tag:theconversation.com,2011:/uk/topics/planned-parenthood-26972/articlesPlanned Parenthood – The Conversation2023-12-04T13:27:26Ztag:theconversation.com,2011:article/2168972023-12-04T13:27:26Z2023-12-04T13:27:26ZTexas is suing Planned Parenthood for $1.8B over $10M in allegedly fraudulent services it rendered – a health care economist explains what’s going on<figure><img src="https://images.theconversation.com/files/562238/original/file-20231128-21-zr2ypf.jpg?ixlib=rb-1.1.0&rect=0%2C1087%2C5094%2C2238&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Texas authorities have long sought to kick Planned Parenthood out of the state.</span> <span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/PlannedParenthoodMedicaid/61c31f85fab64d1893cc49aa2c9444ae/photo?boardId=37be9465fcce45d283d5431cccb20a6a&st=boards&mediaType=audio,photo,video,graphic&sortBy=&dateRange=Anytime&totalCount=469&currentItemNo=2">AP Photo/Eric Gay</a></span></figcaption></figure><p>Planned Parenthood no longer provides abortions in Texas, Louisiana and the other 10 <a href="https://www.guttmacher.org/2023/01/six-months-post-roe-24-us-states-have-banned-abortion-or-are-likely-do-so-roundup">states that have essentially banned abortion</a> <a href="https://theconversation.com/one-year-after-the-fall-of-roe-v-wade-abortion-care-has-become-a-patchwork-of-confusing-state-laws-that-deepen-existing-inequalities-207390">since the Supreme Court handed down its Dobbs v. Jackson decision</a> in June 2022.</p>
<p>But the nonprofit is still providing other services for patients in those places, including cancer screening, contraception and the treatment of HIV and sexually transmitted infections. And <a href="https://www.texastribune.org/2023/08/15/texas-abortion-planned-parenthood-lawsuit/">Texas hasn’t given up</a> on its long-running quest to force the group, which <a href="https://apnews.com/article/abortion-planned-parenthood-states-layoffs-equity-8ca79602fd28226538e5f6148a202646">provides reproductive health care</a> in its nearly 600 U.S. clinics, to stop operating within its borders.</p>
<p>Alongside an anonymous whistleblower identified as “Alex Doe,” <a href="https://www.texastribune.org/2022/01/13/texas-medicaid-planned-parenthood-lawsuit/">Texas authorities are suing Planned Parenthood</a> <a href="https://www.texastribune.org/2023/08/15/texas-abortion-planned-parenthood-lawsuit/">for more than US$1.8 billion</a> in penalties and fees over what they allege are fraudulent Medicaid reimbursements. </p>
<p><a href="https://www.plannedparenthood.org/about-us/newsroom/press-releases/the-facts-on-united-states-ex-rel-doe-v-planned-parenthood-federation-of-america-the-meritless-case-that-could-shut-down-planned-parenthood">Planned Parenthood denies</a> having committed Medicaid fraud. It calls the lawsuit “<a href="https://apnews.com/article/health-texas-medicaid-planned-parenthood-14379403b715dd838b0d18efab629db3">another political attack</a>.”</p>
<p>As an economist who <a href="https://www.grahamgardnerecon.com/">studies the health effects of restricted abortion access</a>, I believe that if Texas prevails in this federal lawsuit, Texans will have even less access to sexual and reproductive health care. Notably, <a href="https://www.texmed.org/Template.aspx?id=59688">the state ranked 50th</a> in access to high-quality prenatal and maternal health care in 2022, and maternal mortality rates in the state more than <a href="https://www.axios.com/local/dallas/2023/07/24/maternal-mortality-in-texas">doubled between 1999 and 2019</a>. The elimination of Planned Parenthood facilities across Texas will likely exacerbate the dismal conditions of reproductive care in the state.</p>
<h2>Blocking Medicaid funds</h2>
<p>Medicaid, a government program that helps low-income people get health care, <a href="https://www.kff.org/medicaid/issue-brief/medicaid-financing-the-basics/.">provides roughly $728 billion in services</a> annually. The federal and state governments split its costs.</p>
<p>In 2016, Texas <a href="https://www.texastribune.org/2016/12/20/texas-kicks-planned-parenthood-out-medicaid/">removed Planned Parenthood from its list of qualified Medicaid</a> providers, blocking Planned Parenthood clinics across the state from receiving any federal or state dollars to pay for expenses covered by Medicaid. Lower courts <a href="https://www.nytimes.com/2017/02/21/us/texas-planned-parenthood-medicaid.html">initially prevented this policy from going into effect</a>. </p>
