Abortion Information

WASHINGTON—The Trump administration is poised to issue a rule unwinding an Obama -era requirement that employee health benefits include contraception, which will spark a fresh round of litigation over an issue that has been before courts for six years.

Federal health officials are expected to finalize a regulation that would allow employers with religious or moral objections to birth control to omit coverage for contraception from their workers’ plans, according to two people familiar with its contents. The regulation closely mirrors an earlier, leaked draft, they said.

The Supreme Court has ruled, in a case brought by the arts-and-crafts chain Hobby Lobby, that “closely held” private companies can invoke religious objections to avoid covering contraception.

The Trump administration rule would allow a much broader set of employers to opt out of offering coverage for birth control, making moot a “workaround’’ designed by the Obama administration that allowed women in some cases to obtain coverage even if their employers had declined to offer it directly.

The rule would fulfill a promise by President Donald Trump to social conservatives, who backed his candidacy but have been frustrated by the pace of his administration has moved to address one of their most significant grievances.

Based on early indications, the expected rule “would go a very long way to restoring religious freedom and conscience rights,” said Hillary Byrnes, assistant general counsel at the U.S. Conference of Catholic Bishops.

She said the rule couldn’t come soon enough. “We’ve been dealing with this mandate for over six years now,” she said. “A lot of people thought the administration would do something pretty quickly, yet here we are in August.”

Reproductive-rights activists say they will sue the Trump administration if it moves ahead with the rule, arguing that the change would unfairly impose employers’ beliefs on their workers and that the administration has cut regulatory corners in writing the policy.

“We are preparing various different legal theories to fight the rule very quickly,” said Mara Gandal-Powers, senior counsel at the National Women’s Law Center, an advocacy group. “We think we have a really strong claim.”

A spokeswoman for the Department of Health and Human Services declined to comment.

As a presidential candidate, Mr. Trump pledged support for Catholics and evangelical Christians who sued President Barack Obama and his top officials over the contraception requirement, contending that it forced them to violate their religious beliefs.

They also opposed a process, which the Obama administration dubbed an accommodation, in which an employer notifies the government of its unwillingness to cover contraceptives. That prompts the insurer administering the employer’s health benefits to assume the cost and administration of providing contraceptives, effectively cutting out the employer.

Religious employers challenged the policy in court, saying it made them complicit in a sin. The Supreme Court last year sent the case back to lower courts.

The Trump administration plans to offer the plaintiffs precisely what they sought: an exemption from the contraception requirement for all employers who want one, according to people familiar with the plan, ending the need for litigation.

Others regard the expected rule as a step back in a decadeslong fight to secure women’s access to contraceptive care.

Lawyers preparing potential legal cases for opponents of the change say that if the rule resembles the leaked draft, the policy could qualify as sex discrimination, since it would disproportionately affect women’s health care. They also plan to argue that leaving a decision on contraceptive coverage to employers could amount to religious discrimination by subjecting workers to the beliefs of their employers.

“If the rule says any employer can withhold this benefit from employees, then you have a whole set of questions about whether the government is enabling employers to impose their beliefs on others,” said Louise Melling, deputy legal director at the American Civil Liberties Union.

People familiar with the proposed rule say the Trump administration plans for it to take effect as it is published. Nicholas Bagley, a University of Michigan law professor who has analyzed much of the health-law litigation of the last six years, has said that could open the administration to lawsuits for implementing the rule without time for public comment and consideration.

“The argument they make is, ‘We’ve thoroughly vetted this issue, and we’re only making a minor change,’” he said. “If that was true, that argument would hold water. But that’s not true in this case.”

Write to Michelle Hackman at Michelle.Hackman@wsj.com and Louise Radnofsky at louise.radnofsky@wsj.com

Appeared in the August 17, 2017, print edition as ‘Contraceptive Rule to Be Reversed.’


