The Clinton health plan: what does it do for reproductive health services?

PIP: Of current concern is whether President Clinton's Health Security Act will provide quality, comprehensive reproductive health services. These services should include preconceptional risk assessment, contraception (including sterilization), infertility services, screening for sexually transmitted diseases and cancers of the reproductive system, prenatal diagnosis, abortion, prenatal care, and maternity care throughout the postpartum period. Clinton's health care reform plan clearly addresses preventive health services, considers the long term, and grants preventive services preferential treatment. Yet, it does not provide specifics on family planning or make it a priority. It does not even address family planning under preventive services. The plan never mentions abortion, despite the president's insistence that abortion care is included. Clinton emphasizes that the national policy is to prevent unwanted pregnancies. The lack of specifics makes it difficult to determine whether the plan will maintain or improve existing reproductive health services. Limited information is available on coverage by private insurance policies. Advantages of the Clinton plan are removal of financial obstacles, permanent eligibility, and uniform coverage of services regardless of income, state, or residence. Unless the plan becomes more specific, disadvantages may include limited or no coverage of family planning services and limited or no access to reproductive health services for low-income women. Managed care programs may not provide sensitive reproductive health services (e.g., abortion) on religious or moral grounds. Many political barriers exist to health care reform. If Congress breaks the policy deadlock, with only cosmetic reform that ignores obvious problems, we will be left with the same, but more exacerbated, issues to be addressed in the future.^ieng

The Supreme Court retreats another step on abortion.

PIP: The 1973 "Roe v. Wade" decision is being further dismantled by the Supreme Court. However, in recent decisions, the new Court majority (except Justice Antonia Scalia) seems to say that there is a constitutional right to abortion. The "Hodgson v. Minnesota" and "Ohio v. Akron Center for Reproductive Health" decisions addressed difficult topics; the ability of a minor to give informed consent; and the rights of parents with regard to minor children. In most circumstances, medical treatment of children must be authorized by a guardian. However, in many states, children may seek treatment for pregnancy, substance abuse, sexually transmitted diseases, and psychological disturbances. In "Planned Parenthood of Central Missouri v. Danforth" and "Bellati v. Baird," the Supreme Court ruled that constitutional protection of abortion could not be conditioned by age, and that parents could not say no to their daughter's wish to have an abortion. If a girl did not want to notify her parent, she could go to a judge instead. The Court never ruled on whether parental notification was constitutional, or whether 1 parent (and, if so, which) or both had to be notified. All of these issues were addressed in "Hodgson" and "Ohio" in ways that were damaging to the welfare and rights of women. In "Hodgson," the Court decided that states may require both biological parents to be notified as long as they have judicial bypass. In "Ohio," the Court approved the state's complicated legal judicial bypass proceedings. It also ruled that the proceedings do not have to be anonymous, just confidential. The reasoning behind the decisions is ambiguous and contradictory. Justice Sandra Day O'Connor agreed that the Minnesota law is very stringent. She said that it was "unreasonable when one considers that only 1/2 of the minors in the State of Minnesota reside with both biological parents." The Court's majority explained that a 48-hour waiting period between the notification and the abortion might place a burden on the rights of the minor, but the Court considered that burden "minimal." The future constitutionally of abortion is on the line. The impending Court changes are the forerunners of more retreat from abortion rights.^ieng

Resolving the abortion controversy.

This article addresses legislative attempts to reverse Roe v. Wade, U.S. abortion laws vis-á-vis those of other developed nations, socioeconomic factors figuring into the decision (or option) to abort, and the positive potential impact of improved contraceptive use.

