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Help raise awareness about Black maternal mortality!

Black Maternal Health Week starts tomorrow
Black women in the United States have among the highest rates of maternal mortality in the developed world.  Black women are three to four times more likely to die from pregnancy or childbirth-related causes than are white women. This week, we are joining the Black Mamas Matter Alliance in a campaign to raise awareness about this crisis and help support the development of solutions through community-driven policy advocacy and health systems change.

There are many ways that you can get involved! Join the Black Mamas Matter Alliance on social media with the official hastags #BMHW2018 #BlackMaternalHealthWeek. See their social media toolkit here.
Today (Tuesday) at 3PM EST there will be a pre-launch tweet chat with leading reproductive justice organizations to advocate for maternal rights and birth justice for Black women.
There will also be several information webinars that will amplify the issues:
  • Wednesday, April 11th at 12PM EST: Black Maternal Health Week launch webinar. Register here.
  • Thursday, April 12th at 12PM EST: "Best Practices in Black Mama Care Work” webinar. Register here.
  • Monday, April 16th at 12PM EST: BMHW Webinar highlighting African Immigrant women's advocacy in maternity care. Register here.
If you live in California, Florida, Georgia, Maryland, Massachusetts, New Jersey, Ohio, or Texas you can also go here to find local events in your area where you can get involved. The week will wrap up on Tuesday, April 17th at 3PM EST with the BMHW finale tweet chat. 
Feminist Women’s Health Center, RWV’s regional coordinator in Atlanta,  will be tabling with the Black Mamas Matter Alliance, Center for Black Women’s Wellness and other Black woman-led organizations, maternal justice advocates, and birth workers for a Film Screening and Community Discussion: Raising Awareness to Advance Black Maternal Health, Rights, and Justice on Thursday, April 12, 2018 at 6pm at the Auburn Avenue Research Library (101 Auburn Avenue NE, Atlanta, GA 30303). There will be a community conversation and advocacy connection as they showcase Death By Delivery, a documentary about the staggering rate of maternal mortality for black women.
FWHC is also partnering with SPARK Reproductive Justice NOW!, the National Institute for Reproductive Health and the State Innovation Exchange to develop a multi-year proactive policy strategy, grounded in the reproductive justice framework, to demonstrate the connections between the harms inflicted on women by abortion restrictions and  the deceptive practices of crisis pregnancy centers, and the high rates of maternal mortality and morbidity in Georgia.
Racial disparities in maternal mortality and morbidity persist among women of all income and educational levels.  Many Black women report chronic stress associated with the constant discrimination and obstacles they have faced because of being both Black and a woman in America. Studies have shown that Black college-educated mothers are more likely to suffer severe complications of pregnancy or childbirth than white women with less than a full high school education.
Even highly-paid celebrities and athletes with good health insurance can be affected. Tennis star Serena Williams suffered a pulmonary embolism that nearly killed her a day after giving birth last September. She told a Vogue magazine interviewer that she had to fight to get the emergency care she needed from health providers who doubted what she was telling them about her symptoms, including shortness of breath. Williams said she persisted because she knew that she had a history of such embolisms.
“Racism is creating these inequities,” explained Dr. Joia Crear-Perry, an obstetrician-gynecologist who is a member of the steering committee of the Black Mamas Matter Alliance and Community Catalyst board member.  Speaking at the New York Maternal Mortality Summit, she said that “When you see inequities in health, don’t think about individuals. Think about systems, because systems create inequities.”  She is founder of the National Birth Equity Collaborative.
The Black Mamas Matter Alliance grew out of a collaboration between the Center for Reproductive Rights and the SisterSong Women of Color Reproductive Justice Collective. The Alliance is now led by a steering committee that includes Kwajelyn Jackson of the Feminist Women’s Health Center, RWV’s regional coordinator in Atlanta.
Another of Raising Women’s Voices’ regional coordinators -- The Afiya Center in Dallas, TX -- is active in the Black Mamas Matter Alliance. The Afiya Center joined allies to successfully advocate for intensive review of all maternal deaths in Texas by a state board. “It’s systemic,” Afiya Center Executive Director Marsha Jones said of the maternal mortality crisis at last month’s Time to Show up for Black Women summit, according to KUT Austin. “It’s not going to be fixed black woman to black women or black man to black man. It’s not going to be fixed that way. We have to literally deconstruct the system that’s been put up.”
The Afiya Center recently released a call to action in order to accurately represent how Black women in Texas are affected during pregnancy. They are gathering stories from Texas women who have been pregnant and had any health issues during their pregnancy. Some of the health issues include preeclampsia, fibroids, preterm birth, heart disease, mental illness, postpartum hemorrhaging, and a host of others. Speaking at the Time to Show up for Black Women Summit, Dr. Joia Crear-Perry encouraged other local communities in Texas to mobilize around these issues. “You have motivated individuals and motivated systems here who want to see improvement and want to see work happen,” she said to the Austin audience. “So it’s now just building on that momentum and getting it going,” KUT Austin reported. For more information on the Afiya Center’s work in Texas, please email
What can be done to help address this health disparity? The Black Mamas Matter Alliance has prioritized driving research, advocacy, clinical improvements, empowerment of Black women, and cultural change: “We envision a world where Black mamas have the rights, respect and resources to thrive before, during and after pregnancy.”
Let’s support the Black Mamas Matter Alliance in bringing national attention to this pervasive health crisis so that more mamas can get the care they need to make it home safely with their babies!