<p>But in 2020, the <a href="https://www.texasattorneygeneral.gov/sites/default/files/images/admin/2020/Press/EnBancOpinion.pdf">5th U.S. Circuit Court of Appeals ruled</a> that the state may exclude Planned Parenthood from receiving Medicaid reimbursement. Since then, Planned Parenthood has continued to operate in Texas, but the availability of health services to the nearly <a href="https://www.plannedparenthood.org/planned-parenthood-gulf-coast/checkup-2021/texas-medicaid-exclusion">8,000 Planned Parenthood patients who rely on Medicaid</a> in the state has been put at risk. </p>
<h2>New legal salvo</h2>
<p>Texas now alleges that Planned Parenthood defrauded the state by billing expenses through Medicaid between 2016 and 2020 while its litigation was pending. The group counters that it legitimately billed Medicaid while the law was blocked by pending legal challenges. </p>
<p>Although Texas doesn’t dispute that the nonprofit provided the health care services for which it billed the state, and which the state paid for, Texas seeks the repayment of <a href="https://www.texastribune.org/2022/01/13/texas-medicaid-planned-parenthood-lawsuit/">$10 million in Medicaid reimbursements</a>.</p>
<p>The potential liability is far larger because it also includes interest, legal fees and civil penalties adding up to more than $1.8 billion. Planned Parenthood says <a href="https://www.plannedparenthood.org/about-us/newsroom/press-releases/statement-from-planned-parenthood-texas-affiliates-and-ppfa-following-oral-arguments-in-baseless-medicaid-false-claims-act-case">the financial burden of the lawsuit</a>, if the state wins, would significantly limit its ability to continue to operate in Texas. </p>
<p>This litigation originated in 2021, when the anonymous whistleblower brought a case against Planned Parenthood under the <a href="https://www.justice.gov/civil/false-claims-act">False Claims Act</a>, which allows an individual to file a lawsuit on behalf of the government.</p>
<p>The <a href="https://clearinghouse.net/case/43987/">state of Texas joined the lawsuit</a> under the direction of Attorney General Ken Paxton in 2022. The case was filed in Amarillo, an area without a Planned Parenthood facility – a jurisdiction that might seem an unlikely choice. There’s one good explanation, however: All cases filed there are heard by <a href="https://apnews.com/article/texas-judge-matthew-kacsmaryk-abortion-pill-fda-75964b777ef09593a1ad948c6cfc0237">U.S. District Judge Matthew Kacsmaryk</a>.</p>
<p>The Trump-appointed judge made headlines in early 2023 when he <a href="https://www.reuters.com/legal/us-judge-hands-anti-abortion-groups-partial-win-over-abortion-pill-2023-04-07/">suspended the approval of a common abortion-inducing pill</a>. Kascmaryk’s anti-abortion history on the bench makes him a strategic choice to rule on the case against Planned Parenthood.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/562240/original/file-20231128-29-q9upvc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Man in a suit and tie looks askance." src="https://images.theconversation.com/files/562240/original/file-20231128-29-q9upvc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/562240/original/file-20231128-29-q9upvc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/562240/original/file-20231128-29-q9upvc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/562240/original/file-20231128-29-q9upvc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/562240/original/file-20231128-29-q9upvc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/562240/original/file-20231128-29-q9upvc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/562240/original/file-20231128-29-q9upvc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Texas is suing Planned Parenthood as directed by Ken Paxton, the state’s attorney general.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/TexasAttorneyGeneralIndictment/64e2bf2f0f2547eab6935851fb542be2/photo?Query=ken%20paxton&mediaType=photo&sortBy=arrivaldatetime:desc&dateRange=Anytime&totalCount=868&currentItemNo=1">AP Photo/Eric Gay</a></span>
</figcaption>
</figure>
<h2>Reduced health care access</h2>
<p>Texas has been curtailing public funding to Planned Parenthood clinics since at least 2011, when the state cut its family planning budget from <a href="https://doi.org/10.1056%2FNEJMp1207920">$111 million to $38 million</a>.</p>
<p>Following those cuts, <a href="https://www.tpr.org/government-politics/2023-09-15/after-a-decade-of-state-led-attacks-texas-seeks-to-bankrupt-planned-parenthood">82 Texas clinics subsequently closed</a> or stopped providing family planning services, about one-third of which were Planned Parenthood affiliates. Many that remained open <a href="https://www.nejm.org/doi/10.1056/NEJMp1207920">reduced their hours</a> under the financial strain.</p>