PIP: Political efforts are underway in the US to achieve a reversal of the 1973 Roe v Wade abortion decision, either through a constitutional amendment or a reversal of the decision by the Supreme Court itself. If access to abortion is to be curtailed, the range of safe, effective contraceptive methods must be increased and contraceptive care must be more integrated into primary health care. Since the 1973 decision, over 1,500,000 US women/year have undergone induced abortion. Of 20 comparable developed countries, the US has the 3rd highest abortion rate (3 abortions/100 women/year), Those who seek abortion are likely to be young, poor, unmarried, black, or Hispanic. The abortion rate among Medicaid recipients is 3 times that of the rest of the population. Most abortions are performed due to a lack of financial resources or existing responsibilities. If the Supreme Court were to impose strict limitations on abortion, poor women would be most affected. Middle- and upper-class women would have the option of traveling to Canada or other countries where abortion is freely available. The US's high abortion rate reflects low contraceptive use. This, in turn, is a result of inadequacies in the US health care system. Fewer birth control methods are available in comparison with other countries, information about contraceptives is not widely disseminated, family planning services are expensive and inconveniently located, and contraceptive care must be obtained from a specialist who is not the woman's regular health care provider.

The politics of birth control.

By the time Senate subcommittee hearings on the "population crisis" ended in 1968, a sizeable consensus had begun to emerge favoring government support of voluntary family planning programs at home and abroad. The goal to develop a national family planning program was easier to set than to accomplish, however, and there have been no lack of difficult questions to haggle over in the past 20 years. Beginning with the Johnson administration, the executive branch of government has tended to favor block-grant funding of family planning services, while Congress has insisted on categorical funding. Conflict has also existed over financial eligibility for government-supported services, over whether teenagers and unmarried women should be served in publicly supported clinics and over which services should be included in the definition of family planning. The Reagan administration has exacerbated the conflicts with attempts to redefine family planning by placing primary emphasis on natural methods and abstinence for those who wish to prevent pregnancy and attempts to deny funding to both domestic and foreign programs that support access to abortion. While future government support for family planning programs does not seem seriously threatened, funding has not grown in 15 years, once the effects of inflation are taken into account, and most programs have had to limit eligibility to survive. The Bush administration is unlikely to be as confrontational as the Reagan administration on the subject of family planning, but the political reality is that conflict can be expected to continue.

Teenage pregnancy in developed countries: determinants and policy implications.

PIP: Because of the high adolescent fertility rates in the US, the Alan Guttmacher Institute (AGI) conducted a 1985 study of adolescent pregnancy and childbearing in 37 developed countries. This was an effort to unveil those factors responsible for determining teenage reproductive behavior. This article presents the data from that study. Birthrates were collected and separated into 2 age groups: for those under 18 and those women 18 to 19 years of age. A 42 variable questionnaire was sent to the public affairs officer of the American embassy and family planning organization in each foreign country to provide additional socioeconomic, behavioral, and educational data. Childbearing was found to be positively correlated with agricultural work, denoting a socioeconomic influence. Adolescent birthrates showed a positive correlation with levels of maternity leaves and benefits offered in the country. The lowest birthrates were found in those countries with the most liberal attitudes toward sex as demonstrated through media representation of female nudity, extent of nudity on public beaches, sales of sexually explicit literature, and media advertising of condoms. A negative correlation was seen for equitable distribution of income and the under 18 birthrate. The older teenage birthrate was found to be lower for countries with higher minimum ages for marriage. They also suggested a responsiveness to government efforts to increase fertility. Some general patterns emerged to explain the high teenage birthrate for the US: it is less open about sexual matters than countries with lower adolescent birthrates and the income in the US is distributed to families of low economic status. A more subtle factor is that although contraception is available, it is not that accessible to young men and women because of the cost. Case studies were presented to provide a more detailed understanding of the reasons for the high adolescent birthrates. Examined are desire for pregnancy, exposure to risk of pregnancy, contraceptive use, access to contraceptive and abortion services, and sex education.^ieng

Politics and abortion.

The legalization of abortion in the United States by the Supreme Court in 1973 bypassed the political process in the majority of the states. Since then, however, political controversy and agitation in relation to abortion has become nationwide. From largely Catholic-based opposition, it has grown to encompass religious fundamentalists and to be a major part of the New Right's agenda. Abortion is now, pro and con, part of the platform of both political parties. The sweeping nature of the Supreme Court's decisions leaves the opposition with very little room to restrict abortion, short of overturning the decisions through a constitutional amendment. Such an amendment requires a two-thirds majority of Congress and passage is unlikely. However, funding bans on scores of federal programmes have succeeded in restricting access to abortion for the poor, the young and minorities. These restrictions are part of a long-term strategy to educate the public as to the evils of abortion with the aim of making it illegal again, either through the adoption of a constitutional amendment or by obtaining a reversal by a hoped-for change in membership of the Supreme Court.

