Republicans in Congress are taking the first of three steps necessary to repeal the Affordable Care Act: The Senate passed the budget resolution to start that process at 1 am on Thursday, and the House is expected to do the same on Friday.
And as they work to repeal the ACA, Speaker of the House Paul Ryan promised last week that Republicans in Congress also plan to defund Planned Parenthood.
The GOP has been trying for years to do both of these things, and now they have the chance to make both happen in one fell swoop — through a process that Democrats will be powerless to stop on their own.
The House Energy and Commerce Committee is working out the details of the Planned Parenthood defunding bill, Ryan’s office told Vox, and the committee hasn’t released those details yet. One possible model could be a bill that passed the House last year, which prohibits Planned Parenthood from receiving federal funds for one year, unless its affiliates and clinics stop performing abortions.
There are a few variations on how such a bill could work, or which particular funding streams it would target. But any bill that takes away all or part of Planned Parenthood’s federal funding would be devastating to women’s health and would gut the nation’s family planning safety net.
In some respects, the move is puzzling. Most Americans, including nearly half of Trump voters, oppose defunding Planned Parenthood, the nation’s largest family planning provider. One in five US women have visited a Planned Parenthood clinic for services like birth control, cancer screenings, STD tests, or pregnancy termination.
Perhaps even more to the point, defunding Planned Parenthood could backfire on Republicans politically. Republicans have threatened a government shutdown over Planned Parenthood funding before, in 2011 and 2015, but they were ultimately forced to back down — mostly because Democrats in the Senate and President Obama were a firewall.
But even now, with Republicans controlling both houses of Congress and the presidency, it could be a bad move. Republicans need at least 50 of their 52 senators to pass the ACA repeal through the budget reconciliation process — and two pro-choice Republican senators, Lisa Murkowski of Alaska and Susan Collins of Maine, won’t commit to voting for the ACA repeal if Planned Parenthood defunding is attached. Just one more Republican defector on top of that (Rand Paul is a likely choice) could make the whole thing a nonstarter.
So why target Planned Parenthood at all? In a broader context, the answer is simple: Planned Parenthood has become a proxy battle for a much bigger, decades-long war over legal abortion. And as a result of that war, other family planning services like birth control and cancer screenings are becoming collateral damage.
Attacking Planned Parenthood is part of a decades-long strategy to make an end run around Roe v. Wade and stop legal abortions
Planned Parenthood has always been a magnet for socially conservative controversy. It was founded by Margaret Sanger in 1916 as a network of contraception clinics, and didn’t offer abortion for many decades. But just offering diaphragms was a radical act in the early 20th century, when contraception was illegal and women were expected to bear as many children as their bodies could endure. Planned Parenthood wasn’t popular with people who favored traditional gender roles a century ago, and that’s still the case today.
But ever since the Supreme Court’s 1973 Roe v. Wade decision established legal abortion, Planned Parenthood has become a new symbolic target for social conservatives. It’s the nation’s largest and most visible abortion provider, and performs nearly half of legal abortions in the US.
Republicans have been trying to defund Planned Parenthood at the state level since the late 1970s — but “defunding” was also a bigger anti-abortion strategy that went much further than Planned Parenthood.
Although Roe v. Wade enraged and energized the pro-life movement, activists knew it might take a while to actually overturn Roe. So they organized, allied with the Republican Party, and came up with ways to at least make it harder for women to get a legal abortion if they couldn’t ban it outright.
One such strategy was to “get the government out of the abortion business,” or forbid public funding for abortions through programs like Medicaid. It was framed as a moral argument: that the US government shouldn’t endorse abortion by giving any funding support to women who have one, or that taxpayers shouldn’t have to fund something they considered immoral.
The 1976 Hyde Amendment was this “abortion business” strategy’s biggest success, and to this day it still bans the use of federal funds for abortion care except in rare circumstances (in cases of rape or incest, or if a woman’s life is in danger — but only her life, not anything else about her physical health).