<p>Texas’ publicly funded family planning clinics <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4386528/">served 54% fewer patients after the budget cuts</a>. Then, in 2013, Texas stopped letting abortion providers and affiliates get any funding through the Texas Women’s Health Program – a decision that caused the federal government to remove all financial support to it.</p>
<p>In response, Texas restructured the program under a new name: “<a href="https://www.texastribune.org/2017/05/05/healthy-texas-women-program-billboards-are-not-enough/">Healthy Texas Women</a>,” entirely funded through the state.</p>
<p>Having lost those funds, <a href="https://www.washingtonpost.com/posteverything/wp/2017/02/07/defunding-planned-parenthood-was-a-disaster-in-texas-congress-shouldnt-do-it-nationally/">31 of Texas’ remaining 74 Planned Parenthood-affiliated clinics closed</a> by 2017.</p>
<h2>Trial slated for April 2024</h2>
<p>This case, which <a href="https://www.reuters.com/legal/planned-parenthood-must-face-trial-over-texas-medicaid-fraud-claims-2023-10-24/">goes to trial in April 2024</a>, targets the three remaining Texas Planned Parenthood affiliates that operate roughly 35 clinics – <a href="https://www.plannedparenthood.org/planned-parenthood-gulf-coast/patients/locations-hours">two of which are in Louisiana</a>.</p>
<p>By late 2023, <a href="https://www.guttmacher.org/state-policy/explore/state-family-planning-funding-restrictions">18 states had abortion-related laws</a> on their books restricting state funds for family planning. Most of these laws target abortion providers, but in only six states does this restriction apply to clinics affiliated with those organizations.</p>
<p>Currently, only Texas prevents Planned Parenthood from receiving any Medicaid funds. Louisiana had an opportunity to join the lawsuit in Texas but instead <a href="https://www.vox.com/politics/2023/5/24/23725897/abortion-planned-parenthood-matthew-kacsmaryk-supreme-court-medical-progress-medicaid">settled with Planned Parenthood</a>, which allowed the organization to continue to receive Medicaid funds in the state.</p>
<p>But legislation in Texas often spurs copycat bills elsewhere. A 2022 Texas restriction on abortion procedures after six weeks of gestation was <a href="https://www.cnn.com/2022/04/28/politics/oklahoma-heartbeat-act/index.html">quickly copied by Oklahoma</a>, <a href="https://www.austinwomenshealth.com/copycat-bans-follow-after-texas-sb-8/">South Dakota</a> and <a href="https://www.forbes.com/sites/alisondurkee/2022/03/23/idaho-enacts-law-copying-texas-abortion-ban---and-these-states-might-be-next/?sh=1a93969525c0">Idaho</a>. </p>
<p>It’s reasonable to expect that other states may pass similar restrictions on Medicaid funding to Planned Parenthood. Already, <a href="https://www.thecentersquare.com/national/article_88fa51ca-1146-11ee-a769-b3bafe8d2051.html">related litigation filed in South Carolina</a> <a href="https://governor.sc.gov/news/2023-06/governor-henry-mcmaster-releases-statement-following-us-supreme-courts-ruling-kerr-v">is pending</a>.</p>
<h2>IUDs and cancer screening</h2>
<p>Planned Parenthood clinic closures and the reimbursement restrictions it faces are reducing the availability of reproductive health services, particularly for low-income people.</p>
<p>After the change in the Healthy Texas Women program, the provision of Medicaid-funded, long-acting reversible contraceptives – a category that includes intrauterine devices (IUDs) and contraceptive implants – fell by 35%, and <a href="https://doi.org/10.1056%2FNEJMsa1511902">Medicaid-paid obstetric care for people giving birth increased by 27%</a>. </p>
<p>In 2015, Texas prohibited Planned Parenthood from receiving <a href="https://www.texastribune.org/2015/08/10/planned-parenthood-be-cut-cancer-screening-program/">state funds for breast and cervical cancer screenings</a> and terminated a contract with Planned Parenthood Gulf Coast to <a href="https://www.texastribune.org/2015/12/22/texas-drops-planned-parenthood-hiv-prevention-prog/">financially support its HIV prevention program</a>.</p>
<p>If the court rules against Planned Parenthood, and the ruling stands after the appeals process that would certainly follow such a decision, access to sexual and reproductive health services in Texas will decline further. </p>
