earlier proposals to restrict abortion coverage in private health plans, this legislation would allow for the sale and purchase of a separate insurance plan, without subsidies, just for the specific purpose of abortion coverage (a "rider"). That offer is meaningless. In essence, it would allow people to prepay for an abortion. Other types of riders, such as for maternity care (which were sometimes offered prior to the ACA), have been expensive if offered at all, because insurance companies must assume that anyone buying coverage for a single service is expecting to make use of that coverage in the coming year. For abortion, it is unclear whether issuers would offer such riders or whether consumers would actually purchase them. In Michigan, a state that enacted such a policy in 2013, no insurance companies reported offering these riders to individuals (although a small number did offer them to employers).

Access to private coverage of abortion is already highly limited

Even without new federal abortion coverage restrictions, U.S. women today are hard pressed to find and use a health insurance plan that covers abortion. Women insured by Medicaid in most states have no abortion coverage, except in case of rape, incest, or life endangerment. Similar restrictions are in place for federal civilian employees, military employees, veterans and their families, and for others who receive their coverage or care through federal programs.

At the state level, 25 states bar abortion coverage, with limited exceptions, in the ACA’s insurance marketplaces. Ten of those states bar abortion coverage under any private insurance plan the state regulates. A total of 21 states specifically bar abortion coverage for public employees.

California and New York are the only states that currently require private health plans to cover abortion. The American Health Care Act would appear to place these states in an untenable position: They might be forced to reverse or stop enforcing their abortion coverage requirement, or state residents might find themselves unable to use federal subsidies to buy any insurance plan offered in the state—effectively, an abortion surcharge of thousands of dollars.

In the remaining states, where abortion coverage is permitted but not required, it is not necessarily available. Analyses of ACA marketplace plans by the Guttmacher Institute and the Kaiser Family Foundation have found that in states that allow abortion coverage, consumers in many counties and some entire states have no choices that actually include that coverage. Kaiser researchers estimate that only three in 10 uninsured women today clearly have insurance options that include abortion coverage.

Limitations on abortion coverage in private insurance matter for women

About four in 10 privately insured abortion patients use their insurance to pay for the procedure, and for those women, abortion coverage may be what makes that procedure affordable. An abortion at 10 weeks’ gestation typically costs around $500, and those costs are considerably higher for abortions later in pregnancy. Paying that amount out of pocket is simply unaffordable for many women: About one-third of uninsured people and lower-income people would be unable to pay for an unexpected $500 medical bill, and roughly another third would have to borrow money or put it on a credit card and pay it back over time.

For the six in 10 privately insured abortion patients who pay out of pocket, it is unclear which specific hurdles they face, but there are numerous potential ones. Some women may have health insurance plans that do not cover abortion, or may not know whether their plan covers the procedure. Many privately insured women have deductibles of several hundred or several thousand dollars that must be met before they can be reimbursed, and thus may have to pay for an abortion out of pocket. In some cases, the woman’s health plan may not include her abortion provider in network. And finally, given the stigma that surrounds abortion, some women may not use insurance coverage because they worry that their insurer, employer, spouse or parent might find out about the abortion. Abortion coverage restrictions contribute directly or indirectly to most of these barriers.

The AHCA is part of a comprehensive strategy against reproductive health and rights

The American Health Care Act would undermine reproductive health broadly by dramatically scaling back federal support for Medicaid and private insurance. The Congressional Budget Office estimates that 24 million additional people would be uninsured by 2026 because of this legislation, losing access to coverage for contraception, maternity care, testing and treatment for sexually transmitted infections and cervical cancer, and much more.

Moreover, these renewed attempts to restrict and ultimately eliminate abortion coverage in private insurance are simply one aspect of a much broader, long-term strategy. Through direct bans and indirect incentives, conservatives are working to ensure that abortion is treated differently from and as less worthy than other types of health care. That aligns with other efforts to make abortion unaffordable and inaccessible, to drive abortion providers out of business, and to negatively shape how Americans view abortion and the women who choose to have them.