9. Will Insurance Pay for My Abortion?
Spoiler alert: probably not. How the Hyde Amendment paved the way for other restrictions on public and private insurance coverage of abortion, and how people pay for their abortions when insurance doesn’t help.
Guests:
Abby Johnson (no, not that one)
Yamani Hernandez, executive director of the National Network of Abortion Funds
Kelsey Ryland, co-director of the All* Above All abortion coverage campaign
Logo by Kate Ryan, theme music by Lily Sloane. Photos courtesy All* Above All.
Garnet Henderson [00:00:00] Hey, everybody. We have quite a few new listeners here, so I just wanted to take a moment and say thank you for listening. I also wanted to let you know, in case you don't already, that Access is a completely independent production. That means the show is produced by a team of one: me. And we're not supported by a big media company or podcast network. That's precisely because I wanted to do something different with this show. I wanted to cover abortion in a way that most media outlets simply do not. So if you like the show, I could really use your help to keep growing our audience. If you're able, you can donate to cover production costs at glow.fm/apodcastaboutabortion. Another really helpful thing you can do is share the show. Share it directly with a friend, share it on social media, share it with that family member you had an argument with over the holidays (just an idea). So that's it. Thank you. And here's the show.
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Garnet Henderson [00:01:38] Welcome to Access: a podcast about abortion. I'm your host, Garnet Henderson, and today we're talking about insurance coverage and how people pay for abortion care when insurance doesn't cover all or any of the cost. So let me start by asking you: if you have health insurance, do you know if your plan covers abortion? Well, up until a few years ago, if you had private insurance, the answer would almost certainly have been yes. But over the last decade or so, more and more states have enacted laws interfering with private insurance coverage of abortion. And the blueprint for these laws is a federal policy that's been making abortion inaccessible for low income people for decades. That policy is called the Hyde Amendment.
Kelsey Ryland [00:02:30] So the Hyde Amendment is a rider in the yearly appropriations process, and I will explain what that is. But essentially it says anyone who gets their health insurance through the federal government cannot have their abortion care covered. So the appropriations process is how Congress decides to spend their money every year. It's the committee that is sometimes called the power of the purse. So every year since 1976 there has been language in the yearly appropriations bill that essentially says none of these funds can be used for abortion. If you are tracking what I'm saying, this means that under both Democrat and Republican led Congresses and with Democrat and Republican presidents for the past 44 years, we have seen the Hyde Amendment included in these federal appropriations bills. And we know the biggest impact really is on families who are working to make ends meet, who are enrolled in the Medicaid program, who are disproportionately folks of color, LGBTQ people and young people. And since Hyde was first passed in the Labor, Health and Human Services Appropriations Bill, we have seen it expand to other programs, impact other populations of folks. And this was really a result of restrictions on abortion coverage being seen as a compromise position for so long. And because of the incredible leadership of Women of Color in our movement, we have seen a huge shift to to say, look, this isn't a compromise. And it's a compromise that has impacted folks of color for way too long.
Garnet Henderson [00:04:17] That is Kelsey Ryland.
Kelsey Ryland [00:04:19] I'm the co-director of the abortion coverage campaign with All* Above All. And so I oversee our abortion coverage work with my colleague Ravina Daphtary and I work largely on our federal side of our work. All* Above All was started about 10 years ago by Women of Color in our movement who really, you know, called folks in and said, look, this policy, the Hyde Amendment, is not OK anymore. The time is now and we're going to work to end it. And we've seen a lot of, at that time there was a lot of resistance. And now I think there's a pretty widely held position that if you consider yourself to be working for abortion access, there's really no way to support abortion coverage bans like the Hyde Amendment. And so we are a coalition of over 130 national, state, local organizations. You know, we work with large mainstream reproductive health rights and justice organizations down to really grassroots local organizations. We work with abortion funds, and it's pretty incredible to see just the breadth of our coalition. And it really, truly inspires me all the time.
Garnet Henderson [00:05:40] A lot of you listening to this probably already knew about the Hyde Amendment, and that's real evidence of the cultural shift All* Above All has led. A decade ago, repealing the Hyde amendment was not even a priority across the board in reproductive rights organizations. Now it's a standard.
