Federal health insurance rules are a moving target, and it's unclear whether Republicans will take another run at replacing the Affordable Care Act. In the meantime, some states are staking out strong positions on coverage of abortion, cementing their position regardless of how the federal landscape changes.
Last Tuesday, Texas Gov. Greg Abbott, a Republican, signed a bill that prohibits insurers in individual and employer plans from covering abortion unless a woman's life is in danger. Women who want such coverage would have to buy a supplemental rider to their plan. That same day, Oregon Gov. Kate Brown, a Democrat, signed an expansive bill that requires health plans to cover reproductive health services, including contraceptive drugs, devices and procedures, without charging consumers anything out-of-pocket. Abortion is one of those services.
Neither of the new laws applies to the large companies that self-fund their health plans and pay their employees' claims directly rather than buy coverage from an insurer.
The federal Affordable Care Act probably deserves some of the credit or blame, depending on your point of view, in both cases.
"The ACA raised the profile of abortion coverage in private insurance," said Adam Sonfield, a senior policy manager at the Guttmacher Institute, a reproductive health research organization that supports abortion rights. The law allowed states to prohibit plans sold on the insurance marketplaces from covering abortion, and 25 states subsequently moved to restrict or prohibit it.
"Many states passed those laws pretty quickly" after 2010 when the ACA was passed, Sonfield said, "and other states took it further," banning or restricting abortion coverage in other private individual and group insurance plans. Ten states prohibit all private insurance plans from offering abortion coverage. Like Texas' law, in eight of those states the only exception is to save a woman's life. No allowances are made for rape, incest or fetal impairment.
"Taking the life of pre-born child, that doesn't change whether it's a case of rape or incest," said John Seago, legislative director of Texas Right to Life, which supported the bill.
Offering abortion coverage as a supplemental rider to an insurance plan would allow women to opt in if they want it, Seago said. The bill's supporters took their cues, he added, from other states such as Kansas, where restrictions have been in place for some time.
Blue Cross Blue Shield of Kansas offers a supplemental abortion policy for group plans — but not individual plans — that costs roughly $80 per member annually, said spokeswoman Mary Beth Chambers.
But abortion rights advocates say that with few exceptions supplemental insurance riders for abortion coverage simply aren't available.
They liken the situation to the problems women faced getting maternity coverage before the ACA passed. Individual policies generally did not cover maternity expenses so women who didn't get coverage through work would have to buy a rider to cover those costs. Often, though, they weren't offered by insurers or were prohibitively expensive. The ACA required maternity coverage in all individual and small-group plans. An analysis by the National Women's Law Center found that only 7 percent of individual plans offered those riders in 2012.
And while women may have ben able to plan ahead to purchase coverage for a pregnancy, "no one wants to think they're going to need an abortion this year," Sonfield said. "It's not something you want to plan for."
The ACA was a force behind Oregon's new law as well, advocates say.
"In other years, this could have been a can that could be kicked down the road," said Grayson Dempsey, executive director of Naral Pro-Choice Oregon, whose organization was part of a coalition of advocacy groups that worked on the law. "Instead, now there was a real urgency to get it done."
The Trump administration is expected to release a revised rule within days that will roll back ACA provisions requiring most employers and insurers to cover contraceptives without cost-sharing. The rule is expected to allow any organization that has religious or moral objections to covering birth control to stop doing so.
The Oregon law requires health plans to cover women's reproductive health services without charging them anything out-of-pocket. It covers all contraceptives approved by the Food and Drug Administration, including vasectomies. Most controversially, it also covers abortion.
An opponent of the law said it will probably lead to more abortions. "When you make something free, it's potentially accessed more," said Liberty Pike, communications director at Oregon Right to Life. Pike said her organization feared that young women would use abortion as birth control.
The organization doesn't have a position on the other elements of the new law, Pike said.
The law has a caveat that allows insurers to offer plans that don't cover contraceptives or provide abortions to religious employers, such as churches.
Two other states, New York and California, require nearly all health plans to cover abortion services, said Gretchen Borchelt, vice president for reproductive rights and health at the National Women's Law Center.
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This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.