We’re working in the states to protect our health care!

There’s a lot to do at the state and local levels!

With Congress on recess following the passage of an omnibus spending package (which we reported on last week), we’re turning our attention to what’s been happening in the states. Our regional coordinators across the country have been busy engaging in state and local advocacy/policy work to protect the health care of women and LGBTQ people. Here’s some of what they’ve been up to!

Massachusetts protects patient confidentiality

Earlier this week, staffers and members of NARAL Massachusetts, our Boston-based regional coordinator, celebrated their third legislative win of the session with the approval of the Protect Access to Confidential Healthcare (PATCH) Act.

Currently, insurers automatically send Explanation of Benefits (EOB) forms listing the provision of potentially sensitive health care services, such as reproductive health care, to the primary subscriber on a health insurance plan. This process compromises the privacy of Massachusetts residents receiving health insurance as dependents on the plan of a parent or spouse. It particularly affects young women, members of the LGBTQ community, domestic violence survivors and people with substance abuse or mental health issues.

 H.2960S.2296 addresses this problem by ensuring that EOBs are sent directly to each patient and that each patient can choose to receive her EOB at an alternate address or electronically. It requires that EOBs include only generic information when sensitive care is received, and guarantees that EOBs are not sent for preventive health services with no cost sharing (such as an STI test or a domestic violence counseling session).

SisterReach raises health issues during Black Folks Day on the Hill

SisterReach, our Tennessee-based regional coordinator, and their new policy initiative, the Deep South Regional Roundtable, held their 2nd annual Black Folks Day on the Hill. Deep South partners, community members and allies statewide went to their state capitols in Tennessee and Mississippi, speaking with key legislators about issues, including health, which affect Black community members in both states.

Some of those issues include proposals to introduce harmful work requirements for Medicaid enrollees, abortion rights and the rights of pregnant women. During the TN hill visit, participants made a presentation to the Shelby County (Memphis) delegation about the issues Memphians face and offered the coalition as a resource to legislators. Black Folks Day on the Hill 2018 was a success, and the partnership looks forward to bigger and better hill actions to come!  The photo shows SisterReach CEO & Founder Cherisse Scott, staff and volunteers posing with State Representative G.A. Hardaway Sr. during Black Folks on the Hill Day in TN.

Making health care more affordable in Maryland

With only a few days left in their state legislative session, members of Consumer Health First, our Maryland-based regional coordinator, are celebrating the passage of a proposed policy that will help protect access to coverage and care for Marylanders. HB1795, which is awaiting Governor Larry Hogan’s signature, will help stabilize Maryland’s individual insurance market by allowing the state to take steps to create what’s called a “reinsurance program.”

Reinsurance programs -- which are almost like insurance for insurance companies – are designed to offset the costs that health plans can incur if they enroll individuals who use a lot of expensive medical care. Without the reinsurance payments, health plans would raise their premiums for all enrollees to cover medical expenses for the higher-cost people.  With the reinsurance payments, health plans would stay affordable for Marylanders who are purchasing them through the individual market.