Yamani Hernandez [00:05:58] And the way that it's talked about, it's just completely different. You hear people say it's racist and discriminatory. And, you know, those are all things that I think was just taken for granted. That of course public funding doesn't pay for abortion. And now, it's just like, 'What?! Public funding doesn't pay for abortion?!' It's more indignation, and this is an injustice. And yeah, a lot of people have been saying that for decades. And so it's very exciting to see the culture evolve and the results of all the labor of the campaign really start to show.
Garnet Henderson [00:06:33] That's Yamani Hernandez, Executive Director of the National Network of Abortion Funds, one of those All* Above All coalition members that Kelsey mentioned. In 2016 Hillary Clinton opposed the Hyde Amendment in her presidential campaign. She was the first presidential nominee from a major party to do that. Four years later, in 2020, Joe Biden was the only candidate in the Democratic primary to say that he wanted to keep the Hyde Amendment. But the outcry was so great when he said that he actually reversed his stance and said he could no longer support the Hyde Amendment. But this change didn't start with white presidential candidates.
Kelsey Ryland [00:07:15] As all organizing goes, right, there are these very public moments where there is kind of a rise in awareness of the issue. But we know that there were years and years of organizing behind the scenes before that happens. And I think that's just a really important part of our history of this work to keep in mind. This didn't just kind of come out of nowhere because presidential candidates started talking about it. That it is really because of the work of Women of Color, of abortion funds, of people on the ground who pushed our movement to this place.
Garnet Henderson [00:07:52] The Hyde Amendment is named for Henry Hyde, who was a member of Congress from Illinois. Here's what he said when he first introduced the amendment that now bears his name: "I would certainly like to prevent, if I could legally, anybody having an abortion--a rich woman, a middle class woman, or a poor woman. Unfortunately, the only vehicle available is the Medicaid bill." So Hyde was very explicit that the point of this policy was to prevent people from having abortions. The average abortion patient in the US is likely to be young, a Person of Color, and living close to or below the federal poverty level. In other words, exactly the sort of person who might qualify for Medicaid. So limiting Medicaid coverage of abortion is a very effective way to cut off access. That said, Medicaid is paid for through a combination of federal and state funds. So there are 16 states that do pay for all or most abortions through Medicaid. 33 states and Washington, D.C. follow the Hyde Standard, which says Medicaid can pay for abortions only in cases of rape, incest or life endangerment. South Dakota actually violates federal law by limiting Medicaid abortion coverage to cases of life endangerment only. Altogether, this means that over half, 55%, of reproductive age women enrolled in Medicaid live in states where Medicaid cannot cover most abortions. More than half of those women are Women of Color. And it's not just Medicaid. Hyde-like provisions have made their way into virtually all areas of federal health policy. So now almost no one who gets health insurance through the federal government can have an abortion covered. This includes people who work for the federal government, serve in the military, those incarcerated in federal prisons, and Indigenous people who rely on a program called the Indian Health Service. 22 states also have laws that restrict abortion coverage for public employees, like their own state level versions of Hyde. And increasingly, there are limits on even private insurance coverage of abortion.
Kelsey Ryland [00:10:19] What we do know is that, you know, insurers, when they are sort of free from these restrictive policies and laws, are inclined to cover abortion care. And in the ACA, abortion coverage was really a flashpoint. And we saw abortion coverage get thrown under the bus in really disappointing ways.
Garnet Henderson [00:10:39] Now, this is a little weedy, but stick with me. The Affordable Care Act, a.k.a. Obamacare, does not require insurers to cover abortion or ban abortion coverage. But part of the law, called Section 13.03, says, like the Hyde Amendment, that federal funds cannot be used to pay for abortions. So the ACA created these health exchanges, right, where you can buy insurance and where you may receive federal subsidies to help pay for your plan. So what Section 13.03 means is that any insurer offering a plan on the marketplace that does cover abortion has to keep at least some funds intended for that coverage in a separate account on the back end. That is to ensure that none of that federal subsidy money helps pay for your abortion coverage.
