The Separation of Abortion from Health Care

Though abortion is a safe and standardized health-care procedure, it has been rhetorically isolated from discussions on reforming the health-care industry and even from debates on Medicare for All. This historical erasure of abortion from health care mirrors the physical isolation of abortion clinics from hospitals and physicians’ offices.

It’s become standard practice for abortion care to be mainly provided in standalone clinics, with only an estimated 4 percent of all abortions in the United States currently performed in hospitals and 1 percent of all abortions performed in physicians’ offices. There were some good reasons for the independent clinic model in the years immediately following Roe, most notably the desire of feminists to provide a comfortable and affordable setting outside of the misogynist medical establishment, and the huge increase in demand, with hospitals not being incentivized to accommodate it. However, in our increasingly hostile political environment, having abortion care completely separated from the medical establishment has made clinics vulnerable to financial and physical attack and helped maintain the stigma around this routine procedure.

It was not inevitable that abortion would become isolated in independently operated clinics. Many abortion advocates in the 1960s and ’70s assumed that hospitals would continue to provide the vast majority of procedures, as they had for legal abortions before Roe, or that they would be split between hospitals, non-hospital clinics, and physicians in private practices. But abortion was effectively stigmatized within the medical establishment, a shortage of abortion providers meant there weren’t enough doctors to carry out the abortions, many legal obstacles were thrown up soon after 1973, and hospitals were not prepared for or willing to accommodate the vast increase in demand for abortion after Roe. So abortions moved to standalone clinics.

Though the legalization of abortion in 1973 was a legislative victory and the result of decades of agitation, the joy that activists felt after the Roe decision turned to disillusionment a few years later, as legalization resulted in neither the acceptance of abortion as an integral part of health care nor respect for its providers.

Before Roe, legal abortions were available almost exclusively in hospitals, where, in certain medical situations, a patient could petition a hospital’s therapeutic abortion committee to request an abortion. These committees, made up of doctors and administrators, only permitted abortions under a narrow set of medical circumstances, such as cases where the life and health of the mother was at risk.

By the late 1960s, these standards evolved to include things like mental health, and in hospitals with therapeutic abortion committees, the procedure was largely available to anyone with the means to access the hospital. In practice, these committees were a way for women with money and connections to access the procedure, while poor women were excluded from taking advantage of this loophole.

Howard Moody and Arlene Carmen, authors of the 1973 book Abortion Counseling and Social Change, said that “‘Therapeutic’ was only a term to describe the difference between rich and poor, white and black, the privileged and the underprivileged, married and single.”

The stigmatization of abortion, even after legalization, led some hospitals to officially limit the number of abortions they allowed, and many others to enact unnecessary restrictions as a means of keeping their abortion rates low, in order to avoid the perception that they were “abortion mills.” In 1978, 75 percent of hospitals required parental notification for any patient under the age of eighteen, 5 percent required parental consent for any unmarried women, 18 percent required patients to obtain spousal consent before an abortion, and a large number of hospitals had physician consultation requirements necessitating a patient meet with a physician a certain number of days before their procedure.

Along with that stigmatization came the move from hospitals to clinics. By 1974, only 30 percent of abortions were performed in hospitals, and only 2 percent were performed in private practices. Despite the fact that abortion was now legal, abortions were being pushed into physically separate clinics.

Barrier After Barrier

Legislative barriers also restricted hospital abortion access in the years immediately following Roe. The most effective were health-care refusal laws, which allowed health-care providers to refuse to provide services related to abortion care without facing legal, financial, or professional repercussions.

By the end of 1974, twenty-seven states had laws allowing hospitals to refuse to provide abortions, and many of these laws stipulated that physicians and hospitals were not obligated to even provide patients with referrals to another provider. This was reinforced with the 1996 omnibus appropriations bill, which prohibited the federal government from denying funding to hospitals that refused to provide abortions.

Lack of instruction from major medical organizations about hospital abortion provision also helped push abortion out of hospitals. According to a 1976 study, twenty-two of the thirty-six major medical organizations, including the Association of American Medical Colleges and the Joint Commission on Accreditation of Hospitals, had no guidelines or best practices for abortion care. This neglect meant that many medical professionals lacked adequate instructions for performing abortions, and thus abortion was not a procedure that could be performed safely in an office. With the absence of support from medical organizations, many hospital administrators reduced or eliminated their abortion services.