Oregon Gov. Kate Brown at Portland International Airport in 2015. (Bruce Ely/The Oregonian/AP)

Oregon Gov. Kate Brown (D) on Tuesday signed into law what advocates called the nation’s most progressive reproductive health policy, expanding access to abortion and birth control at a time when the Trump administration and other states are trying to restrict them.

Called the Reproductive Health Equity Act, the measure requires health insurers to provide birth control and abortion without charging a co-pay. It also dedicates state funds to provide reproductive health care to noncitizens excluded from Medicaid.

Antiabortion groups swiftly condemned the new law, saying it will force taxpayers to foot the bill for a procedure many consider to be a form of murder, and that it cements Oregon’s status as the most liberal state when it comes to abortion.

“Today Gov. Brown demonstrated her extreme bias in favor of the abortion rights lobby, disregarding thousands of future Oregonians whose lives have been further endangered by making their elimination 100 percent expense-free,” Gayle Atteberry, executive director of Oregon Right to Life, said in a statement.

Abortion rights groups praised the measure as a bulwark against an erosion of reproductive rights under Republican leadership in Washington and elsewhere.

The Pro-Choice Coalition of Oregon, which helped write the law, said it will benefit hundreds of thousands of Oregonians, not only by increasing access to abortion but also birth control and postpartum care for low-income women.

“In the face of relentless rollbacks and attacks at the federal level, Oregonians are showing the rest of the country what it means to be resilient and visionary,” Amy Casso, director of the Gender Justice Program at Western States Center, said in a statement. “There is still work to be done, but today we celebrate that more Oregonians have the freedom to decide if and when they have children based on what’s best for them and their family’s circumstances.”

The Trump administration has moved to scale back a federal mandate, under the Affordable Care Act, requiring that employers provide no-cost birth control as part of their insurance plans. It also has sought to eliminate taxpayer money from flowing to Planned Parenthood, a prominent women’s health organization that provides abortions.

The moves follow efforts in two dozen states, most of them led by Republicans, to restrict access to abortion in recent years by imposing strict new regulations on the procedure and on those who provide it.

In an indication that there is still momentum in red states to further constrain abortion access, also on Tuesday, Texas Gov. Greg Abbott signed a bill banning insurance companies from covering abortion as part of their standard health insurance plans. Women in the state would have to pay a separate premium to have abortion coverage.


A much larger group of employers will be able to opt out of offering insurance plans that cover birth control. Photo: Adam Hart-Davis/Science Photo Library/Getty Images/Science Photo Libra

On Thursday, The Wall Street Journal reported that the White House is on the verge of implementing a rule to roll back the Obama-era requirement that employers offer health-insurance plans that include contraception. The news was confirmed by “two people familiar” with the new rule’s contents, which they say is very similar to a draft leaked in late May.

Much like the draft, this rule would reportedly let a “much broader” set of employers opt out of offering plans that cover birth control, if offering that coverage conflicts with their religious beliefs. It also abolishes a “work-around” the Obama White House put in place that would let women circumvent their employers to get free birth control:

[The] process, which the Obama administration dubbed an accommodation, in which an employer notifies the government of its unwillingness to cover contraceptives. That prompts the insurer administering the employer’s health benefits to assume the cost and administration of providing contraceptives, effectively cutting out the employer.

Trump’s religious base has been after him for months about implementing the rule, which they said “would go a very long way to restoring religious freedom and conscience rights.” But reproductive-rights advocates say it “allow[s] an employer’s religious beliefs to keep birth control away from women,” and is therefore vulnerable to a legal challenge.

From a practical standpoint, this could mean that some of the more than 50 million women the rule has benefited could be forced to pay for their contraception out of pocket — something one in three women voters have struggled to do, according to a 2010 poll. And much like his presidency as a whole, Trump’s new rule would go against popular opinion; according to a January Kaiser poll, 77 percent of women and 64 percent of men supportno-co-pay contraception coverage.

Those “familiar” with the rule told WSJ that, rather than open the rule to public comment, they expect it to take effect as soon as it’s published.