Kelsey Ryland [00:11:36] And we saw under the Trump administration an attempt to really beef up that restriction in a way that would disincentivize insurers from even covering abortion. We're really thankful that so far the courts have halted that policy. But, you know, it's just very clear that anti-choice legislators, policy makers, are committed to ending access to abortion and will do that through whatever means possible.
Garnet Henderson [00:12:06] What the Trump administration wanted to do was force insurers to send you a separate invoice for your abortion coverage every month. So two bills, two separate payments. And while that rule was blocked, a lot of insurers had already bailed on covering abortion in their marketplace plans because of Section 13.03. Plus 26 states have enacted laws banning most abortion coverage in their marketplace plans anyway. And now 11 states ban private insurance coverage of abortion altogether. Nine of these states do say that you can get abortion coverage if you purchase an additional rider. But an analysis in 2018 found that none of these theoretical riders were actually available in individual or large group plans. Plus, there's an obvious problem with this whole idea.
Kelsey Ryland [00:13:00] Well, nobody plans, typically, folks do not plan to have an abortion. Like they don't plan to have many other, you know, surgeries or other health conditions that you might need insurance for. That is the point of having insurance. And, you know, you expect that your health coverage should pay for the care that you need, which includes access to abortion.
Garnet Henderson [00:13:25] Now, there are six states that explicitly require private insurance plans to cover abortion. But insurance is complicated, especially now that young people are able to stay on parents' policies until they turn 26. There are more and more people living in one state with an insurance policy issued in another. This brings me to a listener named Abbey Johnson, who reached out to share a story. And if you heard that name and you thought of the anti-abortion activist Abbey Johnson, this is a different Abbey Johnson.
Abby Johnson [00:14:01] I want the name Abby Johnson to be better than it is in the abortion conversation.
Garnet Henderson [00:14:10] OK, so Abbey grew up in Nebraska and recently moved back there. But for about five years, she was living in New York City and working in publishing. Entry level publishing jobs are notoriously underpaid, especially relative to the high cost of living in New York. And Abby says the benefits available to her through work weren't that great either. So because she was still under 26, she opted to stay on her dad's Nebraska based health insurance.
Abby Johnson [00:14:40] I mean, it was like the kind of health insurance that most people don't experience because I was insured. I had $150 individual deductible. Like, that's not something most people have. I had 90%, almost 90%, of out of network coverage. That's the reason why I got to go to therapy and why my friends I was working with, who were working full time and who were insured, and paying a lot to be insured, under the company's plan, didn't.
Garnet Henderson [00:15:20] Abbey had had good experiences with her health insurance. So when she got pregnant, she thought she'd have at least some abortion coverage. And New York is one of those states, by the way, that requires private insurance to cover abortion. But remember, the policy came from Nebraska.
Abby Johnson [00:15:38] It was Thanksgiving Day. And I was by myself in my apartment. And I often have joked that, like, the only thing consistent about me was my period. And so when it was late for five days, I was like, oh, no, oh, no, no. I went to the dollar store, got a pregnancy test (the dollar store ones work exactly the same as much more expensive ones). But yeah, I got myself a pregnancy test and then, I was 23. I was single. I was working until my body was broken. I mean I was not in any emotional or physical state to have a pregnancy and I knew that. And I also didn't, I just didn't want to be pregnant. I took like seven more tests. They all turned out the same. I called the Planned Parenthood as soon as I could. And, you know, I remember thinking, OK, you know, at least I'm in New York, this supposedly liberal utopia. I don't know, at least it won't be like if I were in Nebraska. I don't know what it would be like to get an abortion there and I don't want to find out, but I'm glad I'm in this, like, urban center. And so I made the appointment and I called my insurance, Blue Cross Blue Shield of Nebraska, and, you know, I start talking to the lady. And I'm like, yeah, what would the coverage for this be and she's like, you know, I don't know, let me go look. And so she goes to look and then she reads what I later found out was basically the text of the law passed.