What Hyde did in practice, however, was make abortion less affordable so that fewer women could get it. The Hyde Amendment’s Republican author, Henry Hyde of Illinois, essentially admitted that his measure only targeted poor women: “I certainly would like to prevent, if I could legally, anybody having an abortion, a rich woman, a middle-class woman, or a poor woman,” he said during debate over his proposal. “Unfortunately, the only vehicle available is the … Medicaid bill.”
Eventually, some abortion foes realized they could take funding bans even further. They could pass “indirect” abortion funding bans — not just refusing to fund abortion services directly, but refusing to fund any other services at an organization that also provides abortion.
Bans like these could be used as political leverage to force health providers like Planned Parenthood to make a choice: Continue to provide abortions, or risk going out of business.
Funding bans aren’t the only strategy Republicans and social conservatives have used to try to limit abortion without banning it outright. Since Roe v. Wade, states have enacted 1,142 laws limiting abortion through a variety of means. Some of these laws used targeted regulations, like making abortion clinics meet the building standards of mini hospitals, to force clinics to close for no medical reason.
However, a recent Supreme Court case, the biggest victory in decades for pro-choice activists, is already making it much harder to regulate abortion out of existence through brute force like this. So the pro-life movement is looking for new tactics to get around Roe v. Wade and limit abortion.
But their best tactic is still their oldest: the “abortion business” strategy. Defunding Planned Parenthood and banning insurance coverage for abortion — not to mention the Hyde Amendment — are still very powerful tools to starve abortion providers of the funds they need to stay open, and to make abortion unaffordable for the women who need it.
What does it actually mean to “defund Planned Parenthood” at the federal level?
The more than $500 million Planned Parenthood receives annually from the federal government — the funding that Republicans in Congress now want to take away — pays for specific health services, like birth control or cervical cancer screening, for people who couldn’t afford them otherwise.
Most of the funds (75 percent) are actually reimbursements from Medicaid, the US’s public health insurance program for the poor. Just like with any other insurance, Medicaid patients go to their health care appointment first and then have Medicaid pay all or most of the bill later.
The rest of Planned Parenthood’s federal funds come in the form of grants from Title X, the nation’s only federal program for family planning. Title X grants are awarded on a competitive basis to clinics that meet the program’s standards for family planning coverage and services. Title X subsidizes free or low-cost contraception and other preventive services, and it’s especially helpful for low-income or uninsured people who make too much to qualify for Medicaid.
However, Republican lawmakers often argue that if the federal government funds Planned Parenthood through these programs, it’s still effectively funding abortion — which violates the spirit of the Hyde Amendment.
They say this government funding helps Planned Parenthood “keep the lights on” in the very facilities that also perform abortions. They say “money is fungible” — that if you fund Planned Parenthood’s other services, like birth control and STD tests, it “frees up” the organization to use its other fundraising to pay for abortion.
This argument makes some sense, but it also has dangerous implications. If you accept this premise, there’s almost no limit to what we could consider “government funding” or “government support.” Would a federal employee, whose salary is paid by the government, be violating the Hyde Amendment if she spends some of that money to obtain an abortion? Would she be using “government funds” to “keep the lights on” at Planned Parenthood if she donates to the organization?
And what about other government programs that have funding restrictions? Should we ban Safeway from accepting food stamps as long as it sells wine — because food stamps aren’t allowed to pay for wine, but accepting food stamps gives Safeway extra revenue and helps it “keep the lights on” to sell wine to other customers?
It’s true that if the government stopped paying for Planned Parenthood to accept Medicaid patients or Title X grants, it would be a huge financial blow to the organization.
Federal funding makes up about 40 percent of Planned Parenthood’s budget. Most of its patients are low-income and rely on Medicaid coverage or Title X subsidies for health care. In 2015, a whopping 78 percent of Planned Parenthood’s patients had incomes of 150 percent or less of the federal poverty level. Losing even a significant fraction of these low-income patients would be devastating to Planned Parenthood; it would probably have to close clinics or reduce capacity, which would affect all of its patients, regardless of income.