Hundreds of bills aimed at restricting abortion access are introduced in state legislatures every year, and the ones that become law can have an immediate impact on providers across the country. States that currently have just one abortion clinic are proof of how strict, superfluous requirements force clinics to shutter, leaving women with fewer healthcare options.

Kentucky, Mississippi, Missouri, North Dakota, South Dakota, West Virginia, and Wyoming each have only one abortion clinic. One. For the whole state.
“Of course, states that have shut down all but a single clinic didn’t get there by accident, but as the result of deliberate steps to deny women access to constitutionally protected healthcare,” James Owens, a NARAL Pro-Choice America spokesperson, told Refinery29. “Unfortunately, these states are not alone, as there has been a concerted, nationwide effort to undermine a woman’s access to abortion for more than a decade.”
Mississippi was left with just one clinic providing abortion procedures 11 years ago — Jackson Women’s Health — and it’s been fighting to stay open ever since. Most recently, a crisis pregnancy center moved in right across the street. These types of anti-abortion organizations advertise as clinics offering women advice on pregnancy options, but in reality, they distribute misleading or false information, exaggerate the risks of having an abortion, and pose “counselors” as medical professionals.
So far, Jackson Women’s Health has managed to keep its door open, but now another one-abortion-clinic state is battling to not become the first state with zero clinics.
Kentucky’s Republican governor, Matt Bevin, has effectively shut down abortion clinics and kept an existing Planned Parenthood from providing abortion procedures, leaving the E.M.W. Women’s Surgical Center as the only abortion provider in the state. The American Civil Liberties Union (ACLU) sued Kentucky on behalf of the E.M.W. Women’s Surgical Center in April after the state threatened to revoke the clinic’s license because its agreements with a local hospital and ambulance service allegedly weren’t sufficient. A federal judge allowed the E.M.W. Women’s Surgical Center to stay open until the case concludes.
State requirements forcing abortion clinics to have admitting privileges at nearby hospitals are known as TRAP laws — targeted regulation of abortion providers — because the American Medical Association and the American College of Obstetricians and Gynecologists consider them medically unnecessary and they force clinics that can’t meet those strict standards to close.
In fact, the Supreme Court ruled last summer that similar laws in Texas were unconstitutionalbecause they create an undue burden for women seeking to end a pregnancy, but other states (like Kentucky) still have these types of laws on the books.
Besides the fact that abortion is legal in the U.S., the main problem with having just one (or zero) abortion clinics in an entire state comes down to access. Do women really have the right to choose an abortion if there’s no feasible way for them to get one?
A lack of clinics forces women to travel really far to get healthcare. When Texas abortion clinics closed after the state withheld their funding in 2011, women whose closest clinic shuttered drove an average of 85 miles for health services. This means an increase in travel costs, childcare expenses, and time off work, all of which make it more difficult for anyone — but especially low-income women — to get an abortion. And if a state is left without any abortion clinics, all of those factors would escalate even further.
The ACLU’s case in Kentucky is set to go to trial in September and will determine whether or not the war against abortion will succeed in creating an abortion-free state in 2017.

HB 214 bars private, state-offered, and ACA abortion coverage

Sen. Brandon Creighton, R-Conroe, carried the Senate’s version of HB 214, a bill that bans insurance coverage of abortion care. He failed to accept amendments carving out exceptions for rape or incest survivors. (Photo by Jana Birchum)

Ecstatic to bring their first child into the world, Austin residents Scott Ross and Jeni-Putalavage Ross approached the 21st week of pregnancy with joy.

But a routine trip to the doctor soon revealed a rare and severe chromosomal fetal abnormality. Their future baby would not survive birth. The doctor recommended termination of pregnancy, a decision the couple did not make lightly. Scott said: “We felt a lot of mental anguish, but we knew the anguish – physical and mental – would be even harder if we carried the baby to term.”

Due to complications, Jeni spent seven days in the ICU. All said and done, the Rosses’ medical bill totaled a whopping $64,000. Thankfully, employer-based insurance covered 90% of the tab. However, an anti-choice Texas bill – inches away from becoming law – would have prevented the Rosses and couples like them from receiving insurance coverage for abortion care. “Under the bill, we would have had to pay out of pocket and would have been in dire financial straits, on top of the pain we felt losing our child,” said Scott, who likened the bill to a “pregnancy tax.”