<p>While the lawsuit could bankrupt Planned Parenthood affiliates in the state, driving the organization out at last, it does not appear likely that the national organization would have to foot this massive legal bill and face jeopardy on a larger scale.</p>
<p>And I have no doubt that Texas’ remaining reproductive health care clinics would surely experience an overwhelming demand for their services while trying to fill the gaps left behind.</p><img src="https://counter.theconversation.com/content/216897/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Graham Gardner is affiliated with the Society of Family Planning. </span></em></p>This lawsuit is only the latest chapter in a battle between the state and the reproductive health care provider that heated up in 2011.Graham Gardner, Assistant Professor of Economics, Texas Christian UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1886812022-09-19T12:21:56Z2022-09-19T12:21:56ZProposed federal abortion ban evokes 19th-century Comstock Act – a law so unpopular it triggered the centurylong backlash that led to Roe<figure><img src="https://images.theconversation.com/files/484620/original/file-20220914-25-zu0a8x.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5000%2C3335&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A sign at a July 2022 abortion-rights protest in Santa Monica, California, recalls the country's long history of trying to restrict access to reproductive health care. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/photo-of-lizelle-herrera-is-carried-during-a-protest-march-news-photo/1241944944?adppopup=true"> David McNew/Getty Images</a></span></figcaption></figure><p>Sen. Lindsey Graham has proposed a <a href="https://www.axios.com/2022/09/13/lindsey-graham-national-abortion-restrictions-bill">national U.S. abortion ban</a> barring the procedure after 15 weeks. This push to restrict abortion access across the country follows a rash of new state laws passed by Republicans after the <a href="https://www.scotusblog.com/case-files/cases/dobbs-v-jackson-womens-health-organization/">Supreme Court overturned Roe v. Wade</a> in June. </p>
<p>If American history is any guide, these efforts will ultimately neither reduce abortions nor remain settled law. </p>
<p>I am a <a href="https://scholar.google.com/citations?user=N4nlBvMAAAAJ&hl=en">historian</a> who has studied American culture and law in the wake of the 1873 Comstock Act – the first U.S. effort to restrict access to birth control and abortions. My research finds that previous state and federal efforts to regulate the sexual expression and reproduction of Americans led to unintended consequences – and, in the long term, these laws failed.</p>
<p>Already, I see signs that new anti-abortion laws are triggering a similarly undermining backlash. </p>
<h2>How ‘obscene’</h2>
<p>In 1873, Congress hurriedly passed a law making it <a href="https://www.mtsu.edu/first-amendment/article/1038/comstock-act-of-1873">illegal to send</a> “obscenities” through the U.S. mail. The legislation was branded the Comstock Act after its most vigorous proponent: <a href="https://artsci.case.edu/dittrick/online-exhibits/history-of-birth-control/contraception-in-america-1800-1900/anthony-comstocks-influence/">Anthony Comstock</a>, a U.S. postal inspector and evangelical Christian who believed sexual activity was a sin unless it occurred between a married man and woman for the purpose of procreation. </p>
<p>Birth control and substances used to induce abortion were included in the definition of “obscenity,” because Comstock and his supporters believed that life and death were God’s decisions. The law also banned mailing erotic images and literature. In Comstock’s expansive view, this category included <a href="https://www.jstor.org/stable/43609326">images of athletes wearing tights</a>. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/478951/original/file-20220812-4591-btzygl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Black-and-white drawing showing a rotund man with a mustache dragging a limp woman behind him to a judge's bench in a courtroom" src="https://images.theconversation.com/files/478951/original/file-20220812-4591-btzygl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/478951/original/file-20220812-4591-btzygl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=595&fit=crop&dpr=1 600w, https://images.theconversation.com/files/478951/original/file-20220812-4591-btzygl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=595&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/478951/original/file-20220812-4591-btzygl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=595&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/478951/original/file-20220812-4591-btzygl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=747&fit=crop&dpr=1 754w, https://images.theconversation.com/files/478951/original/file-20220812-4591-btzygl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=747&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/478951/original/file-20220812-4591-btzygl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=747&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A 1915 comic skewering the Comstock laws.</span>