But Planned Parenthood wouldn’t stop performing abortions. It just wouldn’t. No matter how you count it (abortion makes up 3 percent of Planned Parenthood’s services provided, but probably a higher percentage of its revenue), abortion is nowhere close to the majority of Planned Parenthood’s business.
So giving up abortion services wouldn’t solve the organization’s financial woes if it’s defunded — and more importantly, it would go against everything Planned Parenthood stands for. Offering women the full spectrum of reproductive health care, including pregnancy termination, is just too central to its mission.
Now, if Republicans use the budget reconciliation process to defund Planned Parenthood as opposed to a standalone bill passed through regular means, there are limits to what they can do. They could only take away Medicaid funds, not Title X. And they may only be able to do it for one year.
But again, Medicaid makes up the vast majority of Planned Parenthood’s federal funding. Plus, a “one-year” budget appropriation can and will be renewed as many times as Congress wants, and once it’s established it can be hard to get rid of. The Hyde Amendment, after all, was a “one-year appropriation” when it was passed in 1976 — and it has been habitually renewed every year since then, for 40 years and counting.
After that, there’s nothing stopping Republicans (other than political pressure) from going after Planned Parenthood’s Title X funding too. For that matter, there’s nothing stopping them from going after the entire Title X program — Title X is chronically underfunded as it is, but House Republicans have still called for its total elimination in every budget they’ve proposed over the past seven years.
There’s a cruel irony in this last part. Many Republicans don’t want to be seen as actively hostile to women’s health, and often claim that women could just “go somewhere else” for reproductive health care if their local Planned Parenthood shut down due to defunding. Sometimes they give women ridiculous lists of those “somewhere elses” that include false positives like dentist’s offices and school nurses.
But usually, the “somewhere else” Republicans praise the most is our nation’s vast network of thousands of federally qualified health centers and other publicly funded health care providers — most of which are funded by Title X, the program Republicans keep trying to eliminate.
Ryan defends defunding Planned Parenthood as part of Obamacare repeal, says he'd rather direct that $$ to community health centers.— Sahil Kapur (@sahilkapur) January 12, 2017
Some Republicans want to kill Title X for the same reasons that they cite for going after Planned Parenthood: the idea that the money is fungible and can still pay for abortion. Others are simply hostile to the very idea of publicly subsidized contraception.
Either way, all of this is a shocking reminder of just how much the Republican Party has changed over the past few decades on these issues. Title X was originally sponsored by then-Rep. George H.W. Bush, and signed into law by President Richard Nixon — who declared in 1969 that "no American woman should be denied access to family planning assistance because of her economic condition."
Planned Parenthood plays a pivotal role in our health care system. Defunding it would have massive consequences.
There’s a bigger problem with Republican claims that women could just “go somewhere else” if Planned Parenthood were defunded: It’s not true.
Some women, especially higher-income women who can afford to travel or spend more on birth control, can probably find another place to go. But they might not want to. And many women simply have no other options — or the options they do have wouldn’t give them the same quality of care they can expect at Planned Parenthood.
Planned Parenthood says it operates about 650 clinics that serve 2.5 million patients every year nationwide, and about 80 percent of its patients receive services to prevent unintended pregnancy. It also offers education and outreach on sexual health to millions.
Planned Parenthood clinics are “safety net” health centers, which means they use public funds, including Medicaid, to provide free or reduced-fee services to at least some clients.
Planned Parenthood plays a hugely disproportionate role in serving women who need affordable birth control, and who tend to turn to these safety net clinics to get it.
In 2010, there were 8,409 safety net health centers in the US that provided subsidized family planning services, like contraception. Planned Parenthood clinics made up 10 percent of those health centers — but they served 36 percent of the women who got contraceptive care from safety net centers.