Title X and its critics.

PIP: On Arpil 5, 1984 Senator Jesse Helms (R.--NC) was the leadd witness at a hearing before the US Senate Labor and Human Resources Subcommittee on Family and Human Services. The subcommittee was considering the renewal of Title X of the Public Health Service Act, the main national family planning legislation. Helm's prepared text (given in this article) was noteworthy not only for its hyperbole but also for its tone of intense frustration and for its repetition of the main themes enunciated by those less well known and less powerful who have opposed the program since it began. Title X was 1st enacted in 1970 and was reenacted in 1973, 1975, 1977, 1978 and 1981. The program has always had its share of critics; but in the late 1970's with the emergence of the New Right, such groups moved into political power. Title X provided for project grants to be made to public and private nonprofit agencies to provide contraceptive services along with training, technical assistance and other support activities. It also spelled out government responsibilities and functions in relation to human reproduction and population research; and it created the post of Deputy Assistant Secretary for Population Affairs, with direct responsibility for both types of activities within the Department of Health and Human Services. Eligibility for services was broad--applying to all who need and want services, with priority for low-income persons. A requirement of voluntary participation and a prohibition of the use of Title X funds for abortion as a family planning method were clearly stated. Title X has been criticized by Catholics and many other groups. This article attempts to meet criticisms aimed at the functioning, appropriateness and impact of the Title X program, and summarizes the findings of a large body of socialogical and demographic research that has direct or indirect bearing on the issues raised by the critics.^ieng

Some organizational alternatives to increase support for reproductive and contraceptive research.

PIP: Contraceptive development has not been more rapid in the US because worldwide support for reproductive and contraceptive research has diminished. At present, the major source of funding is the US government. Apart from small funds to applied research from the US Agency for International Development (USAID) most funding has been from the National Institute for Child Health and Human Development (NICHD), 1 of the 11 National Institutes of Health (NIH). NIH is the world's premier health research institution. However, the relative priorities set by NIH have often been contested. Recently, there have been numerous proposals by congress to change the organization of NIH. These proposals are aimed at changing NIH's priorities--its overall orientation toward health research, its research on specific subjects and its actual research products. These issues are not new. It is very difficult to make changes in NIH's priorities without changing its organizational structure. In 1968, NIH established the Center for Population Research (CPR) within NICHD. CPR is the world's largest single source of support for reproductive research and contraceptive development. Assessments of its research funding have been made. Organizational alternatives are: 1) earmark funding for contraceptive research; 2) set aside funds for contracts; 3) establish a separate population institute; 4) establish 2 new institutes with a special coordinating mechanism; and 5) create a research center outside NIH. None of these alternatives are likely to be adopted without the active support of the research community and of a substantial segment of the general public. The low budget for contraceptive research does not reflect the importance of such research for the health and well-being of Americans or for the world's population.^ieng

Blocking family planning.

PIP: Reviews the history and development of the national family planning program and the means by which it has been funded, and the current administration's proposals with regard to issues affecting family planning. The issue of block grants to states versus categorical federal funding is of special concern. The author concludes that the existing program should not be buried in block grants to states because experience indicates that this funding mechanism will not generate a nationwide program of services. The categorical approach has succeeded in creating and maintaining a flexible and cost effective program accountable to Congress, the executive branch, and the public. Funds provided in this way are responsible for nearly 1/2 of public support for the family planning clinic program, which was estimated to have averted 5.4 million unintended pregnancies during the 1970s. Block grants would mean severe diminution of this support, and would destroy the accountability and visibility which have guaranteed the program's effectiveness. Additionally, the Center for Population Research, which is responsible for funding most of the world's investigations into new contraceptive methods and evaluation of existing methods, would be jeopardized.^ieng

The Hyde Amendment and the future.