Garnet Henderson [00:17:38] I want to read you just a bit of the text from that law. Here it is. "No health insurance plan, contract or policy delivered or issued for delivery in the state of Nebraska shall provide coverage for an elective abortion, except through an optional rider to the policy for which an additional premium is paid solely by the insured." And just one more section I want to read, here it is: "for the purposes of this section, elective abortion means an abortion a) other than a spontaneous abortion..." [That is the medical term for a miscarriage] "...or, b) that is performed for any reason other than to prevent the death of the female upon whom the abortion is performed. Abbey was pretty shocked by that.
Abby Johnson [00:18:29] OK, so tell me, like when when you know or when a doctor knows. Oh yes, that the death of this unborn child or this mother is imminent. Like what's the billing code for that? Imminent death? Like how blue in the face do you have to be? So, you know, I was just like, Oh. OK, well, thank you. And she's like, yeah, I'm sorry. And then, that was it. And I was like, OK, so I'm on my own here. Which, I don't have $600, because I mean, I was making... my initial hourly pay was $16.49 in the most expensive city in the country. I think at that point I might have been up to like $17and some change, but you know, my rent was between $800-$900, like I needed to eat food. But I was like, you know what, if I have to put this on a credit card, that sucks, but fine. I had friends who I was like, listen, can you spot me if I need it? And they were like, yes. OK, yes. And so I'm learning all this and I'm like trying to contact abortion funds. And I'm calling the Planned Parenthood back and being like, OK, like, what if I can't? I think I can pay for it, but what if I can't? And they said like, come in, we'll figure it out, just show up. And I was like, I will be showing up. And I was out of sick time for the year, so I got a vacation day approved. So I was like, I only need one day because then I'll be fine, and I will be back at work. And I'm running myself ragged. And I'm texting the man who got me pregnant and he's like, prove it. And I'm like, never mind. Whatever. I'm too busy to deal with you. I can't.
Garnet Henderson [00:20:37] But a few days before Abby was supposed to have her abortion, she had a miscarriage.
Abby Johnson [00:20:42] I just started bleeding really heavily. And I knew, or Google knew I should say, what was probably happening. But I was like, I don't know. I still went into work. I was going to the bathroom every hour. I felt terrible. But I was like, I'm fine, I'm fine. I'll just work. I'll just work straight through it. It was the day that I had therapy and I would go on my lunch break. And so I go and see my therapist and I was like, yeah, I think I'm miscarrying. And she was like, Abbey, you need to promise me you will go to either an E.R. or she mentioned the name of this clinic, where she said 'call them, say this, they will see you the next day.'
Garnet Henderson [00:21:36] So Abbey did go to the clinic and the doctors there confirmed that she was having a miscarriage. They told her to keep an eye out for complications like a fever, but that it should be safe for her to just go home. Because her life was not in danger, based on what her insurance company told her, Abbey thought she didn't have coverage and would have to pay out of pocket.
Abby Johnson [00:21:56] Well, I didn't go home. I went back to work, actually, and just placed the doctor's note right on my boss's desk. And then I worked a little bit longer. And then I went home and I fully expected to be charged that $600 or something. I didn't expect any coverage. But what the EOP came back as was coded as a spontaneous abortion, which I then, I'm like, oh, that's so interesting. And I look into it more and spontaneous abortion is another term for miscarriage. But like, I didn't know that, being restricted in that way, that did affect how I sought out care. Because I didn't at first, and I wouldn't have. I mean, it would have been fine, probably, but like also I didn't know what was going on. Like, I was scared. You know, I need care and I deserve care. We all deserve care.
Garnet Henderson [00:23:01] Over half of abortion patients in the United States pay for their abortions out of pocket, whether they have insurance or not.
Yamani Hernandez [00:23:10] It's individual people that are helping other individual people in ways that the government should be supporting the people who live and work in this country. And so, where there is no systemic support, it's literally individual people who have rallied together and come up to raise money and emotional support and all the logistical things that have to happen to get people to care.
Garnet Henderson [00:23:36] That's Yamani Hernandez, again, Executive Director of the National Network of Abortion Funds. And I wanted to talk to Yamani for this episode because abortion funds have come up in nearly every episode of this podcast, but we haven't gone into much detail about them yet. So I did a little count. And of the 13 people who've shared their abortion stories with us so far, six of them, so about half, got help from an abortion fund. Only three had insurance that paid for their abortions.