One of Gov. Greg Abbott’s special session agenda items, HB 214 by Rep. John Smithee, R–Amarillo, (and Senate counterpart SB 8 by Sen. Brandon Creighton, R-Conroe) bars abortion coverage from private, state-offered, and Affordable Care Act (ACA) insurance plans, with an exception for a narrowly defined “medical emergency” but no exceptions for rape, incest, or fetal abnormalities – an especially cruel aspect of the bill that compelled critics and some legislators to dub it the “rape insurance” bill. Women would be forced to somehow anticipate the need for abortion care – an unpredictable life event – and purchase supplemental coverage, defying the point of insurance.

“It’s so frustrating to hear lawmakers call it an ‘elective abortion’ – we didn’t elect to have a child who is incompatible with life,” said Scott. “Like all abortions, it was unforeseen.”

Further, the bill doesn’t require insurance plans to offer the added coverage, or even notify clients if they don’t offer it. “You can be basically flying blind when choosing your insurance plan and not know the plan you’re buying for your family didn’t cover pregnancy termination even if it’s the result of rape or incest,” health care attorney Blake Rocap of NARAL Pro-Choice Texas, pointed out to the Senate’s Business and Commerce committee during a Friday hearing (Aug. 11).Bill authors claim the legislation is about “economic freedom” and allowing those who “philosophically disagree” with abortion to not have to subsidize the procedure, but the measure will end up unnecessarily and unfairly pushing abortion further out of reach for women, especially low-income women, pro-choice advocates caution. Texas isn’t alone in banning abortion insurance coverage; other GOP-controlled states have taken on similar laws: 10 states ban abortion from private insurance, and 25 states bar the procedure from health exchanges, according to the Guttmacher Institute.

On Saturday, during a hearing held well after 5pm, Senate Republicans left their empathy and compassion at the door while swatting down Democrat-authored amendments that sought to carve out exceptions for rape and incest victims and for women with severe fetal abnormalities, before eventually ushering the bill along to third reading in a 20-10 vote on party lines. It’s highly expected to pass the Senate’s final hurdle and eventually head to Abbott’s desk to become law. (House Democrats similarly attempted to include those exceptions, but Republicans callously shot them down when passing through HB 214 earlier this week, as noted in this week’s issue.)

“No one plans to be raped. No one plans to have an abortion. This is what I find so egregious about this bill,” said Sen. José Menéndez, D-San Antonio, who offered an amendment to protect victims of sexual assault from the potential new law – it was knocked down in a 20-10 vote. “This shouldn’t be a partisan issue. It should be about us caring about sexual assault survivors.”

With his amendments killed on the floor, the Senate GOP showed Texans how much they care about sexual assault survivors and all women, loud and clear.


Uganda’s highway A-109 shoots across the plain from Kampala past the occasional storefront shops and open-air kiosks common to the continent’s roadsides. After rising into the verdant tea plantations of the country’s Western Region, it passes through Fort Portal near the Congolese border. From there, a turn off the main road leaves the reasonably well-maintained tarmac behind in favor of red clay washboard and bone-shaking potholes. Finally, it devolves into a footpath running between a few dozen housing compounds in a village called Kalera.

Though Kalera is poor by western standards, it doesn’t approach the desperation found in many poorer parts of Africa. Flinty, hard-working women tend small plots of bananas, potatoes, maize and soybeans. These plots border larger fields of tea, a cash crop. Goats and chickens roam. The village teems with children. Today, at least, there are no men in sight.