Where would the money for the reinsurance program come from? HB1795 would allow the state to apply for what’s called a 1332 waiver to take advantage of federal dollars and state funding in 2019. See Consumer Health First’s testimony in support of the proposal here. Consumer Health First is closely watching HB1792/SB387, which would establish the state funding sources for a reinsurance program. That bill also charges the Maryland Health Insurance Coverage Protection Commission with studying a number of critical areas that can affect the cost of health insurance. These include: creating a state-level individual mandate to have health insurance (to replace the federal mandate that Congress and the President eliminated in the tax bill); merging the small group and individual health insurance markets; the use of subsidies to lower costs and a Medicaid buy-in option.

"We've worked tirelessly since the passage of the Affordable Care Act to bring the voice of the over 200,000 individuals who depend on the individual market for their health care coverage to the Insurance Commissioner during the rate review process," said Beth Sammis, President, Consumer Health First. "The Maryland Insurance Administration staff during a legislative hearing acknowledged we hold their feet to the fire. We will continue our advocacy to hold all policymakers’ feet to the fire until the individual market is stabilized and coverage affordable."

Illinois health care advocates say: Do No Harm!

As part of their advocacy work in opposition to state-based work requirements for Medicaid, RWV regional coordinator EverThrive Illinois and Protect Our Care Illinois, along with 100 partner organizations, sent a letter to Governor Bruce Rauner, a Republican, urging him to oppose adding work requirements to Illinois’ Medicaid program. They outlined the ways in which work requirements would create barriers to health care for Illinois residents, strip people of health benefits, and cost the State of Illinois billions of federal dollars with no benefit for the state. Read the letter in full here.

Meanwhile, EverThrive Illinois and their Protect Our Care Illinois colleagues have been building support for the “Do No Harm Healthcare Act.” This proposed policy, which has been approved in committee, would require the legislature to approve any requests by the Governor to the federal government for waivers that would reduce or restrict health insurance coverage under the Affordable Care Act (ACA) plans, State Employee Group Health Insurance or Medicaid.

This provision would apply, for example, to harmful Medicaid waivers proposals, like those recently approved by the federal government for Kentucky and Indiana, which would impose work requirements on Medicaid recipients. The proposed policy would help ensure that any attempt to restrict access to health care is transparent and open to public debate. For more details on HB 4165 HA1, see Protect Our Care Illinois’ fact sheet.

Trans- and queer-led Brown and Black coalition launches LGBTQ+ Justice Week
Trans Queer Pueblo, our Phoenix-based regional coordinator, and other community groups are taking to the streets with rituals, drag performance, celebration and protests for LGBTQ+ Justice Week.  LGBTQ+ communities of color will bring the Pride celebration to the institutions that detain, incarcerate, deport and kill LGBTQ+ people of color.
At Monday’s Vigil for Liberation event, community members built an altar and performed drag in protest (pictured left) at Eloy Detention Center, the nation’s deadliest detention facility. The protest lifted up deaths in detention due to bad or no medical care and the trauma of trans detainees, such as being caged with people of the wrong gender and being subject to constant harassment, abuse and often rape.  
At a Drag Town Hall, community members invited Phoenix mayoral candidates to participate in an open forum about how to make Phoenix safe for LGBTQ people of color. Community groups discussed the need to fund trans-inclusive women's health clinics and rape crisis centers. The conversation continued with dialogue on economic opportunity as a health issue and the lack of job opportunities for LGBTQ+ people of color due to document status, poverty, racism and transphobia.
WV FREE celebrates ACA anniversary

WV FREE, our Charleston-based regional coordinator, participated in a press event at the state Capitol to celebrate the ACA’s 8thanniversary. At the event, health care advocates highlighted the positive impact the ACA has had on West Virginians, including its role in reducing the uninsured rate among adults from 29 percent to 9 percent. These powerful statistics were complemented by the stories that individual consumers shared about the real life impact the ACA has had on their families. For example, Parkersburg resident Janice Hill talked about her daughter’s struggle with cancer and the life-saving coverage the ACA has provided for her.



Why were we glad to be left out?

