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Written Statement of Dr. Herminia Palacio CEO and President, Guttmacher Institute Hearing on “The Impact on Women Seeking an Abortion but are Denied Because of an Labor, Health and Human Services, Education and Related Agencies Subcommittee, Inability to Pay” House Committee on Appropriations December 8, 2020 Good morning, Chairwoman DeLauro, Ranking Member Cole and members of the Subcommittee.

My name is Dr. Herminia Palacio.


I am the President and CEO of the Guttmacher Institute, a nonprofit research and policy organization committed to advancing sexual and reproductive health and rights in the United States and globally.

Today, I bring my perspective as the leader of an organization that has collected and analyzed data about the provision of abortion in the United States for more than 50 years, and has tracked state abortion policy since the early 1970s.
I also bring 30 years of public health and health care experience, including 15 years practicing internal medicine at San Francisco General Hospital during the height of the HIV/AIDS epidemic.

My patients experienced firsthand how supportive—or oppressive—federal and state policies could be with respect to their sexual health, reproductive autonomy and health care access.

1 September 2020 marked 44 years since Congress first approved the Hyde Amendment.
This policy has unjustly withheld abortion coverage from people enrolled in Medicaid for decades and—in real-people terms—for multiple generations.

Removing this ban is a critical first step toward ensuring people can get the abortion care they need.

I will highlight three main points backed by science and evidence: 1.

Abortion is a health care experience shared by many people.
One in four cisgender women in the United States will have an abortion in their lifetime.1 Likewise, trans men and gender nonconforming individuals can also become pregnant and require access to the full range of pregnancy-related care.

Abortion patients include people of every race, religion and socioeconomic group, and the majority are already parents.2,3 Nonetheless, 75% of abortion patients in the United States have low incomes, and the majority are people of color.

2.
2.

The harmful burdens of the Hyde Amendment are intentionally and unjustly imposed on Black and Brown people, and on people with low incomes.

In other words: The Hyde Amendment targets people who have been historically marginalized and who are bearing the greatest brunt of the current pandemic.

2 We are now nine months into a pandemic that brings into sharp relief racial, gender and economic injustices—issues core to the subject of this hearing.
Research conducted by my Guttmacher colleagues in April and May offers an early look at the pandemic’s implications for sexual and reproductive health.4 Notably, 34% of women reported wanting to delay getting pregnant or to have fewer children because of COVID-19.

These changes were more common for women belonging to groups who already experience systemic health and social inequities.
For example, 44% of non-Hispanic Black women and 48% of Hispanic women wanted to delay pregnancy or have fewer children because of COVID-19, compared to 28% of non-Hispanic White women.4 Lower income women (37%) were also more likely than higher income women (32%) to indicate these changes in fertility preferences.
At the same time, non-Hispanic Black (38%) and Hispanic (45%) women were more likely than non-Hispanic White women (29%) to experience delays of sexual and reproductive health care or to have trouble getting their birth control because of the pandemic.

4 These barriers were also more commonly experienced among lower income women (36%) than higher income women (31%).
These findings provide a snapshot of how COVID-19 is compounding existing inequities by disproportionately affecting the sexual and reproductive health of Black, Brown and low-income communities—communities that are also often blocked from affordable abortion care by the Hyde Amendment.

Whether it is a global health pandemic or racist policies like the Hyde 3 Amendment, the consequences fall hardest on people already marginalized by systemic discrimination.

This is where health insurance comes in.


The importance of health insurance to defray costs of medical care in the United States cannot be overstated.
It helps patients gain entry into the health care system, get the care they need, and avoid large and often unanticipated medical bills.5 Health insurance also saves lives: Research demonstrates that thousands of premature deaths have been averted in states that expanded Medicaid under the Affordable Care Act.6 Abortion is precisely the kind of medical care for which health insurance is critically important.
On average, an abortion at 10 weeks’ gestation costs around $550—which could be someone’s entire rent payment—and the cost increases over time.7 Associated expenses such as unpaid time off from work, childcare and travel increase the financial burden and are exacerbated by restrictions that make abortion more difficult to access.
This is a large a financial burden for millions of Americans: Even before the current recession, 24% of American households had less than $400 in the bank and 37% would have struggled to cover an emergency expense of $400.8,9 Yet, the Hyde Amendment intentionally leaves millions of people who are already struggling financially without abortion coverage.
As of 2018, more than 7 million women aged 15–44 enrolled in Medicaid lived in the 34 states and the District of Columbia where abortion coverage was not available because of the Hyde Amendment.10 Three million of these women were living below the federal poverty line.

4 Black and Brown women are disproportionately likely to be insured through Medicaid and therefore subject to the Hyde Amendment’s restrictions.
In 2018, 31% of Black women and 27% of Hispanic women aged 15–44 were enrolled in Medicaid, compared with 16% of White women.11 These Medicaid enrollment patterns are themselves the legacy of oppressive laws and policies too expansive to cover in this testimony; I will only note that the evidence linking structural racism to social and economic inequality is abundant.