Among OB-GYN clinicians in private practice, there was also a fear of tainting their reputations and being seen as an “abortionist,” with all of the negative connotations of participating in the unsanitary, illegal, and immoral practice of back-alley providers before legalization.

And doctors faced significant logistical barriers to incorporating abortion care into their private practices. A single physician or even a small group practice believed they would be unable to keep up with the demand for abortion while continuing to provide other aspects of OB-GYN care, partly because there were so few trained abortion providers and partly because of conflicting guidelines and insufficient support from medical associations for standardizing abortion care.

Many obstetricians had little to no experience performing abortions, and most were not involved in the fight to repeal abortion laws. Dr Leon Zussman, a Manhattan gynecologist and obstetrician, was quoted in a New York Times article published a few days before abortion was legalized in New York in 1970, saying, “We’ve all been frustrated all these years by having to refuse so many, so no one will say no now. But I would not want to be known as an abortionist. Maybe the next generation wouldn’t consider that a stigma, but with me it will persist until I die.”

Practioners and abortion advocates in New York State disagreed about the best way to accommodate what they assumed would be the flood of demand, and the implementation of legal abortion care was watched closely as a model by other states who expected to repeal abortion laws in the years to come.

Many doctors and activists argued that if abortion were to be made accessible to poor women, the procedure would have to be available in places where costs could be kept low, so they pushed for abortion to be available in doctors’ offices and clinics. Lawrence Lader, chairman of the executive committee of the National Association for the Repeal of Abortion Laws said about the new law legalizing abortion in New York, “What do you pass a law for if a few medical‐hierarchy bigwigs are going to make it 50 or 60 percent ineffective?”

The less popular position was taken by Dr Robert Hall, a New York City physician and passionate supporter of reforming abortion laws who argued for a ban on abortions outside of hospitals. He foresaw that the clinic model of service would make it easy for organized medicine to abdicate its responsibility to provide abortions as part of routine gynecological care and predicted that it would marginalize the procedure.

Non-hospital clinics overall did not have the same restrictions that hospitals put in place to limit the number of abortions provided and also offered other “supportive services” such as contraceptive counseling and birth control, testing and treatment for sexually transmitted infections, and general sex education. The costs for patients were also much lower at freestanding clinics. Early clinics were often formed through collaboration between medical professionals, second-wave feminist activists, and progressive religious leaders who were more concerned with making the procedure as accessible as possible than they were with making a profit; prices were often kept artificially low. By the end of the 1970s, an abortion in a hospital was more than twice as expensive as one performed in a clinic.

But in the current environment of open hostility, it’s become clear that providing abortions at specialized standalone clinics that operate outside of the medical establishment is a losing strategy. Those clinics will remain vulnerable to both funding attacks and physical attacks, and abortion care will continue to be marginalized and de-prioritized. One way to ensure long-term protection for and equal access to abortion is by demanding that it be treated as health care and integrating it into primary or gynecological care under a national health-care system.

The Case for a Nationalized Health-Care System

Medicare for All would be a hugely beneficial step for abortion access, providing full reproductive health care and effectively nullifying the Hyde Amendment, which bans federal funding for abortion. Under Title VII of Bernie Sanders’s “Medicare for All” bill in 2017, “any other provision of law in effect on the date of enactment of this Act restricting the use of Federal funds for any reproductive health service shall not apply to monies in the Trust Fund” — meaning that Hyde couldn’t apply to Medicare funds.

It also represents a chance for reproductive rights activists and providers to incorporate abortion care into the medical establishment, so that the procedure would be less vulnerable to legislative and financial attacks in the long term.

Though both Bernie Sanders’s 2017 Medicare for All bill and Rep. Pramila Jayapal’s Medicare for All Act of 2019 would make all health care, including abortion care, free at the point of access through a single-payer system, M4A would keep private for-profit hospital systems intact and would not necessarily make abortion more accessible for people living in rural areas, many of whom are served by Catholic hospitals. One in six hospital patients in the United States is now treated in a Catholic facility, which are legally able to refuse to provide abortion services through “consciousness clauses.” The number of Catholic-owned or affiliated hospitals in the United States has grown by 22 percent since 2001, and in some states, Catholic hospitals make up more than 30 percent of all hospitals, with most following religious rules that ban abortion, sterilization, in vitro fertilization, and all contraception except for natural family planning.