New federal spending bill mostly omits anti-women provisions
After six months of stop-gap spending bills and two government shutdowns, Congress passed an omnibus spending package late last week to fund the government through the rest of the 2018 fiscal year. Despite a last minute Fox News-inspired veto threat, Donald Trump signed the package into law five hours later, averting a third shutdown just hours before the deadline.
The bill was perhaps most notable for what it did notinclude on women’s health and other progressive priorities, with some of our biggest victories coming from blocking GOP attempts to add dangerous new anti-women policy language.
As we noted earlier this month, conservatives were pushing hard for language in the omnibus to make up for their defeats last year on Planned Parenthood. The omnibus is likely one of the last big, must-pass bills Congress will take up before the election, and opponents of abortion access saw it as their last chance to “defund” Planned Parenthood by blocking the popular health provider from receiving any federal funding, whether through reimbursement for serving patients insured through Medicaid or through Title X federal family planning grants. In the end, the bill didn’t include any attacks on Planned Parenthood or other abortion providers.
Similarly, Republicans had sought to codify into law the Trump administration’s proposed regulatory attacks on reproductive and LGBTQ health care. As we noted last week, the Trump administration has proposed a rule that would make it easier for doctors, nurses, pharmacists, hospitals, clinics and insurance companies to deny us care, based on their religious, moral or personal beliefs.  (See more on this topic below.)  An attempt to include religious refusal language similar to the proposed Trump rule into the omnibus bill provision was dropped, as was a proposed ban on fetal tissue research. 
Likewise, the bill maintained level funding  for the Title X family planning program and for the Teen Pregnancy Prevention program, but didn’t make any policy changes -- neither codifying into law the Trump administration’s proposed attacks on the two programs,nor protecting the programs from those attacks.
This still leaves these priorities at the mercy of a hostile anti-science, anti-woman, and anti-LGBTQ administration, but without the same force of law and without setting dangerous new precedents. History has shown that once these kinds of policy riders are added to spending bills, they are notoriously difficult to remove—as evidenced by the four decade-long fight to strip out Hyde amendment language blocking low-income women’s access to abortion care, if federal funds are used.
Finally, the bill did not include any funding to shore up Affordable Care Act (ACA) health insurance  marketplaces that have been rocked by GOP sabotageWe opposed several provisions in the Republican-only package released by Senators Lamar Alexander (TN) and Susan Collins (ME) that would have increased costs for moderate-income enrollees and created a de facto ban on private insurance coverage of abortion under the ACA.
What did the spending bill include?
 The bill included critical increases in funding for the Department of Health and Human Services (HHS)—$10 billion over last year—with new funding for substance use disorders and mental health. The National Institutes of Health (NIH), the Centers for Disease Control and Prevention (CDC), and community health centers also won increases, as did a number of other intersectional priorities related to women’s health, such as low-income housing.
Unfortunately, the bill also includes more funding for several of Mike Pence’s pet projects at HHS, including abstinence-only education under the rebranded title of “Sexual Risk Avoidance Education.”
The package also modestly improves the ability of the CDC to conduct research related to gun violence—long blocked by Republicans—by clarifying through accompanying report language that nothing in the bill prohibits the CDC from doing so. Without dedicated funding for gun research, it’s unclear how much of a difference the bill will make. But symbolically, it’s the first small step toward recognizing gun violence as a public health issue that Congress has made in a generation, with ramifications for women’s health. On average, a woman in the U.S .is fatally shot by her current or former intimate partner every 16 hours. The bill also includes language improving the National Instant Criminal Background Check System (NICS) but does not include language gutting state regulation of concealed carry permits. For years, gun hardliners had been refusing to pass the bipartisan Fix NICS legislation unless it was paired with pro-gun legislation; their failure in the omnibus suggests that the tide may be turning on Congress’s ability to take up sensible gun reforms.
On lingering questions around immigration, public health and the Dreamers, the bill represented a stalemate. Democrats had hoped to enact a permanent pathway to citizenship for those immigrants brought to the US as children but the White House offered only a temporary reprieve, no better than what several federal courts have already granted the Dreamers through litigation. Congressional negotiators rejected Trump administration requests for detention beds, an attack on “sanctuary cities” and border wall funding—providing instead a much smaller pot of money to repair and replace existing fencing and explicitly prohibiting the use of funds for concrete structures.
We raised our voices to oppose the Trump religious refusal rule!
On Tuesday, Raising Women’s Voices submitted comments calling for the Trump administration to withdraw its proposed rule to expand the ability of health providers to deny care based on religious, moral or personal objections. We pointed out the harm the rule would cause for groups that already face obstacles in obtaining care – women and LGBTQ people, especially those of us who are low-income, immigrants, people of color, people with disabilities, and transgender or gender non-conforming people.  You can find our comments here.
We helped generate additional organizational and individual comments on the proposed rule through a social media campaign, #DontDenyUsCare, that cited actual instances in which women and LGBTQ people have already suffered care denials, even without the rule.  On Monday, we co-hosted with Community Catalyst a Twitter storm in which more than 30 organizations participated, including Lambda Legal, the National Women’s Law Center, the National Family Planning and Reproductive Health Association (NFPHRA), the National Center for Lesbian Rights, Moms Rising, SisterSong and the National Asian Pacific American Women’s Forum. 
Eighteen of our RWV regional coordinators participated in the Twitter storm and/or submitted written comments to HHS: The Afiya Center, California Latinas for Reproductive Justice (CLRJ), COLOR, EverThrive Illinois, Indiana Religious Coalition for Reproductive Justice, Kentucky Health Justice Network, Lesbian Health Initiative, Maine Consumers for Affordable Health Care, Montana Women Vote, NARAL Minnesota, New Mexico Religious Coalition for Reproductive Choice, New Voices Pittsburgh, Northwest Health Law Advocates, Planned Parenthood of Southern New England, Oregon Foundation for Reproductive Health, SisterReach, Wisconsin Alliance for Women’s Health, and WV Free. 