As our country undergoes a racial reckoning, I want to be clear: The Hyde Amendment is a racist policy.

3.
3.

The adverse consequences of withholding abortion coverage are serious and long-lasting.

People struggling to pay for abortion care report diverting money from other urgent needs, such as paying rent and utilities or even feeding their family.12 Others rely on family members for financial help, receive financial assistance from clinics or sell their personal belongings.2,12,13 These are unconscionable sacrifices to require of people and their families in order to access health care.
Many people with low incomes experience delays accessing abortion care because of the time and effort needed to pull together funds: Fifty-four percent of women in the Turnaway Study (which examined the consequences of receiving an abortion compared to continuing an unwanted pregnancy) reported that having to raise money for an abortion delayed their care.14 Moreover, people can get caught in a cruel cycle, in which delays associated with raising the 5 money can lead to additional costs and subsequent delays.
The median cost of an abortion in the second trimester is 2–3 times more than in the first trimester.7 Because of these challenges, Medicaid coverage can mean the difference between getting abortion care and being forced to continue a pregnancy.
A literature review conducted by the Guttmacher Institute concluded that among women with Medicaid coverage subject to restrictions like the Hyde Amendment, one in four who seek an abortion are forced to continue the pregnancy.15 Forcing someone who wants an abortion to continue a pregnancy is a violation of their reproductive autonomy.
Moreover, it is tantamount to requiring them, against their wishes, to accept the risks of pregnancy- and labor-related complications, including preeclampsia, infections and death.
The United States has the highest maternal mortality rate among developed countries, with dramatic but preventable racial inequities caused by systemic racism and provider bias.16 Black and Indigenous women’s maternal mortality rates are 2–3 times the rate for White women, and 4–5 times as high among older age groups.17 I ask you to reflect on these overlapping and perverse indignities: The Hyde Amendment disproportionately withholds abortion coverage from communities of color, a potential consequence of which is being forced to continue a pregnancy in a system in which Black and Indigenous people are astonishingly more likely to die.
6 Moreover, the risks of other consequences do not end with a safe delivery.
The Turnaway Study found that denying wanted abortion care can have adverse consequences for women’s health, safety and economic well-being.18 For example, among women experiencing intimate partner violence, being forced to carry an unwanted pregnancy to term can delay separation from the partner, resulting in ongoing exposure to violence.19,20 In addition, compared with women who get the abortion they seek, women who do not obtain a wanted abortion have four times greater odds of subsequently living in poverty.21 They also have three times greater odds of being unemployed, and they are less likely to be able to have the financial resources for basic needs such as food and housing.
These consequences are not short- lived: The negative financial impacts of denying abortion care can persist for several years.22 In sum, the Hyde Amendment has been unjust and harmful from the very beginning.

Today, it exists as part of a broader landscape of abortion restrictions that work together to place enormous burdens on people seeking abortion care—burdens that push abortion out of reach when they prove insurmountable.
Shamefully, six in 10 women of reproductive age in this country live in states with policies that are designed to create barriers to abortion care.23 Moreover, while this subcommittee is focused specifically on the Hyde Amendment, this policy’s broader legacy extends throughout federal policy.
Congress and the executive branch have used the Hyde Amendment as a model for analogous restrictions on abortion coverage for people insured or receiving health care services through other federal government programs.24 7 This includes federal employees and their dependents, military personnel and their dependents, veterans, Peace Corps volunteers, American Indians and Alaska Natives, people held in federal prisons or detention centers, and people with low incomes in the District of Columbia.
When someone decides to have an abortion, they should be able to do so with dignity, on the timeline that meets their needs, and with affordable, equitable access to care.

Anything less is a fundamental violation of reproductive freedom and autonomy.
It is also in direct violation of widely accepted standards of quality of care, particularly the tenets of patient-centered, timely and equitable care.25 Congress—starting with this subcommittee—has both the opportunity and ethical imperative to lead toward reproductive justice, beginning with this first step of eliminating the Hyde Amendment.

I thank you for this opportunity and look forward to answering your questions.
1 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.

2 Jerman J, Jones RK and Onda T, Characteristics of U.S.
Abortion Patients in 2014 and Changes Since 2008, New York: Guttmacher Institute, 2016, https://www.guttmacher.org/report/characteristics-us-abortion-patients-2014.

3 Jones RK, People of all religions use birth control and have abortions, Guttmacher Institute, 2020, https://www.guttmacher.org/article/2020/10/people-all-religions-use-birth-control-and- have-abortions.
4 Lindberg LD et al., Early Impacts of the COVID-19 Pandemic: Findings from the 2020 Guttmacher Survey of Reproductive Health Experiences, New York: Guttmacher Institute, 2020, https://www.guttmacher.org/report/early-impacts-covid-19-pandemic-findings-2020-guttmacher- survey-reproductive-health.
8 5 Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services, Access to health services, 2020, https://www.healthypeople.gov/2020/topics- objectives/topic/Access-to-Health-Services 6 Broaddus M and Aron-Dine A, Medicaid Expansion Has Saved at Least 19,000 Lives, New Research Finds, Washington, DC: Center on Budget and Policy Priorities, 2019, https://www.cbpp.org/sites/default/files/atoms/files/11-6-19health.pdf.