Planned Parenthood operates many of its clinics in areas where health care access is scarce. About one in six US counties have a Planned Parenthood clinic. In 332 of those counties, Planned Parenthood serves at least half of safety net family planning clients. In 103 counties, Planned Parenthood is the only safety net center that offers family planning services.
Planned Parenthood has a robust network of providers. And it specializes in reproductive health care services — which isn’t the case for all clinics that offer contraception.
Many safety net clinics are primary care centers that also offer birth control. And primary care clinics are simply less well-equipped than clinics focused on reproductive health care to offer women the full range of contraceptive options. That’s especially true when it comes to the methods of birth control, like IUDs and implants, that are most effective at preventing pregnancy, and that can reduce abortion rates dramatically when they are used.
All of this is why, as Vox’s Sarah Kliff has explained, there’s just no way for other clinics to pick up the slack if Planned Parenthood goes away, at least not without years of deliberate capacity building. And we’ve learned that when states defund Planned Parenthood, that usually doesn’t happen. Women just get less health care.
“Unfortunately, many communities do not have a glut of general reproductive health care providers just waiting around to serve patients,” said Kelly Baden, interim senior director of US policy and advocacy at the Center for Reproductive Rights. “And so it's not simple to just suddenly tell somebody they'd have to go somewhere else.”
How would defunding Planned Parenthood actually affect people’s lives?
In practice, defunding Planned Parenthood takes funding away from its mostly low-income patients — who might be forced to seek care elsewhere if the government stopped subsidizing their visits to Planned Parenthood. Low-income women will be hit especially hard, but all Planned Parenthood patients may be affected.
Reproductive health care is an incredibly basic, essential need, especially for women. Pregnancy is both a major medical event and a major financial one, and the decision of whether and when to give birth or become a parent is one of the most foundational, life-altering choices a person can make. Sexually transmitted diseases threaten lives and fertility if left undetected or untreated. Birth control can literally affect women’s lives every day, from helping them fully participate in public life by avoiding unwanted pregnancy to alleviating the horrifying symptoms of endometriosis or premenstrual dysphoric disorder (PMDD).
And to put it bluntly, having a vagina can be really expensive.
Do you know how much it costs as a woman just to test for a UTI if you don't go to PP? With insurance? Roughly $180.— Liz (@LizWelle) January 6, 2017
For people who have no income to spare, Medicaid and Title X are the only ways they can afford these very basic health care services. And Planned Parenthood is usually the best place — or even the only place — they can get those services. That’s why, according to the Congressional Budget Office, federal defunding would mean cutting off basic health care options for hundreds of thousands of women.
Together, Medicaid and Title X combine to form our nation’s family planning safety net. Unfortunately, that safety net isn’t well-funded enough to actually meet the country’s needs for subsidized contraception — about 20 million women were in need of publicly funded contraceptive services in 2014, and only 7.8 million (39 percent) got them.
But those publicly funded services still helped prevent 1.9 million unintended pregnancies in 2014, according to the Guttmacher Institute. And the rates of unplanned birth and abortion would have each been 68 percent higher otherwise.
We’ve seen a preview of how that progress could be reversed nationwide, after looking at some of the 12 states that already restrict family planning funds for abortion providers.
Texas is a particularly sobering example. After the state kicked Planned Parenthood out of its Women’s Health Program in 2013, other providers didn’t step up to fill in the gaps — women just got less health care. In areas that had been served by Planned Parenthood before defunding, prescriptions for the most effective forms of birth control plummeted by a third, and women on Medicaid had 27 percent more births than normal.
So why Planned Parenthood specifically?
When you ask Republicans why they’re so determined to keep Planned Parenthood from getting any more public funding, these days they might tell you it’s about the undercover videos released in 2015 by an anti-abortion front group called the Center for Medical Progress (CMP). They might tell you that the videos prove Planned Parenthood was “selling baby parts for profit,” or that it’s a “national criminal enterprise.”