<span class="attribution"><a class="source" href="https://dlib.nyu.edu/themasses/books/masses054">The Masses</a></span>
</figcaption>
</figure>
<p>State versions of the original Comstock Law soon swept the United States. By 1900, 42 states had passed <a href="https://muse.jhu.edu/chapter/1906208">similar legislation</a> outlawing the production, sale, possession or circulation of “obscene” matter in their own jurisdictions. </p>
<p>These statutes ruled until the Supreme Court declared a right to privacy in medical decision-making nearly 100 years later, in <a href="https://supreme.justia.com/cases/federal/us/381/479/">Griswold v. Connecticut (1965)</a>. </p>
<p>This is the same ruling that was cited eight years later to protect the right to have an abortion in the now defunct <a href="https://www.law.cornell.edu/supremecourt/text/410/113">Roe v. Wade</a>.</p>
<h2>Impractical enforcement</h2>
<p>Comstock zealously enforced the laws he’d advocated for, both as a detective for the privately funded New York Society for the Suppression of Vice, and as an inspector for the U.S. Post Office Department. In attempting to eradicate contraceptives – including condoms and early forms of diaphragms – Comstock organized the arrests of numerous defendants. </p>
<p>However, he had difficulty getting prosecutors, juries and judges to see the seriousness of many of the “crimes” he investigated. In the late 19th century, wealthier Americans already <a href="https://artsci.case.edu/dittrick/online-exhibits/history-of-birth-control/contraception-in-america-1800-1900/19th-century-artifacts/">regularly used birth control</a>. </p>
<p>“Of all the indictments prior to 1878, pending in the Court of General Sessions, not one has been tried the past year,” Comstock wrote in his 1879 annual report for the society.</p>
<p>In one of these cases, <a href="https://timesmachine.nytimes.com/timesmachine/1878/07/11/80722044.pdf?pdf_redirect=true&ip=0">The New York Times reported</a>, Comstock was chastised by a New York City district attorney named Phelps for his “sharp practice” in investigating Dr. Sarah Blakeslee Chase. These included his posing as a client to obtain birth control products and repeatedly harassing the suspect. A grand jury threw out the case, stating that it “did not think it for the public good.” </p>
<p>Even when Comstock obtained a conviction, many defendants were pardoned immediately. </p>
<p>Enforcing new anti-abortion laws is similarly unpopular with many legal professionals today. Shortly after the Supreme Court issued its opinion in Dobbs, <a href="https://www.nytimes.com/2022/06/29/us/abortion-enforcement-prosecutors.html">more than 80 elected prosecutors</a> vowed not to bring indictments in cases involving abortion. </p>
<p>As they recognize, conservative courts in jurisdictions with zealous anti-abortion prosecutors – who <a href="https://www.al.com/news/2022/09/pregnant-women-held-for-months-in-one-alabama-jail-to-protect-fetuses-from-drugs.html">in some states are already enforcing new laws</a> – will soon be filled with a host of extremely sympathetic defendants: relatives who assist <a href="https://www.washingtonpost.com/lifestyle/2022/07/14/10-year-old-abortion/">children who are victims of rape</a> in obtaining an illegal abortion, <a href="https://news.bloomberglaw.com/health-law-and-business/doctors-fearing-legal-blowback-are-denying-life-saving-abortions">doctors saving the lives of mothers at risk</a>, and those who choose to help <a href="https://www.nytimes.com/2022/07/23/health/pregnant-woman-cancer-abortion.html">pregnant cancer patients</a> in making the best possible decisions for their health. </p>
<p>Enforcement of America’s new Comstock laws will likely once again make witnesses and defendants more sympathetic in the eyes of judges and jurors – and the public – undermining whatever support remains for these laws. </p>
