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The Honorable Carolyn B. Maloney Acting Chairwoman, Committee on Oversight and Reform United States House of Representatives Washington, DC 20515 The Honorable Jim Jordan Ranking Member, Committee on Oversight and Reform United States House of Representatives Washington, DC 20515 November 14, 2019 Re: Hearing on “Examining State Efforts to Undermine Access to Reproductive Health Care” Dear Acting Chairwoman Maloney and Ranking Member Jordan: Thank you for the opportunity to submit this statement on behalf of the Guttmacher Institute for the November 14, 2019 hearing entitled “Examining State Efforts to Undermine Access to Reproductive Health Care.” As a nonprofit research and policy organization committed to advancing sexual and reproductive health and rights in the United States and globally, the Guttmacher Institute has collected and analyzed information about the provision of abortion in the United States for more than 50 years.
We have also systematically tracked and analyzed state efforts to restrict access to this constitutionally protected form of health care since the early 1970s.

State Abortion Policy Landscape For nearly a decade, state lawmakers hostile to abortion have been relentless in their pursuit of restrictions designed to prevent people from exercising their constitutional right to end a pregnancy: Since January 2011, states have enacted 484 new abortion restrictions.
This onslaught has shifted the abortion policy landscape dramatically.

To assess how and where the volume of abortion restrictions has changed over time, analysts at the Guttmacher Institute considered whether six types of abortion restrictions and six types of policies that support abortion rights were in effect in the states in 2010 and 2019.

Based on the number of policies in each of these groups, a state is placed in one of seven classifications, ranging from very hostile to very supportive.
In 2019, 29 states have policy landscapes considered hostile to abortion.

Nearly 40 million women of reproductive age (58% of the total number) live in these states.1 Strikingly, the extent to which states demonstrate hostility to abortion has intensified significantly since 2000, even as the overall number of hostile states has remained the same: In 2010, no states were considered very hostile to abortion, whereas 10 states were hostile states and 19 leaned hostile.
Today, these numbers have shifted towards the extreme end of the spectrum: 6 states are considered very hostile, 16 are hostile and 7 lean hostile.
State Abortion Policy Landscape, 2010 and 2019 Very Hostile Hostile Lean Hostile Middle-ground Lean Supportive Supportive Very Supportive 2010 0 10 19 9 10 2 0 2019 6 16 7 7 9 4 1 Guttmacher Institute 2 These classifications are more than a useful rhetorical tool: they reflect the very real overlay of policies that control if and how people are able to get the abortion care they need in a given state.
Research suggests that barriers to abortion care may exacerbate each other, meaning that the more restrictions a person encounters, the more difficult it can be to access care.2 As states enact more and more restrictions, moving along the spectrum from “leaned hostile” to “very hostile,” the reality of abortion access for people in those states becomes ever grimmer.
Recent Efforts to Restrict Abortion In the years immediately following the 2010 midterm elections, the onslaught of abortion restrictions was largely characterized by clinic shutdown laws thinly veiled as safety measures intended to protect women’s health.3 In 2016, the U.S. Supreme Court found two prominent examples of these laws to be unconstitutional.

Nonetheless, just a few short years later, the newly conservative Supreme Court plans to consider a reprise of one of these laws in 2020.
Meanwhile, state legislatures determined to restrict abortion have increasingly turned to more obvious tactics, embracing a range of measures intended to ban all, most or some abortions outright.
In the first half of 2019 alone, state legislatures (primarily across the South, Midwest and the Plains) enacted 59 abortion restrictions, 25 of which would ban all, most or some abortions.4 The most prominent trend to emerge from these recent efforts are bills that seek to ban abortion earlier and earlier in pregnancy—in particular, bills that would ban abortion as early as six weeks after the last missed period, which is before many people know they are pregnant.
In the first half of the year, bans on abortion by gestational age were enacted in nine states:  Alabama enacted a total ban on abortion;  Georgia, Kentucky, Louisiana, Mississippi and Ohio banned abortion as early as six weeks of pregnancy;  Missouri banned abortion at eight weeks;  Arkansas and Utah banned abortion at eighteen weeks of pregnancy.

Fortunately, courts have stepped in to block these laws from going into effect while litigation proceeds.
But these examples demonstrate two important things about lawmakers’ tactics and intentions.

First, they make clear the underlying goals of eliminating abortion services and teeing up court cases that will present the Supreme Court with the opportunity to significantly roll back abortion rights in the United States.