But this also isn’t the first time a series of later-discredited propaganda videos have sparked a moral panic about Planned Parenthood on Capitol Hill. We saw the same pattern in 2011 — when false claims that Planned Parenthood was complicit in sex trafficking (along with political tensions over abortion coverage in the Affordable Care Act) gave so much political fuel to then-Rep. Mike Pence’s annual quest to defund Planned Parenthood that it threatened a government shutdown.
In fact, various anti-abortion activists (including CMP’s David Daleiden) have mounted nine sting operations against Planned Parenthood in the past 15 years. Not one has produced evidence of widespread wrongdoing, and all have been discredited. Yet still, every time, Republicans in Congress jump at the chance to open an investigation or threaten a shutdown in the aftermath.
Congressional Republicans, it seems, are making a calculated gamble: They are hoping the misleading smear campaigns Planned Parenthood has faced over the years have been effective enough that they can eliminate access to reproductive health services for millions of lower-income people without paying a political price.
Today, Planned Parenthood is the nation’s largest, most visible, most well-branded reproductive health care provider — and that alone makes it an obvious target for pro-life activists who believe that every abortion is an unconscionable murder.
But anti-abortion activists have one big problem. Most Americans have a more nuanced view of abortion, and support a range of women’s reproductive choices even if they personally think abortion is wrong. Seven in 10 Americans don’t want Roe v. Wade to be overturned, and the best available data suggests that 25 to 30 percent of women will have an abortion before age 45.
It’s tough for abortion opponents to convince these people to share their outrage that abortion is legal. And it’s politically awkward to admit that defunding Planned Parenthood is mostly about banning abortion.
For some anti-abortion activists, the solution has been turning Planned Parenthood into a symbol of everything they hate about abortion. They level accusations that they hope will shock people who support abortion rights in the same way that they themselves are shocked by legal abortion. They allege that Planned Parenthood routinely kills born-alive infants and callously butchers pregnant women; that it performs illegal “partial-birth abortions”; that it condones child sex trafficking or encourages statutory rape; or that it makes illegal profits from “selling baby parts.”
None of these allegations are remotely true, as every credible investigation has found. But prominent Republican lawmakers repeat these claims, even during investigative committee hearings — and you’d think that if they really believed these awful things were happening, they might call for much more serious consequences than taking away Planned Parenthood’s federal funding.
It’s very clear that abortion is the real enemy. After all, funding attacks on family planning providers who offer abortions aren’t always specifically directed at Planned Parenthood. Many states bar “abortion providers” or “private family planning clinics” from receiving state family planning funds, not just Planned Parenthood.
Before Mike Pence made the war on Planned Parenthood go mainstream in 2011, he spent every year since 2007 trying and failing to pass a different bill: banning all abortion providers from receiving Title X funds, instead of banning Planned Parenthood specifically from receiving all public funds.
Still, even when the laws are worded more generically, the lawmakers often make it very clear who the real target is — because Planned Parenthood is the easiest, most obvious target to attack.
Anti-abortion Republicans act like abortion is so morally toxic that any money flowing anywhere near it becomes tainted. Title X’s family planning services are tainted by Planned Parenthood, because Planned Parenthood is tainted by its abortion care — never mind that this care isn’t paid for by tax dollars.
This obsession with financial “purity” means that contraception and other family planning services get thrown under the bus. Some Republicans may think that contraception itself is a moral evil; others may just think it’s acceptable collateral damage in the war on abortion. A few Republicans want no part in a messy funding fight. Still others may really believe their own unlikely story about how if Planned Parenthood went out of business, women could just go somewhere else for care.
But in today’s Republican Party, the moral imperative to stamp out public funding for Planned Parenthood has completely trumped the moral imperative to make sure low-income women, and men, can get comprehensive reproductive health care.