PIP: The U.S. Supreme Court has affirmed the constitutionality of the Hyde Amendment prohibiting federal funding for virtually all abortions for indigent women eligible for medical assistance. The Hyde Amendment represents a compromise on the politically sensitive issue of legality of all abortions. Despite the political controversy, however, real gains have been made since the Court decision legalizing abortion in 1973, in providing abortions services and lowering their costs. With the cutoff of Federal funds, however, most states will probably not support abortion services, thus rendering the poor and young especially vulnerable to the consequences of unwanted pregnancies. Barring the restoration of public funding, and noting that the cost of replacing it with private philanthropy is too high to be realistic, the author suggests some ways in which the cost of abortion services could be held down. Among these are setting up low cost clinic services in areas where no such services exist, thus alleviating substantial travel expenses for poor rural women; advertising the availability of such services and making other efforts to assure earlier, safer, less expensive procedures; encouraging clinics and hospitals to bill Medicaid for medical services related to (but not involved in) the abortion procedure; instituting outpatient abortion services in hospitals; and establishing satellite and mobile services by larger facilities to serve outlying areas.^ieng

Abortion funding restrictions on FY 80 DC budget limited to federal portion.

PIP: The House of Representatives retreated from its rigid antiabortion stance on the fiscal year 1980 District of Columbia appropriations bill and October 16th accepted an amendment that limits the bill's federal funds for abortions but does not impose any prohibition upon city-raised revenues. The Senate went along with the House "compromise" which limits use of the federal portion of the District's budget (about 15%) to abortion funding only in instances of life endangerment, rape or incest. Resolution of the abortion dispute enabled passage of the city's $1.4 billion budget. Until now, the District of Columbia paid for all medically necessary abortions for poor women. The funds used were locally raised revenue and that part of the city budget which came in the form of a federal payment. The new amendment, in effect, places the District in a situation similar to the 50 states -- the city may opt to fund abortions with state revenues in cases where the federal government refuses to pay. It is likely that the District will continue its liberal funding policy, but it is now required to institute a new accounting system to ensure that only city-raised revenues are being used for expenses relating to abortion.^ieng

Is support of abortion political suicide?

PIP: A systematic review of national and local press coverage of congressional races makes possible a general appraisal of the significance of the abortion issue in the 1974 general election; analysis of polls conducted by congresspersons offers further clues to voter sentiment regarding this issue. Congressional initiatives in regard to abortion following the 1973 Supreme Court decision fell into 3 major categories: 1) introduction of proposals for constitutional amendments to reverse the Supreme Court decision; 2) efforts to exempt both individuals and institutions from having to perform or to allow the performance of abortion; 3) attempts to prohibit or restrict the use of federal funds for abortion in domestic or foreign programs. Many districts are so "safe" that the incumbent is virtually assured of election without campaigning, so a more reliable test of the importance of the abortion issue is to examine what happened to those incumbents whose hold over their districts was generally acknowledged to be insecure or who faced especially strong challengers. The voting records and election outcomes of 119 incumbents were scrutinized. Incumbents from unsafe districts fared considerably more poorly than those from safe areas in the 1974 elections. 1% of the safe incumbents lost compared to 31% of those whose races were considered close. Antiabortion candidates from unsafe districts had a much higher casualty rate (39%) than proabortion candidates (8%); while those with mixed records fared about the same as congresspersons from unsafe districts generally. Among Republicans running in close races, 42% of the antiabortion incumbents were defeated, about the same porportion of casualties as among Republicans in unsafe districts generally. Among Democrats, all of the 12 proabortion incumbents from unsafe districts were reelected, while 2 of the 8 who voted consistently in opposition were defeated. When party affiliation is controlled and attention is on those districts where a single issue might conceivably have made the difference between victory and defeat, the losses among antiabortion incumbents were heavier than those losses among those who voted in favor of legal abortion. The data show conclusively that support of legal abortion does not constitute political suicide.^ieng