Inside Story

Trump (and Pence) versus women’s health

The administration continues to roll out hostile policies

Lesley Russell 4 June 2019 2376 words

In the driver’s seat: vice-president Mike Pence. Patrick Semansky/AP Photo

From the very beginning, and right across the board, decisions by Donald Trump and his administration have adversely affected women’s health. Aside from their continuing efforts to undo Obamacare, which will reduce health insurance coverage for millions of women, they have curtailed support for reproductive health, abortion and pregnancy, limited free contraception, and narrowed the scope of civil rights in healthcare.

Rather than reflecting any strong convictions on his part, Trump’s attacks on women’s reproductive services and rights play to a key constituency — the evangelical Christian right — that helped him get elected. He has delivered on his promise of a more conservative Supreme Court by appointing two conservative judges, Neil Gorsuch and Brett Kavanaugh, to the nine-member Supreme Court, thus giving conservatives a crucial five–four majority. This has energised evangelical voters, who seem strangely unconcerned about Trump’s moral character, and especially the anti-abortion movement, which sees a once-in-a-generation opportunity to tear down Roe v Wade, the landmark 1973 ruling that enshrines women’s rights to abortion.

Overseeing the changes to women’s health services are health department appointees with strong links to vice-president Mike Pence, who is seen as the driver of these initiatives in the White House. Pence, who has said he wants to see Roe v Wade “on the ash heap of history,” helped offset evangelicals’ concerns about Trump, who once supported abortion rights and described himself as “very pro-choice.” (Pence’s imprimatur worked: Trump got 80 per cent of their votes.)

In his first week in office the president reinstated what is known as the Mexico City policy, which blocks American aid to foreign organisations that provide abortions, abortion counselling or referrals, or advocate to decriminalise abortion or expand abortion services, even if these actions are not funded with American money. Introduced under the Reagan administration, the rule has been lifted or reinstated repeatedly, depending on whether a Democrat or a Republican is in the White House.

Later in 2017, secretary of state Rex Tillerson announced an expansion of the policy to all international health aid provided by the US government (nearly US$9 billion), including funding for maternal and child health, nutrition, HIV/AIDS, the prevention and treatment of diseases including tuberculosis and malaria, and some water, sanitation and hygiene programs. Earlier this year, the issue was ramped up further when Tillerson’s successor, Mike Pompeo, announced steps to fully enforce the policy, including withdrawing some funding and calling for “a strict prohibition on backdoor funding schemes and end-runs around our policy.”

Concurrent attempts are being made to replicate these restrictions within the United States. A proposed overhaul of Title X family planning programs set up under president Richard Nixon would require clinics receiving Title X funds and providing abortions to do so through physically and financially separate entities, and prohibits these clinics from referring patients to separate abortion providers. (Under the 1977 Hyde amendment, Title X grant-holders must not use federal funds to provide abortions, except in exceptional circumstances.)

These restrictions are aimed primarily at Planned Parenthood, a major provider of women’s healthcare and reproductive services. Pence’s fingerprints are clearly visible: as a congressman in 2007, he introduced the first bill to strip federal funding from Planned Parenthood. Support for that quest has become a litmus test for conservative lawmakers.

Legal challenges mean that the overhaul is on hold. In the meantime, grants under Title X have gone out without the usual high-level scrutiny, based solely on the final decision of a deputy assistant secretary of health who is a longstanding advocate of sexual abstinence programs. The new restrictions on the program will limit poor women’s access not just to abortion but to the wide range of essential healthcare services organisations like Planned Parenthood provide.

The attack on family planning extends beyond Title X to Medicaid and Obamacare, and beyond contraception and abortion to stripping away the ability of poor and under-served women to access primary care and preventive-health screening services. While Republicans have failed to repeal Obamacare, the Department of Health and Human Services has stealthily dismantled a number of provisions in ways that adversely affect women.

A major rollback allows employers to claim a religious or moral objection to the birth control coverage mandate, under which all insurance policies must provide cover without co-payments for all contraception approved by the Food and Drug Administration. Although this ruling went into effect immediately, it is under legal challenge, and its impact has been muted, particularly in those states that require health insurance to cover prescription contraceptives.

