The GOP Obamacare replacement defunds Planned Parenthood and restricts abortion coverage

The bill to repeal and replace the Affordable Care Act will effectively defund Planned Parenthood for one year by cutting the organization from Medicaid reimbursements, according to the highly anticipated Congressional Budget Office’s analysis of the bill, released Monday.

While the bill doesn’t mention Planned Parenthood by name, the CBO report anticipates that only Planned Parenthood, its affiliates, and clinics would be affected through the guidelines put forward under the Republican-backed American Health Care Act.

That could actually spell trouble for the bill in the Senate. Singling out Planned Parenthood, and not other family planning providers, could be considered an “extraneous matter” that isn’t relevant to the federal budget. If so, that would be a violation of the Byrd Rule, and would make the bill ineligible to pass with a simple majority through the budget reconciliation process.

If the defunding provision passed, though, the CBO found that it would reduce access to “services that help women avert pregnancies” — especially for people who are low-income or live in rural areas. The report concludes that about 15 percent of people who “reside in areas without other health care clinics or medical practitioners who serve low-income populations” will experience reduced health care access.

The CBO also estimates that the one-year defunding will reduce direct federal spending by $234 million by 2026 — but that the government will have to spend an additional $77 million on Medicaid over that time period, due to an increase in unplanned births and the fact that some of the resulting children will qualify for Medicaid.

The bill can actually go further than this, though. It also threatens to dismantle the entire private insurance market for abortion coverage, not just public funding for abortion providers.

Under the Republican plan, if a woman wants a health insurance plan that will cover abortion, she (and possibly her employer) won’t be able to use tax credits to buy it.

And if this bill passes, there’s no guarantee that women will have any good options for private insurance coverage of abortion — a procedure that, out of pocket, can cost from $500, for an earlier abortion, to tens of thousands of dollars, for a later one.

Under the new Republican plan, any insurance plans that cover abortion — unless the woman became pregnant through rape or incest, or if the abortion is needed to save her life — won’t be eligible for tax credits.

Tax credits help make insurance more affordable for some consumers. That means insurance coverage for abortion, specifically, will be more expensive. These restrictions also apply to the tax credits that some small businesses use to purchase health care plans — but those tax credits will be gone anyway by 2020.

To be clear, the bill doesn’t ban abortion coverage directly. Nor does it prohibit anyone from buying abortion coverage, or a separate insurance “rider” for that coverage. It just doesn’t allow that coverage to be subsidized by the government.

That means many consumers would have to go out of their way to find a plan that covers abortion — and once they did, it would be more expensive. And if abortion insurance coverage is both expensive and a logistical hassle, many consumers simply won’t buy it.

That wouldn’t leave insurance companies much incentive to offer abortion coverage at all, even if it’s technically not prohibited by law. Indeed, it gives insurers almost no other choice but to stop covering abortion in many, or even most, of their plans.

“It’s clear the goal is to try to eliminate private coverage of abortion entirely,” Megan Donovan, senior policy manager at the Guttmacher Institute, told Vox in an earlier interview.

There are also serious limitations to the “exceptions” under which a woman can get abortion coverage in this bill. For instance, if a woman has an abortion because she discovered late in her pregnancy that her baby wouldn’t survive birth, or because she has other health complications that make pregnancy risky but wouldn’t present an immediate threat to her life, that’s still considered an “elective” abortion that can’t be covered by federal funds.

Thanks to the Hyde Amendment, these restrictions already apply to most federal funds — including Medicaid. That’s why federal funds don’t pay for abortion at Planned Parenthood; they only fund other medical procedures.

In practice, defunding Planned Parenthood takes money away from its mostly low-income patients, who might be forced to seek care elsewhere if the government stopped subsidizing their visits to Planned Parenthood. Low-income women will be hit especially hard, but all Planned Parenthood patients may be affected if clinics are forced to close as a result of budget cuts.

The more than $500 million Planned Parenthood receives annually from the federal government — the funding that Republicans in Congress now want to take away — pays for specific health services, like birth control or cervical cancer screening, for people who couldn’t afford them otherwise.

Most of the funds (75 percent) are actually reimbursements from Medicaid, the US’s public health insurance program for the poor. Just like with any other insurance, Medicaid patients go to their health care appointment first and then have Medicaid pay all or most of the bill later.

The rest of Planned Parenthood’s federal funds come in the form of grants from Title X, the nation’s only federal program for family planning. Title X grants are awarded on a competitive basis to clinics that meet the program’s standards for family planning coverage and services.

Title X subsidizes free or low-cost contraception and other preventive services, and it’s especially helpful for low-income or uninsured people who make too much to qualify for Medicaid.

The ACA repeal bill targets Medicaid. Another proposal that just passed the House targets Title X, by making it easier for states to block Planned Parenthood from receiving federal Title X grants.

Again, Title X grants are competitive. When Planned Parenthood affiliates and clinics earn Title X grants, it’s because they have proven they can administer better care than other local providers.

If the government stopped paying for Planned Parenthood to accept Medicaid patients or Title X grants, it would be a huge financial blow to the organization.

Federal funding makes up about 40 percent of Planned Parenthood’s budget. Most of its patients are low-income and rely on Medicaid coverage or Title X subsidies for health care.

In 2015, a whopping 78 percent of Planned Parenthood’s patients had incomes of 150 percent or less of the federal poverty level. Losing even a significant fraction of these low-income patients would be devastating to Planned Parenthood; it would probably have to close clinics or reduce capacity, which would affect all of its patients, regardless of income.

President Trump recently suggested that Planned Parenthood might be able to keep its funding if it stopped offering abortions, The New York Times reported Monday. Technically, under the wording of the bill, this is true.

But there’s just no way Planned Parenthood would stop performing abortions. It would go against everything the organization stands for. Offering women across the country the full spectrum of reproductive health care, including pregnancy termination, is just too central to its mission.

“The White House proposal that Planned Parenthood stop providing abortion is the same demand opponents of women’s health have been pushing for decades, as a part of their long-standing effort to end women’s access to safe, legal abortion,” Planned Parenthood Federation of America president Cecile Richards said in a statement. “Planned Parenthood has always stood strong against these attacks on our patients and their ability to access the full range of reproductive health care.”

Richards added: “We are glad that the White House understands that taking away the preventive care Planned Parenthood provides is deeply unpopular and would be a disaster for women’s health care.”

While targeting Planned Parenthood’s funding is popular among Republicans, most Americans don’t consider it a priority. Polling suggests most Americans, including nearly half of Trump voters, oppose defunding Planned Parenthood, the nation’s largest family planning provider. One in five US women have visited a Planned Parenthood clinic for services like birth control, cancer screenings, STD tests, or pregnancy termination.

Republicans have threatened a government shutdown over Planned Parenthood funding before, in 2011 and 2015, but they were ultimately forced to back down — mostly because Democrats in the Senate and President Obama were a firewall.

That’s why many GOP members of Congress have expressed reservations about lumping Planned Parenthood defunding and ACA repeal together.

Republicans need at least 50 of their 52 senators to pass the ACA repeal through the budget reconciliation process — and two pro-choice Republican senators, Lisa Murkowski of Alaska and Susan Collins of Maine, have said they oppose linking ACA repeal to Planned Parenthood defunding.