Yamani Hernandez [00:24:05] I mean, the average grant size that an abortion fund gives is about $250. And I would say that most people that call have something to contribute to it. And so they're trying to close a gap. I mean, even if it's like I have $50, but I need $200 or I have $50 but I need $500. I'd say, you know, earlier in pregnancy in particular, like those are the kind of numbers that we would be talking about and thinking about. Obviously some people don't know that abortion funds exist or they don't know that they can, what it would take to get help. And so I think sometimes people are calling later than they would have if they had known they could get help sooner. And so, of course, the cost of the abortion is rising the longer the pregnancy continues. And so sometimes we're talking thousands of dollars just for the procedure. And that's not considering travel to get there or losing wages or having to find child care. And so even in a case where it's a first trimester abortion, if you only have one clinic in your state and you're not anywhere near it and it's going to take you days to get there and all of those things, like something that would have been a few hundred dollars all of a sudden costs a few thousand dollars. And most of us, most people who live and work in this country, don't have that kind of money saved.
Garnet Henderson [00:25:34] Many abortion funds are entirely volunteer run, whereas others have staff and some have a combination of the two. No two are exactly the same.
Yamani Hernandez [00:25:43] I usually explain to people what an abortion fund is by saying that abortion funds are grassroots organizations, which means usually very local, hyperlocal organizations, that are in cities, states and regions that actually help make the legal right to abortion reality. And what I mean by that is that they help people pay for their abortions when they can afford them. They help people either get a ride or provide rides for people who need transportation to their appointments. They help with child care or paying for child care. They help with hotel stays or home stays. And many of them also provide emotional support or abortion doula support. But they also do organizing and advocacy work to try to change the conditions that make their work necessary. And so that means changing the systems that are impacting people's access to abortion. There is no one size fits all with abortion funds. And that's one thing that's really beautiful about abortion funds. And it's one thing that makes it complex sometimes. But right now we have 83 member organizations, and they're mostly based in geographies. So they're mostly based in, like we fund in this city, or we fund in this state. Some fund by a region. There's some that fund populations. So, like, Indigenous Women Rising funds Indigenous folks, or the Mariposa Fund funds undocumented people. So some of them have different focuses. And yes, some are only an abortion fund. And like that is the organization. And then some have a fund that is situated in a larger organization, and some are situated within clinics. So there's kind of a wide breadth of type of abortion fund, and the budgets really can vary. It's a diverse population of funds in some ways, and other ways we want to see, actually, the population of people at abortion funds become more racially diverse. And that's something that we've been working a lot on.
Garnet Henderson [00:27:57] The National Network of Abortion Funds was actually created by its member organizations, and it helps them with training and support in a number of different areas.
Yamani Hernandez [00:28:07] We're in the midst of a big effort right now to help resource abortion funds, so that there's parity amongst all abortion funds. So that one abortion fund may give like $50 to $100 grants to another abortion fund, may do $500 grants. So we really want somebody who's calling an abortion fund to be able to count on the same amount of support no matter which abortion fund they call. And have one case manager and not have to sort of do this crowdfunding thing where they go around to, say, each additional, each abortion fund to get fifty here, one hundred here. And we just feel like that makes the system kind of broken, actually, to pass on more of that hassle and hustle to the people who are looking for support.
Garnet Henderson [00:28:55] Abortion funds are picking up a lot of slack for our broken health system, and the pandemic has hit them hard
Yamani Hernandez [00:29:03] The pandemic is something that abortion funds have been feeling very acutely. I mean, both in terms of the fundraiser last year. Normally that fundraiser raises about $2,000,000 a year, and last year it raised about $500,000 or $600,000. And we tried to make that up at the National Network of Abortion Funds by doing like a crisis relief fund and we were able to mobilize another $2,000,000 to send out to our members, which we're really proud of. And we're still, we're hearing that the demand is double for most abortion funds, that's what they're experiencing. And all of the conversation about the shortcomings of government stimulus and government support for people who have been impacted for the pandemic is basically just passed on to individuals and local non-profits to try to close that gap. And it's just been, it's been a nightmare for many people, for our members definitely, trying to deal with double the demand and less resources.