<p>Beyond prosecutions, the tactics necessary to prevent women from obtaining abortions are even less practical today than they were in the late 19th century. </p>
<p>Enforcing anti-abortion laws may include <a href="https://www.wired.com/story/insterstate-travel-abortion-post-roe/">restricting interstate travel</a>, <a href="https://www.nytimes.com/article/medical-abortions-mifepristone-misoprostol-illegal.html">blocking interstate and international postal services</a> and attempting to <a href="https://www.axios.com/2022/07/01/roe-battlefield-online-abortion-information">censor information</a> about sexual health. All of these would require laborious investigations and extensive cooperation from law enforcement agencies and private corporations who will likely have little desire to involve themselves in unpopular prosecutions. </p>
<p>And that’s assuming that any of these methods survive court challenges. </p>
<h2>Uniting disparate factions</h2>
<p>By the time of Anthony Comstock’s death in 1915, backlash to his zealous overreach had provoked <a href="https://doi.org/10.1017/S1537781420000304">growing solidarity</a> among activists and attorneys determined to defeat his agenda. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/484616/original/file-20220914-6106-v30h3v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A woman sits in a chair being tended to by a nurse, standing" src="https://images.theconversation.com/files/484616/original/file-20220914-6106-v30h3v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/484616/original/file-20220914-6106-v30h3v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=876&fit=crop&dpr=1 600w, https://images.theconversation.com/files/484616/original/file-20220914-6106-v30h3v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=876&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/484616/original/file-20220914-6106-v30h3v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=876&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/484616/original/file-20220914-6106-v30h3v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1101&fit=crop&dpr=1 754w, https://images.theconversation.com/files/484616/original/file-20220914-6106-v30h3v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1101&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/484616/original/file-20220914-6106-v30h3v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1101&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Margaret Sanger at America’s first family planning clinic in New York.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/birth-control-activist-margaret-sanger-consults-with-fania-news-photo/588649364?adppopup=true">Bain News Service/PhotoQuest/Getty Images</a></span>
</figcaption>
</figure>
<p>Women’s rights activists, including Margaret Sanger, Emma Goldman and Mary Ware Dennett – formerly focused on competing goals and strategies – joined in common cause to repeal the Comstock laws. Their efforts led to the creation of new and powerful national civil liberties organizations, including Planned Parenthood and the American Civil Liberties Union. Both used lobbying and lawsuits to contribute to the death of the original Comstock laws.</p>
<p>These groups are <a href="https://www.msn.com/en-us/news/us/aclu-planned-parenthood-file-lawsuit-against-ohio-over-abortion-rights/ar-AA11pwZM">still fighting</a> new abortion restrictions today. And once again, post-Dobbs, disparate individuals and groups are raising their voices in common cause. </p>
<p><a href="https://www.politico.com/news/2022/08/22/doctors-abortion-state-capitals-00052946">Obstetricians</a> from around the country have begun lobbying politicians and forming their own pro-choice political action committees for the first time. TikTok influencers like <a href="https://www.tiktok.com/@0liviajulianna?lang=en&itid=lk_inline_enhanced-template">Olivia Julianna</a> are rallying young citizens to vote for pro-choice politicians. And <a href="https://www.theverge.com/2022/6/28/23186432/abortion-roe-scotus-howard-stern-my-favorite-murder-podcast">diverse podcasters</a>, from one-time provocateur Howard Stern to the hosts of the true crime show “My Favorite Murder,” are sharing resources with their listeners and expressing support for abortion rights. </p>
<h2>Ballot box backlash</h2>
<p><a href="https://www.nytimes.com/interactive/2022/08/25/upshot/female-voters-dobbs.html">Newly registered</a> and energized voters are turning out to support candidates and ballot initiatives that reflect the nation’s <a href="https://www.pewresearch.org/politics/2022/07/06/majority-of-public-disapproves-of-supreme-courts-decision-to-overturn-roe-v-wade/">majority support for abortion rights</a>. </p>