Also on Tuesday, National Women’s Health Network Health Policy Intern Maddy McKeague (to the right of the speaker in the photo) represented Raising Women’s Voices at a press conference outside HHS headquarters, during which a coalition of women’s health and LGBTQ health organizations announced they had gathered and were about to submit 200,000 comments in opposition to the rule. 



Trump rule would make it easier for providers to deny us care!

Here’s your chance to speak out against the harmful Trump rule!

The Trump administration wants to make it easier for doctors, nurses, pharmacists, hospitals, clinics and insurance companies to deny us care, based on their religious, moral or personal beliefs. We must speak out against this proposed rule that would especially harm women and LGBTQ people.

What can you do? Go here for suggested talking points and a direct link to the Health and Human Services Department page where you can submit your personal or organizational comments opposing this destructive rule. The deadline to submit comments is Tuesday, March 27, so we all must act quickly!

You can also join a #DontDenyUsCare Twitter storm on Monday, March 26, from 1 to 2 p.m. Eastern that will be co-sponsored by Raising Women’s Voices and Community Catalyst to coincide with the start of LGBTQ Health Awareness Week. The goal will be to let more LGBTQ people know about the threat posed by this proposed rule and encourage more people to submit personal comments opposing it. Go here for social media “badges” we have created and suggested posting text you can use.

How do we know what the consequences of the proposed rule would be? Sadly, too many women and LGBTQ people have already suffered the kinds of health care denials that would get worse under Trump’s rule. We know a lesbian couple in California were denied infertility services by a fundamentalist Christian physician who didn’t approve of same-sex couples having children.  We also know that a transgender teen in Georgia was denied medically-prescribed testosterone injections by an objecting clinic provider who commented, “What kind of a doctor would do this to a girl? And we know a transgender man was denied a hysterectomy for gender transition purposes by a hospital in New Jersey.

How would Trump’s proposed rule make things worse? Existing harmful religious refusal policies apply primarily to abortion and sterilization services.The proposed rule would allow health providers to refuse to provide “any lawful health service or activity based on religious beliefs or moral convictions.” This expansive interpretation could lead to provider denials based on personal beliefs that are biased and discriminatory, such as objections to providing care to people who are transgender or in same-sex relationships, or are not based in scientific evidence, such as refusals to provide emergency contraception out of the unfounded belief that it can cause abortion.

The rule would protect refusals by anyone who would be “assisting in the performance of” a health care service to which they object, not just clinicians. An expansive interpretation of “assist in the performance of” thus could conceivably allow an ambulance driver to refuse to transport a patient to the hospital for care he/she finds objectionable. It could mean a hospital admissions clerk could refuse to check a patient in for treatment the clerk finds objectionable or a technician could refuse to prepare surgical instruments for use in a service.

On an institutional level, the right to refuse to “assist in the performance of” a service could mean religiously-affiliated hospital or clinic could deny care, and then also refuse to provide a patient with a referral or transfer to a willing provider of the needed service. Indeed, the proposed rule’s definition of “referral” goes beyond any common understanding of the term, allowing refusals to provide any information, including location of an alternative provider, that could help people get care they need.