 By limiting women’s family planning options in Uganda, “we are likely to get a higher number of abortion cases and more maternal deaths.” Jemiima Mutooro is a village health worker trained by Reproductive Health Uganda (RHU) using U.S. Agency for International Development (USAID) funds provided through the International Family Planning Foundation. She walks through Kalera carrying a black satchel. Inside the satchel is a day planner, pens, bandages, alcohol swabs and, most important, several small tamper-proof foil packages. Sayana Press, the novel, possibly revolutionary, family planning device within those packages is the subject of a pilot program sponsored by an international consortium that, along with RHU, includes the Uganda Ministry of Health and the Bill and Melinda Gates Foundation.

Global Gag Rule Uganda
Akiiki Jemiima Mutooro is one of 40 village health workers trained by Reproductive Health Uganda using USAID funds. (Charles Ledford)

Developed by Pfizer and the Seattle-based non-profit PATH, Sayana Press is as simple in form as it is obvious in function: a fingernail-sized clear plastic bubble holds a milky liquid – a three-month dose of the contraceptive progestin – and is attached to a short needle. The device is small, easy to use, disposable and effective. And because it’s also suitable for self-dosing, Sayana Press could give women in remote areas like Kalera – where isolation, cultural pressures and economic marginalization severely constrict contraceptive options – a previously unimaginable degree of reproductive autonomy.

Or the initiative could be severely curtailed – an early victim of a radical and asymmetric “America first” doctrine that pits the richest country on the planet against, among others, more than 200 million women worldwide who are in need of family planning services.

Global Gag Rule Uganda
A health worker holds a Sayana Press progestin-only contraceptive before administering it in Kalera Village.(Charles Ledford)

By any measure, most of those women are far removed from the White House, Trump Tower, Mar-a-Lago and the fundamentalist churches and cathedrals of America’s conservative faithful. But what geography, wealth and power once separated, Republican President Donald Trump brought together three days after his inauguration when he reinstatedRonald Reagan’s Mexico City Policy.

Also known as the Global Gag Rule, the Reagan-era document cut off US family planning assistance funds to foreign non-governmental organizations (NGOs) that perform abortions or even so much as mention the option of legal abortion to their clients. Since its inception in 1984, the policy has been a convenient political ping pong ball. Each subsequent Republican administration has renewed it, and each Democratic administration has rescinded it.

Global Gag Rule Uganda
A patient receives the injection of the contraceptive progestin from the Sayana Press. (Charles Ledford)

Trump’s version of the policy expands the restricted funds beyond family planning assistance to include all US “global health assistance.” According to the Kaiser Family Foundation, that’s at least $9.5 billion that now go toward efforts to fight malaria, Zika, HIV/AIDS and even malnutrition.

Just as the flawed rollout of the president’s immigration ban sowed widespread chaos, Trump’s gag rule has left NGOs involved in sexual and reproductive health worldwide scrambling to fully understand its scope. No one is yet sure exactly what this expanded language will mean or how the new restrictions will be implemented.

One thing is certain: More than 150 organizations have denounced the global gag rule’s previous iterations as having caused serious harm around the world. And legacy organizations like the International Planned Parenthood Federation (IPPF) and Marie Stopes International have said that, on principle, they will refuse to accede to the new policy’s restrictions. That means their local member associations, like Reproductive Health Uganda, will lose USAID funding and could be crippled.

Global Gag Rule Uganda
Surrounded by pregnant women and their caretakers, Jackeline Nikungu, 32, (center) waits to give birth to her fifth child. (Charles Ledford)

During an interview in his office in Fort Portal, Dr. Richard Obeti, assistant district health officer for Uganda’s Kabarole District, which includes Kalera, acknowledged both the uncertainty and the risk. “We are worried,” he said. “We rely on groups like Reproductive Health Uganda to bridge the gaps in our health care system.” He finds the Global Gag Rule’s potential negative impact on programs like the Sayana Press initiative to be particularly troubling: “Sayana Press prevents unwanted pregnancies which would otherwise end in abortion,” he said. By limiting women’s family planning options in a country where abortions have for years been legal only under the most extraordinary of circumstances, he said, “we are likely to get a higher number of abortion cases and more maternal deaths.”

