It’s pretty easy to go full Handmaid’s Tale when imagining what’s in store for reproductive rights in Trump’s America. There’s Supreme Court–nominee Neil Gorsuch, who wrote the Tenth Circuit decision that privileged Hobby Lobby’s shareholder’s religious beliefs over employees’ right to contraception. And Tom Price, the new director of Health and Human Services, who has twice sponsored legislation that would give a zygote constitutional rights starting at the moment of conception. State legislatures are now in session, delivering a blizzard of anti-abortion bills: some packaged as moderate, many others obviously unconstitutional, all sharing the end goal of challenging and finally finishing off Roe. But despite (or because of) all that, we can skip panicking over Roe, and zero in on the immediate problems women are already facing.
A crucial new report based on data from the National Network of Abortion Funds confirms what reproductive-justice advocates have been saying for a long time: Abortion is already all but inaccessible for poor Americans. The report provides concrete evidence that the Hyde Amendment — which since 1976 has prohibited federal funds, including Medicaid and Affordable Care Act dollars, from covering most abortions — impedes poor women’s access to the procedure. The data also paints a stark picture of disparity, as young and black women are most affected by the prohibition.
“People who are African American and younger are having distinct difficulties financially accessing abortion services,” says Gretchen Ely, associate professor at the University of Buffalo School of Social Work and lead researcher of the academic study upon which the report is based. “What you have here is a distinct representation of the ageism, classism, sexism that follows the unintended — or intended — consequences of restrictions on abortion in certain states and on the federal level,” Ely explains. “It’s an excellent representation of the intersection of all the ‘isms’.” A majority of women who seek abortion are poor or low-income, so those women and their financial struggles belong front and center in public conversations about abortion.
For the study, Gretchen Ely and her co-authors looked at 3,999 intakes from the George Tiller Memorial Fund, one of 70 similar NNAF–affiliated nonprofit funds that provide assistance to low-income women. The Tiller Fund was established just hours after Dr. George Tiller, an abortion provider, was shot and killed in his church in Wichita in 2009. The fund prioritizes patients who are seeking second-trimester procedures, which comprise a small percentage of overall abortions nationwide. (This means that the data is isn’t a perfect microcosm of national trends.)
This study is the first to analyze data from an abortion fund. And since courts evaluate abortion laws based on whether they create “an undue burden” for women seeking an abortion, it’s vital that advocates know precisely what obstacles poor women — the women the funds exist to help — are facing. Last June, for example, the Supreme Court threw out Texas’s HB2 after the clinics’ attorneys were able to prove that the law forced patients to travel long distances after clinics closed, creating financial hardship and potentially insurmountable obstacles.
“In my eyes, this data is a picture of an undue burden at the financial level,” Ely says. “Most Western nations provide some kind of abortion assistance on the federal level. Because we don’t do that, NNAF and the other abortion funds are filling in where public-health policy should be taking responsibility.”
Those of us who came of age after Roe probably assume the Hyde Amendment is inevitable too. But when the federal-funding ban was new, its fate wasn’t certain. Right after the law took effect in 1976, a New York woman on Medicaid sued the government to stop the law, saying it would force her to carry her unwanted pregnancy to term. Americans United for Life (AUL), the legal organization whose attorneys have been the premier architects of the anti-abortion movement, helped the government make its case. John Gorby, the AUL attorney who helped clinch the case, Harris v. McRae, when it went before the Supreme Court, told me that at first he was ambivalent about defending the Hyde Amendment.
Gorby was conflicted about the Hyde Amendment, because he believed that it meant that the government was guaranteeing a right to the rich but not the poor. A former public defender, he considered his anti-abortion advocacy to be civil-rights work, “defending the unborn.” He explains: “I was bothered by the idea that somehow, if there is a fundamental right to decide whether to bear a child and it costs money to implement that decision, then it bothered me to deprive the indigents of that right.” But Gorby also anticipated that the federal-funding ban would lead to more funding restrictions in the states, and the “domino effect” would make it harder for physicians to provide abortions in general. He ultimately helped write the AUL’s brief to the Supreme Court, which made the same argument to the justices that they would later use to uphold the Hyde Amendment. Poverty, not the Hyde Amendment itself, the justices wrote, had blocked the poor woman from exercising her right to choose abortion.
In his dissent, Justice Thurgood Marshall predicted that minority women would be most harmed and wrote, “The consequence is a devastating impact on the lives and health of poor women. I do not believe that a Constitution committed to the equal protection of the laws can tolerate this result.”
Thirty-six years later, data from the new study vindicates Marshall’s dissent:
Roughly half the women who sought help from the Tiller Fund were black, when only about 13 percent of the United States population and about 36 percent of women who seek abortions nationwide are. These numbers also corroborate other studies that have shown that black women face more barriers to accessing health care in general and so are much likelier than white women to die in childbirth or of cervical cancer, which with routine care should be preventable.
1,511 of the 3,999 women already had multiple children.
The average distance a Tiller Fund recipient traveled to have an abortion doubled from 97 to nearly 200 miles between 2010 and 2015. For women having second-trimester procedures, the distance tripled. This is significant because that same time frame is when state assemblies across the country began passing hundreds of abortion restrictions at an unprecedented clip.
Women needed to come up with an average of $2,248 to pay for their procedures. And they needed to cobble together assistance from multiple sources.
Because a disproportionate number of these women were seeking second-trimester abortions, their procedures were more expensive than most. Ely says the data also suggests that many women had to delay their procedures until they got together enough money. Because procedures cost more as a pregnancy advances, once women are delayed they end up needing more money. This traps them in a race against the clock — gestational-week limits vary based on state law. Women in these kinds of situations often don’t have access to credit cards or family members who can help out.
And that leads us to what’s most urgent in the fight for reproductive rights now. If Ely’s hunch is right, a 20-week ban on abortion could be a de facto total ban for many poor women. Twenty-week bans have already been enacted in 19 states, and one was passed in Pennsylvania last week. Plus, under Trump, with Republicans holding total trifectas in 25 states, lawmakers are going to keep trying to use budgets and incremental restrictions to isolate reproductive health care from the rest of medicine. The proposed plan to prohibit Medicaid from reimbursing abortion providers like Planned Parenthood when they provide pap smears, mammograms, IUDs, and other preventative care is just one example of that strategy.
The Tiller Fund recipients’ circumstances are sobering evidence that any attack on reproductive health-care providers will be felt most acutely by already marginalized women. And that means we need to pay attention to the changes that don’t necessarily seem sweeping or dramatic — the state budgets, the local laws — because changes in policy that create hiccups for wealthy or middle-class Americans potentially deny others’ their most basic freedoms.