A patchwork of federal laws, as well as many state laws, currently prevent “discrimination” against individuals and institutions that refuse to provide abortion or sterilization. In many states, these laws apply not only to private institutions but also to public ones. Only thirteen of the forty-four states that allow health-care institutions to refuse to provide abortion services limit the exemption to private or religious health-care institutions.

Under a national health-care system, even with government-funded and operated hospitals, we would need to fight to ensure that all providers include abortion care. This will be much easier to demand once abortion services are more widely available, fully integrated into the medical establishment, and funded through a single-payer health-care system.

The benefits of a single-payer system are significant, though it’s also important that the Left doesn’t delude itself into thinking that Medicare for All will solve all reproductive rights issues. In 2010, the Affordable Care Act (ACA) was signed into law and extended the Hyde Amendment’s restrictions on abortion coverage to states’ newly created health insurance exchanges. The ACA allows states to prohibit abortion coverage entirely in health insurance plans offered through an exchange. Since the law was implemented, twenty-six states have barred health plans participating in the exchange from covering abortion.

As of 2016, six in ten women in the United States do not have the option of selecting a plan with abortion coverage through their exchange, and 1.2 million women do not have access to affordable coverage for abortion care, either through Medicaid or subsidies from their state’s health insurance exchange.

Reproductive Rights Activists Have an Important Role to Play

Central to our demands should be the integration of abortion care into the medical establishment and the repeal of all state abortion restrictions. These are connected struggles for activists, as the long isolation and stigmatization of abortion within the medical establishment has made the procedure an easy target for restrictions like “heartbeat bans,” waiting periods, and mandated counseling.

That isolation has also made clinics easy targets for medically unnecessary Targeted Regulation of Abortion Providers (TRAP) laws, which require that abortion providers adhere to arbitrary rules regarding things like clinic corridor width and size of procedure rooms. In eighteen states, TRAP laws even apply to facilities where only medication abortion, also known as the abortion pill, is offered. The Supreme Court will soon review a restrictive abortion law from Louisiana that would require any doctor performing abortions in clinics to have admitting privileges at nearby hospitals — a law that is nearly identical to the Texas law struck down in Whole Woman’s Health v. Hellerstedt in 2016.

With the rise in the use of medication abortion, it should be easier than at any other point in modern history to integrate early abortion care into private practice and hospital settings. Medication abortion, an extremely safe, non-surgical procedure involving two oral medications provided at up to ten weeks’ gestation, accounted for 39 percent of all abortions in 2017, up from 29 percent in 2014. But there are barriers to integrating medication abortion into primary care.

One is that in many parts of the country, especially in rural areas, primary care is largely provided by advanced practice clinicians (APCs) like nurse practitioners, nurse midwives, and physician assistants. Meanwhile, thirty-four states mandate that only physicians can provide abortions, even medication abortions, despite evidence that APCs can safely perform first-trimester abortions. Maine recently passed a bill that allows nurse practitioners, physician assistants, and certified nurse-midwives to provide abortion medication and perform in-clinic abortions, joining other Democrat-led states that are moving to protect and expand abortion access.

Another significant barrier is the fact that mifepristone, one of the two drugs used in medication abortion, is regulated under the FDA’s Risk Evaluation and Mitigation Strategy (REMS). These regulations mean that prescriptions for mifepristone cannot be filled in a regular pharmacy. Providers must go through a special registration process and stock the drug in their clinic, requiring additional administrative costs and potentially making those providers targets for anti-abortion protestors. Experts have long called for mifepristone to be removed from REMS, and the American Civil Liberties Union is currently challenging the restrictions in a case in Hawaii.

Medicare for All would be a huge victory for reproductive rights activists, eliminating many of the economic barriers to abortion and effectively nullifying the Hyde Amendment. And we won’t stop there. For a truly equitable health-care system that serves every patient’s reproductive health-care needs, we must demand a well-funded national health service, the repeal of all state abortion restrictions, and the dissolution of for-profit hospitals that create a tiered system of health-care access and exploit religious freedom laws to refuse to provide essential care.

It’s going to take a powerful and organized reproductive justice movement to ensure that abortion care is included in whatever version of Medicare for All is seriously considered by lawmakers. The demand that abortion be treated like the safe and common health-care procedure it is needs to be backed up by a fighting movement to integrate abortion care into the medical establishment, and to improve that medical establishment through a nationalized health-care system. These are big dreams, but they don’t have a chance of becoming a reality until we mobilize a strong grassroots coalition of reproductive justice and health justice activists behind them.