The rule does not address how a patient’s needs would be met in an emergency situation. There have been reported instances in which pregnant women suffering medical emergencies – including premature rupture of membranes (PPROM) and ectopic pregnancies-- have gone to hospital emergency departments and been denied prompt, medically-indicated care because of institutional religious restrictions.  This lack of protections for patients is especially problematic in regions of the country, such as rural areas, where there may be no other nearby hospital to which a patient could easily go without assistance and careful medical monitoring enroute.

The proposed rule includes no exceptions for emergency situations and makes no reference to the Emergency Medical Treatment and Active Labor Act (“EMTALA”), which requires hospitals that have a Medicare provider agreement and an emergency department to provide to anyone requesting treatment an appropriate medical screening to determine whether an emergency medical condition exists, and to stabilize the condition or if medically warranted to transfer the person to another facility. Under EMTALA every hospital is required to comply – even those that are religiously affiliated. Because the proposed rule does not mention EMTALA or contain an explicit exception for emergencies, some institutions may believe they are not required to comply with EMTALA’s requirements. This could result in patients in emergency circumstances not receiving necessary care.

Health care institutions would be required to notify employees that they have the right to refuse to provide care, but would not be required to notify patients about the types of care they will not be able to receive at that hospital, pharmacy, clinic or doctor’s office. The rule sets forth extensive requirements for health care institutions, such as hospitals, to notify employees about their refusal rights, including how to file a discrimination complaint with OCR. The rule requires posting of such notices on the employer’s website and in prescribed physical locations within the employer’s building.

By contrast, the rule contains no requirement that patients be notified of institutional restrictions on provision of certain types of care. Such notification is essential because research has found that patients often are unaware of service restrictions at religiously-sponsored health care institutions.

What should we say in our comments to Department of Health and Human Services (HHS)? You can find a template letter of comment here that you can tailor to your own organization. But here’s the bottom line: The proposed pule will allow religious beliefs to dictate patient care by unlawfully expanding already harmful refusals of care. The proposed rule is discriminatory, violates multiple federal statutes and the Constitution, fosters confusion and harms patients contrary to the Department’s stated mission.  For all of these reasons, we call on the Department to withdraw the proposed rule in its entirety.

Meanwhile, Congress set to vote on spending bill

Congress is set to vote this week (maybe even today!) on a 2,000+ page omnibus spending bill to fund the government. Current stopgap funding expires on Friday. Based on early reports of what made it into the bill (e.g. increases for health research and other key priorities) and what didn't (attacks on Planned Parenthood) we're cautiously supportive. But with the text released to the public only hours before Congress begins voting, we're still going through the bill to see what it will mean for all of our women's health priorities.

While it’s not included in the omnibus bill, the Senate could also take a vote tomorrow on package to stabilize ACA marketplaces. As we noted last week, the package is controversial because it could raise out-of-pocket costs for moderate-income enrollees andwould make it all but impossible to get abortion coverage through the individual market. Look for our recap of congressional action next week.



Reproductive health at risk in Congressional funding fights!