Obamacare’s birth control coverage mandate is broadly supported by Americans, perhaps because it appears to have reduced women’s spending on contraception (on average every woman saves $255 per year). In all, about fifty-five million women have directly benefited from the no-cost birth control mandate.

This and other requirements — including a ban on insurance providers charging women more than men for coverage, the abolition of co-payments for breast cancer screening, and mandatory cover for maternity and newborn care — mean that Obamacare has delivered significant benefits for women, especially women below the federal poverty line. Indeed, women are more likely than men to have been helped by Obamacare; conversely, of course, they are more likely to suffer from any dismantling of the law.

The battle over abortion is being fought most strongly at the state level. Over recent months a number of Republican-majority states have enacted anti-abortion legislation with the aim of getting a case before the Supreme Court that delivers the holy grail: an overthrow of the Roe v Wade ruling.

FiveThirtyEight has analysed the diverse and extensive anti-abortion restrictions enacted since 2011. This year alone, 304 have been introduced by state legislatures. Most egregiously and most recently, the (female) governor of Alabama signed into law a bill that makes abortion a crime at any stage of pregnancy, with no exceptions for rape or incest. Under this law, any doctor who performs an abortion is liable for up to ninety-nine years’ prison. Some eight other states, including Georgia, Kentucky, Mississippi and Ohio, have also outlawed abortion beyond the point at which a doctor can detect an embryonic heartbeat — around six weeks, that is, before most women know they are pregnant.

Writer Jessica Valenti recently showed how many of the people (mostly men) who have legislated these bills don’t seem to know enough about how women’s bodies work to pass a high school health class. This minimal understanding of biology means they have no understanding of how their legislation will affect real-life women.

None of the new draconian restrictions has yet gone into effect, either because of delays built into the legislation itself or because of legal challenges. But public health experts are concerned about the public health crisis that looms if and when they do. The states with the most restrictions on access to abortions also have the highest rates of maternal and infant mortality, and although there is no necessary connection, abortion access is a proxy for access to healthcare and education and correlates with poverty. I wrote about America’s appalling maternal and child health statistics for Inside Story last year; the concern now is that limiting access to abortion will contribute to a further worsening.

Largely unremarked, meanwhile, is the fact that the US abortion rate has fallen dramatically over the past decade. A new report from the Centers for Disease Control and Prevention shows that the national rate declined 26 per cent between 2006 and 2015, hitting the lowest level on record. A decline in teen pregnancies and better use of contraception by young adults are seen as the likely causes.

Colorado has offered free birth control at family planning clinics for some years, and since 2009 the state has seen a 40 per cent drop in the teen birthrate (a faster rate of change than nationally) and a 42 per cent drop in the teen abortion rate. At the same time, the caseload for a state program that provides nutritional support for low-income women and their babies has fallen by 23 per cent.

But getting an abortion is increasingly difficult in many parts of the United States. The last clinic in Missouri, for example, is about to close following the state’s decision not to renew Planned Parenthood’s licence. Five other states (Kentucky, Mississippi, North and South Dakota, and West Virginia) have just one clinic.

The flurry of anti-abortion legislation around the nation is matched by the legal challenges being filed in response. At least twenty cases relating to abortion are in the legal pipeline that leads to the Supreme Court, but the route is long and complicated.

During his election campaign, Donald Trump said that overturning Roe v Wade “will happen automatically in my opinion because I am putting pro-life justices on the court.” But past experience shows that he and abortion opponents can’t rely on a conservative-leaning Supreme Court to deliver the results they hope for.

Anti-abortion campaigners had hopes in 1992 that a conservative Supreme Court would overthrowing Roe v Wade in its judgement on Planned Parenthood of South Eastern Pennsylvania v Casey. But even justices who had been sharply critical of Roe were not prepared to go that far. Three Republican-nominated justices — Sandra Day O’Connor, Anthony Kennedy and David Souter — recognised that Roe could only be overturned “at the cost of both profound and unnecessary damage to the court’s legitimacy” and worked behind the scenes to deliver a compromise.