And therein lies the irony. In 2011, the most recent year for which government figures are available, half of all pregnancies in the country were unintentional, according to the Uganda Bureau of Statistics. A 2017 Guttmacher Institute study estimates that 26 percent of these unintended pregnancies end in abortion.

More unintended pregnancies mean more unsafe abortions and more children than a family can afford. The original Mexico City Policy claims that “U.S. support for family planning programs is based on respect for human life, enhancement of human dignity, and strengthening of the family.”

On the ground in countries like Uganda, the actual consequences of the policy may be more ruined lives, more undignified death and more poverty.

These are the consequences of the 2017 version of US’ anti-abortion Global Gag rule


A college student has traveled to the D.C.-area from Georgia for an abortion, only to learn at her check-up at the clinic that the procedure will cost $4,000 more than she anticipated.

The D.C. Abortion Fund shared the student’s story, without providing identifying details, to help raise money on her behalf. The nonprofit provides grants to pregnant people who need assistance paying for the procedure. While a majority of the patients are local, about 15-20 percent of their cases are from other parts of the country.

“By the time she figured out that she was pregnant, she was too far along to be seen by a clinic in Georgia,” says Meghan Faulkner, the co-director of case management at DCAF. The cut-off for abortions in Georgia, and 23 other states, is 20 weeks post-fertilization. “One of the closest clinics available [for her procedure] was a clinic in Germantown … It’s not uncommon at all for patients to be traveling that far.

Compared to Georgia and, more nearby, Virginia, Maryland has significantly fewer restrictionson abortion. There is no waiting period (Virginia requires patients to get an ultrasound and then, in most cases, wait 24 hours before an abortion), and can be performed any time before the fetus is viable.

The patient was largely paying her own way, with some assistance from DCAF and other abortion funds.

The cost of an abortion varies, depending on how far along in a pregnancy the patient is, the type of anesthetic, and whether there are health complications. A first trimester procedure costs a couple hundred dollars on average, and increases as the pregnancy progresses.

“The later second-trimester procedures that patients come to our area for, it can be $5,000, $6,000, $7,000. $8,000 is the highest we see on a more regular basis,” says Faulkner. What can be tricky is that, as women are trying to raise money for the procedure, the cost for it continues to rise. “A lot of the reason patients need our support and face high costs is because they aren’t able to get coverage.”

The Hyde Amendment, a budget rider attached annually to Congressional appropriations bills since 1976, prevents the use of federal funds to pay for abortion, with few exceptions, affecting people on Medicaid, federal employees, Peace Corps volunteers, federally incarcerated women and women in immigration detention centers, military personnel, and Native Americans. A similar rider called the Dornan Amendment ties D.C.’s hands when it comes to using locally raised funds to pay for the procedure (Congress keeps trying to make the policy permanent law). Virginia doesn’t use its state funds to pay for the procedure in most cases, a choice made by commonwealth officials.

Plus, there are costs beyond the actual abortion. “If someone is traveling from out of state, they’re paying for travel,” says Faulkner. “There’s a hotel cost. There’s also your companion—folks usually travel with someone to have an escort to be with them. There’s lost wages, because most of the people that we are helping don’t have paid sick leave or much, if any, vacation time. And childcare is another big one.” Later second trimester abortions generally take at least two days, unlike the outpatient procedure for those undergone in the first trimester.

DCAF exists to help fill the monetary gap. In fiscal year 2015, the organization assisted 1,200 patients, according to Faulkner, a number they well exceeded the following year, though they haven’t finalized the numbers for 2016 yet.

For the student from Georgia, her costs rose by $4,000 because she miscalculated when her pregnancy began. DCAF has already pledged to help pay the difference. “This particular patient was a college student who doesn’t have a ton of resources to say, ‘great, l’ll just pay $5,000 on my credit card.”

“We’ve worked with a number of patients who’ve faced similar things, especially if they’ve already come up with the money and gotten themselves here,” says Faulkner. “It”s often panic and feeling like, ‘How is this happening? I’ve done everything I possibly could and I’m facing another barrier.'”


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