Second, legislators are willing to essentially try anything, passing a range of bans and playing politics with people’s health in order to see what works and achieve their goals.
Missouri is perhaps the most telling example in this regard: not content to simply ban abortion at eight weeks, the legislature included additional bans at three other gestational ages in anticipation of litigation.

Abortion Restrictions are Cruel and Discriminatory One in four women in the United States will have an abortion in their lifetime.5 When someone decides to have an abortion, they should be able to do so affordably, with dignity and on the timeline that meets their needs.
Anything less is a fundamental violation of reproductive freedom and autonomy.

Guttmacher Institute 3 The recent wave of abortion bans at the state level gets right to the heart of the antiabortion agenda: eliminating abortion care outright.

Yet the endless list of other restrictions attached to abortion care over the years is no less insidious.
Restrictions that close clinics, force people to delay abortion care, or impact the quality of care they receive have a disproportionate impact on low-income women, women of color and young women.6 Moreover, as people struggle to overcome legal, financial and logistical obstacles to obtaining abortion care, the passage of time can push that care further out of reach: The further along a pregnancy is, the higher the cost and the fewer the providers who offer abortion services.7 Whether state law mandates a medically unnecessary procedure, forces clinics to close, or withholds insurance coverage of abortion care, the sacrifices required to overcome these obstacles and end a pregnancy are cruel and unconscionable.
Despite the cruel intentions behind them, state abortion restrictions overall do not appear to be the primary driver of recent declines in abortion nationwide.8 However, certain abortion restrictions— particularly those known as Targeted Regulation of Abortion Providers (TRAP) laws—have played a clear role in shutting down clinics in some states, thereby reducing access to abortion and likely preventing some people from getting the care they seek.
The landmark Turnaway Study by researchers at the University of California, San Francisco (UCSF), found that denying access to wanted abortion care can have serious consequences for women’s health and well-being.9 For example, women denied abortions are more likely than those who receive abortion care to experience:  short-term anxiety and loss of self-esteem;  ongoing exposure to intimate partner violence; and  serious complications during the end of their pregnancies, such as eclampsia and death.
The UCSF study also found that women denied a wanted abortion are more likely than their counterparts to experience financial hardship and economic insecurity.10 For example, they are:  more likely to be enrolled in public safety net programs;  more likely to report not having enough money to cover basic needs;   three times more likely to be unemployed; and four times more likely to fall below the Federal Poverty Level.
State Lawmakers and Congress Can Take Steps to Protect and Expand Access to Abortion State legislatures can take steps to protect and expand access to abortion, and some are already doing so.11 For example, in 2019:12  Illinois, New York, Rhode Island and Vermont enacted laws that declare reproductive health care—including abortion—a fundamental right and prohibit government interference in reproductive health decisions.13 Guttmacher Institute 4  Illinois, New York and Maine approved measures permitting advanced practice clinicians to provide abortions, thereby expanding the pool of medical professionals who are eligible to provide such care.
 Maine became the 16th state to provide abortion coverage to people enrolled in Medicaid.

Illinois and Maine also adopted policies requiring private insurers to cover abortion care.

(Illinois previously updated its Medicaid coverage to include abortion in 2017).14  Nevada and New York repealed laws criminalizing abortion, removing a legal mechanism for punishing providers in the event Roe v. Wade is overturned.
Efforts like these can help ensure that abortion, and reproductive health care more generally, is available and accessible to people seeking care in those states.

However, in the face of ongoing and escalating attacks on abortion elsewhere around the country, congressional action is needed to put an end to the relentless cycle of harmful state laws, and to ensure that abortion access does not depend on a person’s income or zip code.

The Women’s Health Protection Act (H.R.


2975), reintroduced on May 23, 2019 by Congresswomen Judy Chu (D-CA), Lois Frankel (D-FL) and Marcia Fudge (D-OH) would put an end to medically unnecessary and burdensome restrictions and bans on abortion.

It is urgently needed to ensure that people can access abortion free from such restrictions, regardless of where they live.

The EACH Woman Act (H.R.


1692), led by Congresswomen Barbara Lee (D-CA), Jan Schakowsky (D-IL) and Diana DeGette (D-CO), would restore insurance coverage of abortion to people enrolled in Medicaid and other federal programs.15 It would also allow private insurers to offer abortion coverage free from political interference.

