How one state removed barriers to Medicaid-funded abortions
by Sue Frietsche, Women's Law Project
In 1977, Congress first passed the Hyde Amendment, which allows the use of federal Medicaid funds for abortions only in cases of rape, incest or when the woman's life is in danger. States have the option of paying for abortions under broader circumstances ("medically necessary" abortions), but they must use state dollars to do so. Pennsylvania is one of 34 states that limit Medicaid coverage of abortion to rape, incest and endangerment of the woman's life. Yet even within the strict parameters of this federally mandated right, many women in Pennsylvania who qualify for Medicaid funded abortions face serious obstacles in accessing them. Recognizing a widespread problem, the Women's Law Project, Greater Philadelphia Women's Medical Fund and CHOICE Hotline joined forces (with the support of the Institute for Reproductive Health Access) to identify and remove these barriers. Their experiences reflect an important new approach to expanding abortion care for low-income women.
Passed in 1993, the Pennsylvania Abortion Control Act was even more restrictive than the federal Medicaid law. In order to qualify for a Medicaid-funded abortion in Pennsylvania, the woman had to personally report the rape to the police, including the name of the assailant, if known. In the case of life endangerment, two physicians had to certify- that the woman would die without an abortion. The Women's Law Project challenged the rape reporting and second-physician certification requirements in federal court, and in 1995, we won.
We thought that by lifting these onerous restrictions, we could ensure that women in these serious circumstances would have timely access to Medicaid-funded abortion care, but we were wrong: desperate calls from women kept coining into our offices a host of barriers were preventing women who were eligible for Medicaid abortions from getting them. At first, we dealt with each case on an emergency basis, but over time we came to realize that we needed to develop a plan to specifically tackle the obstacles to abortion coverage under Medicaid.
Our first step was to meet with abortion providers from across Pennsylvania to talk to them about what was stopping women from accessing Medicaid abortions. We discovered breakdowns at every stage of the process:
- The forms to be filled out by providers and women to show eligibility for a Medicaid abortion were confusing and intimidating. They required survivors to know the legal distinction between rape and incest, and to give the date of the assault that led to their pregnancy (an impossibility for some incest survivors who had been assaulted repeatedly); the forms implied that only the doctor providing the abortion could complete the certification: and they required the survivor to check off whether or not she had reported the crime to the police, without informing her that a police report was not necessary.
- Many doctors did not believe women who told them they had become pregnant from rape. Some doctors imposed a quota on themselves, setting an arbitrary limit on the number of abortions they were willing to provide for rape survivors.
- Some providers would not accept Medicaid forms from certain HMOs; the HMOs were not familiar with the legal requirements governing Medicaid abortion.
- Women who received fee-for-service care, as opposed to care through a managed care plan, had absolutely no access to abortion services.
- There was confusion about eligibility: what constituted a "life threat" — did it include only physical threats, or could a threat of suicide be taken into account?
- Many women, even when difficulties with their Medicaid coverage were resolved, were unable to afford the costs of travel to the limited number of abortion providers in the state, or to out-of-state providers who were sometimes their only option.
These meetings clarified the need for advocacy to ensure that the Medicaid coverage we thought we had won back in was actually going to benefit women. With financial and technical support from the Institute for Reproductive Health Access, we formed a small working group that met regularly for several years with the sole purpose of eliminating the barriers to Medicaid funded abortion. The group's discussions resulted in several important steps forward:
Improving public understanding
We started by tackling the dearth of accurate information. With the invaluable assistance of Community Legal Services in Philadelphia, we researched and wrote brochures explaining when Medicaid would cover abortion in Pennsylvania. These brochures were posted on the Women's Law Project website and distributed to 10,000 abortion providers, family planning agencies, rape crisis centers, domestic violence shelters, emergency rooms, social workers, welfare advocates and women's activists around the state.
Gaining support of public officials
The election of a pro-choice governor (Ed Rendell) provided momentum, as the new administration swept away decades of hostile reproductive health policies. We redrafted the intimidating Medicaid forms and met with the Department of Public Welfare (DPW) to urge streamlining the forms. DPW also designated a troubleshooter to whom we could turn for help in solving problems with particular cases. This assistance has ranged from confirming that a client was actually enrolled in the Medicaid program, to faxing departmental guidances about abortion eligibility to skeptical HMOs, to expediting a clients enrollment in the Medicaid system.
One of the most positive outcomes of our communication with the new administration was its offer to help train interested abortion providers on how to bill for their services. With this guidance, and through regular communication with providers around the state, we were able to convince more providers to accept Medicaid reimbursement, thereby expanding options for low-income women.
Getting women to providers
Even with coverage for services, we found that the need to travel to get an abortion was an obstacle for many women. In theory, the solution to this problem was Pennsylvania's county-based Medical Assistance Transportation Program (MATP), which covers transportation to and from any Medicaid-covered service. But there are 67 counties in Pennsylvania with 67 different sets of instructions for accessing MATP. We educated ourselves and providers about how to use this system, and built relationships with some of the county-level welfare supervisors who were able to intervene to solve eligibility problems and answer questions.
Trying to convince a huge bureaucracy to sensitively and promptly provide a stigmatized service was a daunting task at times, but the investment was worth every minute. By taking the time to identify and systematically address barriers to this vital and time-sensitive care, we were able to make great strides in helping Pennsylvania women. Most gratifying, the project helped to change attitudes toward rape and incest survivors, brought light to navigating the Medicaid system, and even transformed our own expectations of ourselves. Now when a problem arises with abortion and Medicaid, we expect that we can and will solve it, and the patient will receive the medical care to which she is entitled.
Just recently, a call came into our office that would have given me nightmares a few years ago. It was from an indigent woman in her mid-second trimester of pregnancy who was not yet enrolled in the Medicaid system (a process that can take as long as a month). She had an appointment for an abortion in New York in a matter of days and was afraid that if she broke that appointment, she would not be able to get another in time. It took only a few phone calls to confirm her eligibility', activate her Medicaid card and make arrangements with activists in New York to help her while she was there—a world of difference from the chaos we had become accustomed to before the Medicaid project taught us to expect more.
Adapted from Removing Barriers to Medicaid-Funded Abortion: What Advocates Can Eearn from the Pennsylvania Experience, by Sara Sills and Sue Frietschefor the Institute for Reproductive Health Access and the Women's Law Project. Available at www.prochoiceny.org assets files removingbarriers.pdf or by calling 212.343.0114. The report suggests actions for working at the state level to expand access to Medicaidfunded abortion care.