Congress threatening Planned Parenthood, abortion coverage
There’s only a week to go before the federal government will once again be on the brink of shutting down. Conservative Republicans are trying to use the crisis to block Planned Parenthood from receiving any federal funding. They’re also insisting that any effort to shore up health insurance markets contain a provision effectively banning private abortion coverage in Affordable Care Act (ACA) plans. 
Such an abortion ban would go well beyond the Nelson Amendment included in the ACA.  That provision prohibits the use of federal funding to pay for abortion coverage, but it allows marketplace plans to include abortion coverage as long as that portion of the premium is paid for by an individual’s private payments. In contrast, abortion opponents in Congress want to totally ban private abortion coverage if anyportion of the premium is paid for with federal funds, essentially imposing the Stupak Amendment that they tried and failed to add to the ACA.
Planned Parenthood threatened in “omnibus” funding bill
The action by conservative Republicans is taking place as Congress is negotiating the last pieces of an “omnibus” spending package to fund the government through the end of the fiscal year. Current stopgap funding expires on March 23. Originally slated for a House vote this week, the timeline has been pushed to early next week. While most of the spending decisions have been finalized, big questions remain over more than a hundred controversial policy changes that Republicans hope to tie the bill. The package is likely one of the last big, must-pass bills Congress will take up before the election, making it the last chance for members of Congress to win legislative victories that they can take home.
Anti-abortion conservatives, in particular, are clamoring for a win now that Republicans have given up on attempting a third reconciliation package, which would have let them once again try to force through attacks on Planned Parenthood and other abortion providers with just 50 senators. The omnibus bill will require 60 votes to overcome a filibuster in the Senate, but hardliners hope that Democrats don’t have the appetite for another shutdown. They want the GOP to use the omnibus to block Planned Parenthood from accessing all federal funding, whether through reimbursement for serving patients with Medicaid insurance or through Title X federal family planning grants.
In 2015, Republicans came close to shutting down the government over Planned Parenthood funding, but ultimately backed off. It’s unclear whether cooler heads will once again prevail, whether we’re headed for a third shutdown this year, or whether this is simply a cynical gambit to win concessions from Democrats in other areas like financial reform or environmental regulations. As congressional leadership is fond of saying, nothing is decided until everything is decided. Other proposed “poison pill” provisions relevant to women’s health include codifying Trump’s plan to eliminate the Teen Pregnancy Prevention (TPP) Program and funding his anti-immigrant deportation force.
Abortion coverage ban not the only problem with market stabilization proposals
Congress is also negotiating a market stabilization package to shore up ACA insurance markets rocked by GOP sabotage. At stake are cost-sharing reduction (CSR) payments to insurance companies and federal funding for state-based reinsurance programs.
As we’ve noted previously, insurance companies are required by law to keep cost-sharing (e.g. co-pays, deductions, and co-insurance) artificially low for low-income enrollees in the ACA marketplaces. So, for example, someone with an income of 150% of the federal poverty level who signs up for a plan that would normally carry a $2,000 deductible might end up having no deductible at all. Then, the federal government is supposed to reimburse insurers through CSR payments.
An immediate cut-off in those payments could have been disastrous, with insurance companies abruptly raising premiums across the board or leaving ACA markets altogether. But because Trump spent months teasing whether or not he would block the payments, insurance markets had time to prepare in clever ways.
In 36 states (representing 85% of ACA enrollees), insurance companies working with state insurance regulators carefully increased premiums in such a way that actually lowered out-of-pocket costs for low- and moderate-income enrollees. That’s because financial assistance from the federal government is pegged to the cost of an area’s second lowest cost silver plan—even if the enrollee chooses a less comprehensive bronze  plan or a more comprehensive gold plan. When the Trump administration cut off CSR reimbursements, insurers were forced to raise premiums to compensate. But few raised premiums on all plans. Instead, many insurers increased premiums only on silver plans, while keeping premiums stable in bronze and gold plans—a practice known as “silver loading.”
With the government paying more for premium assistance, many enrollees found themselves with free or close-to-free bronze plans or with gold plans that were actually cheaper than silver plans. This is one reason why, despite the administration’s brazen attempts to sabotage the open enrollment period for 2018, enrollment stayed so high.
Reinstating CSR payments now that markets have adjusted to life without them would save the government money, because the CSR payments are lower than the cost of subsidizing higher premiums. But it would do soat the expense of low- and moderate-income enrollees who will see their out-of-pocket premium costs rise. With the repeal of the individual mandate in last year’s GOP tax bill and the Trump administration’s promotion of worthless “junk” health plans, consumers would face strong financial incentives to drop out of comprehensive ACA markets.
Republicans would like to use the savings from reinstating CSRs to fund state reinsurance programs. Reinsurance helps buffer insurance companies against very large losses—like those associated with an unusually sick and expensive pool of enrollees. Without reinsurance, a company has to price the risk of really sick enrollees into higher premiums for everyone. With reinsurance, a company can keep premiums lower and be compensated if claims rise above a certain level.
However, as the Center on Budget and Policy Priorities notes, the GOP proposal would mean taking financial help away from low-income enrollees to reduce premiums for middle-income enrollees. We can—and should!—fund reinsurance to lower costs for enrollees who don’t qualify for financial assistance, but we don’t need to pit low- and middle-income families against each other. We can make health insurance more affordable for everyone.

Moreover, under the GOP proposal, no plans accessing CSR support and no plans backstopped by reinsurance could cover abortion, no matter who pays for the actual premium costs associated with abortion care. The likely net effect would be to discourage private abortion coverage in any ACA plan. That would set a very dangerous precedent that is simply wrong for women’s health!