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The new Obamacare repeal bill is the worst yet for women’s health

The Graham-Cassidy bill has all the problems of its predecessors — and some new ones.

Supporters of Planned Parenthood at a rally in Los Angeles on June 21, 2017.
Supporters of Planned Parenthood at a rally in Los Angeles on June 21, 2017.
MARK RALSTON / Getty Images
Anna North is a senior correspondent for Vox, where she covers American family life, work, and education. Previously, she was an editor and writer at the New York Times. She is also the author of three novels, including the New York Times bestseller Outlawed.

Republicans’ latest effort to repeal Obamacare may look a little different from previous attempts — sponsors argue, for instance, that the plan lets states keep Obamacare if they want to. But when it comes to reproductive health care, the bill sponsored by Sens. Bill Cassidy (R-LA) and Lindsey Graham (R-SC) is a lot like previous repeal bills, except in areas where it’s much harsher.

Like previous bills, Graham-Cassidy imposes new restrictions that would make it harder for people to get insurance coverage for abortion, and for low-income patients to visit Planned Parenthood. Also like the other bills, it threatens Medicaid coverage and makes it easier for states to get rid of maternity care requirements.

A new element in this bill is that its program of block grants would create new ways for the federal government to restrict abortion coverage. Republican-led state legislatures have been working to curtail abortion access and pull funds away from Planned Parenthood for years now; Graham-Cassidy would accomplish both goals on a national scale.

Graham-Cassidy includes a lot of familiar abortion restrictions

The bill includes a provision, similar to those in previous repeal bills, that would effectively bar the use of federal Medicaid funds to pay for care at Planned Parenthood clinics. This would mean low-income patients who rely on Medicaid wouldn’t be able to get care at Planned Parenthood. Backers of such provisions have often claimed that community health centers would be able to fill in the gaps left by Planned Parenthood, but many reproductive health experts say this is unrealistic, since those centers would have to double or even triple the number of patients they saw for certain services. In order to replace Planned Parenthood’s contraceptive services, one of the many services they offer, health centers would have to see 2 million extra patients nationwide, according to the Guttmacher Institute.

What’s more, Planned Parenthood is a trusted and familiar provider for many patients, who may not necessarily know anything about their local community health center. As Dan Ramos, a state representative from Ohio, told the New York Times last year, “If someone doesn’t know where to turn, they know that Planned Parenthood provides a service that they might need.”

Like its forebears, Graham-Cassidy also includes restrictions on abortion coverage. Patients who got a tax credit to buy insurance on the individual market wouldn’t be able to use it to purchase insurance with abortion coverage, and small businesses that received a tax credit for providing insurance to their employees wouldn’t be able to offer plans covering abortion. Over time, this would mean fewer people would be able to buy individual plans that covered abortion, and so fewer insurers would offer them. Patients who can’t get insurance coverage for abortion are sometimes forced to forgo food or other necessities to pay for the procedure and may try to self-induce an abortion, which can be dangerous.

Graham-Cassidy would let states cut requirements that insurers cover essential health benefits, meaning insurance companies could stop offering maternal care or prescription drug benefits. Thirteen million women could lose access to maternal care.

Finally, the bill would end the Medicaid expansion, potentially depriving millions of low-income Americans of coverage. (The Congressional Budget Office announced on Monday that it would release a “preliminary” analysis of the bill early next week, but that won’t include an estimate of how many would lose coverage.) One in five women of reproductive age get their health insurance through Medicaid, and cuts to the program would put essential reproductive health services out of reach of many low-income Americans, especially black and Latino patients. More than half of all births and three-quarters of publicly funded family planning services are currently covered by Medicaid.

The bill also adds a new way for the federal government to restrict abortion at the state level

The new concerns for reproductive rights in Graham-Cassidy largely stem from its block grant program. As Vox’s Sarah Kliff explains, the bill would repeal Obamacare’s individual tax credits and the Medicaid expansion in 2020, and replace them with grants to the states. Those grants could then be spent in a variety of ways — on high-risk pools, for instance, or on programs “to help individuals purchase health benefits coverage.” But, crucially, none of the money from the grants could be spent on insurance coverage for abortion.

Many states already have restrictions on insurance coverage for abortion. But Graham-Cassidy would require all states to ban abortion coverage in any program that gets federal block grant money. If it took money to offer subsidies for individual coverage or otherwise bolster the individual market, then it would have to restrict abortion coverage on that market. If it used federal funds to offer subsidies to employers, the ban on abortion coverage would affect the employer market too.

Essentially, the federal government would have the states over a barrel — if they wanted money to help keep their residents covered, they’d have to sacrifice abortion coverage to get it.

Because there’s no telling yet exactly what states would do with the block grants, or how the law would be interpreted, it’s not clear what the impact of the abortion restrictions would be. But the block grant program would certainly offer the federal government a new and powerful tool to restrict abortion coverage, including in states that have few restrictions in place now.

It’s also worth noting that spending for the bill would expire in 2026, meaning that unless Congress acted to replace the block grant money somehow, anybody who relied on that money for any reproductive health care — or, indeed, any health care at all — would be out of luck.

Moderates in the Senate have expressed reservations over past repeal bills that would have left millions of low-income Americans uninsured. Sens. Lisa Murkowski (R-AK) and Susan Collins (R-ME) have opposed stripping funding from Planned Parenthood — and have voted against every repeal bill so far. As Vox’s Dylan Scott reports, the bill still needs a CBO score and the approval of the Senate parliamentarian before it can come to a vote, and in order to pass it, the bill’s sponsors can only afford to lose two Republican votes.

Graham-Cassidy would leave millions without coverage and severely curtail reproductive health coverage nationwide. It remains to be seen if that’s enough to kill it.

Correction: This article originally stated that the Graham-Cassidy bill would require states that got federal block grant money for their Medicaid programs to stop using state Medicaid funds to cover abortion. The bill would not do this.