It is urgently needed to ensure that all people can afford abortion care, regardless of their income or source or insurance.
Taken together, these two bills would go a long way towards protecting and promoting access to abortion in the United States.16 On behalf of the Guttmacher Institute, I urge the members of this committee to support these critical bills.

Thank you for the opportunity to provide these comments.
Sincerely, Heather D. Boonstra Director of Public Policy 1 Guttmacher Institute, State Abortion Policy Landscape: From Hostile to Supportive, New York: Guttmacher Institute, 2019, https://www.guttmacher.org/article/2019/08/state-abortion-policy- landscape-hostile-supportive.
2 Jerman J et al., Barriers to abortion care and their consequences for patients traveling for services: qualitative findings from two states, Perspectives on Sexual and Reproductive Health, 2017, 49(2): 95- 102, https://www.guttmacher.org/journals/psrh/2017/04/barriers-abortion-care-and-their-consequences- patients-traveling-services.
Guttmacher Institute 5 3 Boonstra HD and Nash E, A surge of state abortion restrictions puts providers—and the women they serve—in the crosshairs, Guttmacher Policy Review, 2014, 17(1):9-15, https://www.guttmacher.org/gpr/2014/03/surge-state-abortion-restrictions-puts-providers-and-women- they-serve-crosshairs.
4 Nash E et al., State policy trends at mid-year 2019: states race to ban or protect abortion, 2019, https://www.guttmacher.org/article/2019/07/state-policy-trends-mid-year-2019-states-race-ban-or- protect-abortion.

5 Jones RK and Jerman J, Population group rates and lifetime incidence of abortion: United States, 2008-2014, American Journal of Public Health, 2017, 107:1904-1909, https://www.guttmacher.org/article/2017/10/population-group-abortion-rates-and-lifetime-incidence- abortion-united-states-2008.
6 Guttmacher Institute, Induced abortion in the United States, Fact Sheet, New York: Guttmacher Institute, 2019, https://www.guttmacher.org/fact-sheet/induced-abortion-united-states.

7 Jerman J and Jones RK, Secondary measures of access to abortion services in the United States, 2011 and 2012: gestational age limits, cost, and harassment, Women’s Health Issues, 2014, 24(4):e419– e424, http://www.whijournal.com/article/S1049-3867(14)00058-9/fulltext.
8 Nash E and Dreweke J, The U.S. abortion rate continues to drop: once again, state abortion restrictions are not the main driver, Guttmacher Policy Review, 2019, 22:41-48, https://www.guttmacher.org/gpr/2019/09/us-abortion-rate-continues-drop-once-again-state-abortion- restrictions-are-not-main.

9 Advancing New Standards in Reproductive Health (ANSIRH), Turnaway Study, https://www.ansirh.org/research/turnaway-study.
10 ANSIRH, Socioeconomic Outcomes of Women Who Receive and Women Who are Denied Wanted Abortions, San Francisco: ANSIRH, 2018, https://www.ansirh.org/sites/default/files/publications/files/turnaway_socioeconomic_outcomes_issue_ brief_8-20-2018.pdf.

11 Nash E and Donovan M, Ensuring access to abortion at the state level: selected examples and lessons, Guttmacher Policy Review, 2019, 22:1-7, https://www.guttmacher.org/gpr/2019/01/ensuring- access-abortion-state-level-selected-examples-and-lessons.
12 Nash E et al., State policy trends at mid-year 2019: states race to ban or protect abortion, 2019, https://www.guttmacher.org/article/2019/07/state-policy-trends-mid-year-2019-states-race-ban-or- protect-abortion.

13 Nash E, Mohammed L and Cappello O, Illinois steps up as other states decimate abortion access, 2019, https://www.guttmacher.org/article/2019/06/illinois-steps-other-states-decimate-abortion-rights.
14 Sonfied A and Nash E, States lead the way in promoting coverage of abortion in Medicaid and private insurance, 2019, https://www.guttmacher.org/article/2019/06/states-lead-way-promoting- coverage-abortion-medicaid-and-private-insurance.

15 Donovan M, EACH Woman Act offers bold path towards equitable abortion coverage, 2019, https://www.guttmacher.org/article/2019/03/each-woman-act-offers-bold-path-toward-equitable- abortion-coverage.
16 Donovan M, With abortion rights in peril, here’s what Congress must do, 2019, https://www.guttmacher.org/article/2019/05/abortion-rights-peril-heres-what-congress-must-do.

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