7 Witwer E et al.
7 Witwer E et al.

Abortion service delivery in clinics by state policy climate in 2017, Contraception, 2020, 2:100043, https://www.guttmacher.org/article/2020/10/abortion-service- delivery-clinics-state-policy-climate-2017.

8 Board of Governors of the Federal Reserve System (BGFRS), Report on the Economic Well- Being of U.S.
Households in 2019—May 2020, Washington, DC, 2020, https://www.federalreserve.gov/publications/2020-economic-well-being-of-us-households-in- 2019-dealing-with-unexpected-expenses.htm.

9 Bhutta N and Dettling L, Money in the Bank?

Assessing Families’ Liquid Savings using the Survey of Consumer Finances, BGFRS, 2018, https://www.federalreserve.gov/econres/notes/feds-notes/assessing-families-liquid-savings- using-the-survey-of-consumer-finances-20181119.htm.
10 Guttmacher Institute, special tabulations of data from the 2018 American Community Survey.

11 Sonfield A, U.S. insurance coverage, 2018: The Affordable Care Act is still under threat and still vital for reproductive-age women, Guttmacher Institute, 2020, https://www.guttmacher.org/article/2020/01/us-insurance-coverage-2018-affordable-care-act- still-under-threat-and-still-vital.

12 Jones RK et al., At what cost?


Payment for abortion care by U.S. women, Women’s Health Issues, 2013, 23(3):e173–e178, https://www.guttmacher.org/sites/default/files/pdfs/pubs/journals/j.whi.2013.03.001.pdf.

13 Center for Reproductive Rights (CRR), Whose Choice?

How the Hyde Amendment Harms Poor Women, New York: CRR, 2010, https://reproductiverights.org/story/whose-choice-how- the-hyde-amendment-harms-poor-women.
14 Roberts SCM et al., Out-of-pocket costs and insurance coverage for abortion in the United States, Women’s Health Issues, 2014, 24(2): e211–e218, http://dx.doi.org/10.1016/j.whi.2014.01.003.

15 Henshaw SK et al., Restrictions on Medicaid Funding for Abortions: A Literature Review, New York: Guttmacher Institute, 2009, https://www.guttmacher.org/report/restrictions- medicaid-funding-abortions-literature-review.
16 American College of Nurse-Midwives, Black Mamas Matter Alliance and International Confederation of Midwives, Eliminating the Racial Disparities Contributing to the Rise in U.S. Maternal Mortality, no date, https://www.midwife.org/acnm/files/cclibraryfiles/filename/000000007740/Eliminating-the- Racial-Disparities-Contributing-to-the-Rise-in-U.S.-Maternal-Mortality-ACNM-BMMA- ICM.pdf.
17 Petersen EE et al., Racial/ethnic disparities in pregnancy-related deaths—United States, 2007– 2016, Morbidity and Mortality Weekly Report, 2019, Vol.

68, No.

35, 762–765, https://www.cdc.gov/mmwr/volumes/68/wr/mm6835a3.htm?s_cid=mm6835a3_w.

18 Advancing New Standards in Reproductive Health (ANSIRH), Turnaway Study, https://www.ansirh.org/research/turnaway-study.
9 19 Mauldon J, Foster DG and Roberts SC, Effect of abortion vs. carrying to term on a woman’s relationship with the man involved in the pregnancy, Perspectives on Sexual and Reproductive Health, 2015, 47(1):11–18, https://onlinelibrary.wiley.com/doi/full/10.1363/47e2315.

20 Roberts SCM et al., Risk of violence from the man involved in the pregnancy after receiving or being denied an abortion.

BMC Medicine, 2014, 12(144), https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-014-0144-z.
21 Foster DG et al., Socioeconomic outcomes of women who receive and women who are denied wanted abortions in the United States, American Journal of Public Health, 2018, 108(3):407- 413, https://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2017.304247.

22 Miller S, Wherry LR and Foster DG, The Economic Consequences of Being Denied an Abortion, Cambridge, MA: National Bureau of Economic Research, 2020, https://www.nber.org/papers/w26662.
23 Nash E, State abortion policy landscape: from hostile to supportive, Guttmacher Institute, 2019, https://www.guttmacher.org/article/2019/08/state-abortion-policy-landscape-hostile- supportive.

24 Donovan MK, In real life: federal restrictions on abortion coverage and the women they impact, Guttmacher Policy Review, 2017, 20:1–7, https://www.guttmacher.org/gpr/2017/01/real- life-federal-restrictions-abortion-coverage-and-women-they-impact.
25 Agency for Healthcare Research and Quality, Six domains of health care quality, 2018, https://www.ahrq.gov/talkingquality/measures/six-domains.html.

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