The three reaffirmed what they called the “essential holding” of Roe: “the right of the woman to choose to have an abortion… and to obtain it without undue interference from the state.” That Supreme Court decision set the “undue burden” standard by which abortion laws are currently judged, and could well be applied to a case currently before the court concerning a law that requires a waiting period for an abortion after a woman has a sonogram.

But just as Trump can’t be sure what result he will get from the Supreme Court, neither can those who seek to protect Roe v Wade rely on a 1992-style outcome when the next challenge is brought forward. During their confirmation hearings, both Gorsuch and Kavanaugh made the customary statements about respecting the Supreme Court’s precedents, including Roe. But a recent majority opinion from the court, written by Justice Clarence Thomas and including Gorsuch and Kavanaugh, stated that it was fine to do away with the rule of precedent if the current majority believes that the precedent represents “an incorrect resolution of an important constitutional question.”

Thomas is the only remaining justice from the 1992 Supreme Court. When the court recently waved through an appellate court’s decision to block an Indiana law that would have prohibited women from choosing abortions after a diagnosis of a disability such as Down Syndrome or because of the fetus’s gender, he issued a twenty-page statement that likened abortion rights to “modern day eugenics.” He went so far as to state that a “growing body of evidence suggests that eugenic goals are already being realised through abortion.” Little data exists to support his statements and he has been accused of manipulating the evidence he quotes.

Vice-president Mike Pence (who coincidentally had signed the Indiana law when he was governor) praised Thomas on Twitter. Perhaps foreshadowing legal fights to come, Justice Ruth Bader Ginsburg said that Thomas’s opinion displayed “more heat than light.” What is clear is that the Supreme Court is in no hurry to take up the abortion issue (and might deliberately avoid doing this ahead of the 2020 election). Supporters of abortion rights cling to the hope that when the court does return to the issue, chief justice John Roberts will respond as Justice Kennedy did in 1992. Given the chief justice’s support for the constitutionality of Obamacare, this optimism may be justified.

Despite the steady erosion of abortion rights in conservative Republican states, national support for the Roe v Wade ruling is strong. An NBC/Wall Street Journal poll last year found that 71 per cent of Americans — including 52 per cent of Republicans — didn’t believe Roe v Wade should be overturned: the highest level of support since that poll began in 2005. A more recent poll had 46 per cent of respondents saying the Supreme Court should uphold Roe if the issue comes before the justices, with 36 per cent saying the Supreme Court should modify the ruling and only 18 per cent wanting it overturned altogether.

Whatever Americans say about abortion and however they vote, abortion is a routine part of American women’s reproductive healthcare. Approximately 25 per cent of women in the United States will undergo an abortion before the age of forty-five, a similar rate to those of most developed countries. About 13 per cent of women who have an abortion identify as evangelical protestants. Poor women account for the majority of abortion patients and financial stress plays a major role in women’s decision-making.

As these issues continue to play out during the 2020 presidential campaign, they may present Trump and the Republicans with a tough choice between keeping their base happy and improving their support among women. A Pew Research poll found that Trump’s support among white evangelical voters has fallen from 78 per cent to 69 per cent since 2016, with only 55 per cent preferring Trump as the Republican nominee in 2020 when they are given other options such as Pence.

With most Americans disapproving of the Alabama abortion ban, Trump has joined a chorus of senior Republicans (including Senate leader Mitch McConnell, House minority leader Kevin McCarthy, senior Alabama senator Richard Shelby and senator Mitt Romney) distancing themselves from the decision. Trump said his view is “the same position taken by Ronald Reagan” — that abortion should only be legal following incest or rape — disregarding or unaware of the fact that Reagan, as governor of California, signed a liberal abortion law.

Some of the Democrat presidential candidates seem keen to make this a campaign issue. But while abortion is clearly on the minds of politicians, it’s less clear that it will be a crucial issue for voters in 2020. On the other hand, access to healthcare will be a huge issue, especially for those women who are most affected by the Trump agenda. They are the same women who, in 2016, voted overwhelmingly against him. •