Garnet Henderson [00:30:08] So can things change? Is the Hyde Amendment really on its way out? Well, advocates are a bit disappointed that President Biden has yet to even say the word abortion during his time in office. But they are hopeful. For years now, All* Above All has campaigned for a bill called the EACH Act, which would repeal the Hyde Amendment and prohibit any federal bans on private insurance coverage for abortion, setting a model for the whole country.
Kelsey Ryland [00:30:38] So it would really be a huge step forward and showing, what we sometimes say in federal policy land, the sense of Congress, that abortion coverage should be included in all health insurance and particularly in Medicaid, that is provided through the federal government. The late Ruth Bader Ginsburg said there will never be a day in our country where a wealthy woman cannot get an abortion. And I think that is very likely true. And so what this really comes down to is, you know, if we are people who say that we care about racial justice and economic justice, which, you know, we do, there's really no way to support restrictions on abortion coverage.
Garnet Henderson [00:31:26] I asked both Kelsey and Yamani what they hope to see President Biden do next.
Kelsey Ryland [00:31:30] It's an exciting time to have new leadership in our country. And we are really looking forward to seeing President Biden's full budget come out in a couple of months and are anticipating that that budget will not include the Hyde amendment. Additionally, we've had House leadership say that they'll remove the Hyde Amendment from appropriations bills, which is huge. To our knowledge, that's only happened once in the 90s, and that bill didn't make it out of the House. So this is really an incredible opportunity to show that the tide has changed and to show a change in leadership. In the Senate, unfortunately, the filibuster remains in the way of a lot of progressive legislation, but we have a lot of strong champions in the Senate and there is work to do to make sure that Hyde doesn't expand, that we don't see any more proliferations of Hyde into other pieces of policy. We just introduced EACH and we immediately had as many co-sponsors for intro that we ended last Congress with, which is is really exciting. So, you know, we think there's a lot of opportunity still. And there are still some Senators who who we need to be reaching out to, to let them know that in order to be on the side of economic and racial justice, they need to be on the side of ending the Hyde Amendment.
Yamani Hernandez [00:33:00] We're hoping that they do the right thing, that they keep some of those campaign promises and that the Hyde Amendment. We believe that we're the closest we've ever been to having the Hyde Amendment repealed, and so that's what we expect. I will say it's been disappointing to hear him not use the word abortion, in the way that we expected or hoped for him to do. But we have such amazing champions in Congress that have been pushing to repeal the Hyde Amendment and working in tandem with the All* Above All campaign, and the EACH Act for years now. So we know that it's not just about one person. There's a whole body here that is supportive and really pushing.
Garnet Henderson [00:33:47] Yamani and Kelsi both pointed out that there's a lot of positive change that can be made on the state and local level, too. For example, in recent years, Illinois and Maine have passed laws proactively requiring their Medicaid programs to cover abortion. New York City and Austin, Texas, have even created their own municipal abortion funds. And Abbey had another abortion funding idea that I wanted to share. Remember that guy who wouldn't help her pay for her abortion?
Abby Johnson [00:34:17] I do text him every year. Like I'm like, hey, I made this donation to this abortion fund in Nebraska if you'll match me? Never gotten a response. But I will continue texting and donating and, like, match my donation, why don't you?
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Garnet Henderson [00:34:52] That's all for today, folks. Access is produced by me, Garnet Henderson. Our logo is by Kate Ryan and our theme music is by Lily Sloane. Many thanks to today's guests, especially Abby, who reached out to me to share her story after hearing the show. If you'd like to do the same, you can email me at Accesspodcast@protonmail.com, and that's in the show notes. Remember, you can donate to the show by visiting glow.fm/apodcastaboutabortion, and that's in the show notes too. Don't forget to subscribe to Access wherever you get your podcasts, and please leave us a rating or review so more people can find the show. Follow us on Twitter and Instagram @ACCESSpod. A full transcript of this episode will be available on our website, apodcastaboutabortion.com.
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