<p><a href="https://www.nytimes.com/interactive/2022/08/02/us/elections/results-kansas-abortion-amendment.html">Kansas roundly rejected an anti-abortion referendum in August 2022</a>. And more states will soon vote on state constitutional protections for abortion, <a href="https://www.wxpr.org/politics-government/2022-09-12/michigan-dems-hope-for-boost-from-abortion-ballot-initiative">including Michigan</a>.</p>
<p>The Comstock laws were not repealed quickly. And it’s now clear that American women’s right to reproductive health care remained tenuous after their demise. </p>
<p>Viewing the past as prologue, however, suggests that, once again, <a href="https://www.pewresearch.org/fact-tank/2022/06/13/about-six-in-ten-americans-say-abortion-should-be-legal-in-all-or-most-cases-2/">unpopular</a> anti-abortion laws will cause unintended consequences that, in the long run, will render them both ineffective and ultimately futile.</p><img src="https://counter.theconversation.com/content/188681/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Amy Werbel does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>US history suggests that Republican efforts to restrict reproductive rights will be difficult to enforce and widely reviled, undermining their effectiveness – and ultimately causing their demise.Amy Werbel, Professor of the History of Art, Fashion Institute of Technology (FIT)Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1858412022-07-28T12:25:47Z2022-07-28T12:25:47Z‘Rage giving’: Charities can get a boost from current events, such as controversial Supreme Court rulings<figure><img src="https://images.theconversation.com/files/473454/original/file-20220711-26-qiraph.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5607%2C3732&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Giving to a cause tied to nettlesome news may calm the nerves.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/woman-is-angry-about-her-computer-news-photo/548849571?adppopup=true">Wodicka/ullstein bild via Getty Images</a></span></figcaption></figure><p>When anger over everything from the killing of unarmed people of color to new restrictions on access to abortion bubbles over, many Americans act on it.</p>
<p>One avenue for someone who has gotten fed up with current events is to take part in protests, such as <a href="https://www.aljazeera.com/news/2022/6/11/thousands-rally-against-gun-violence-after-mass-shootings-surge">marching for gun reform</a> in response to mass shootings. Another is by what <a href="https://scholar.google.com/citations?hl=en&user=Ay7ZS0cAAAAJ">nonprofit</a> and <a href="https://scholar.google.com/citations?user=3qOb1RwAAAAJ&hl=en">philanthropy scholars</a> like to call “rage giving” – charitable donations motivated by strong emotions and dissatisfaction with the political climate. </p>
<p>In our <a href="https://www.cambridge.org/core/elements/abs/rage-giving/7D91A09D64D1514AF3C19F6690A4BD75">new book about this phenomenon</a>, we explain that people often donate to nonprofits following breaking news about events they consider to be tragic or unjust. By donating, people may feel they are addressing the wrong they want to see righted, or they can express a strong politically driven view or value. </p>
<h2>Divisive moments</h2>
<p>When news coverage grows and collective anger culminates in high-profile marches, rage givers can experience an emotional release by channeling their feelings into <a href="https://www.theringer.com/tech/2018/6/22/17494052/rage-giving-trump-immigration-twitter">something they consider positive</a>.</p>
<p>Quick bursts of anger sometimes called “<a href="https://www.usatoday.com/story/tech/2018/06/20/rage-giving-fuels-record-fundraising-immigrant-children/718272002/">fury triggers</a>” <a href="https://doi.org/10.1111/bjso.12522">usually drive these gifts</a>. </p>
<p>We have found that waves of rage giving are often sparked by divisive political moments. These unexpected spikes in donations are typically fueled by extensive media coverage. </p>
<p>For example, after the <a href="https://www.npr.org/2022/05/27/1101490738/uvalde-buffalo-mass-shooting-similarities">mass shootings in Uvalde, Texas, and Buffalo</a>, New York, <a href="https://buffalonews.com/business/local/as-donations-flow-in-after-tops-shooting-the-first-grants-are-rolling-out/article_d871d938-ddfa-11ec-99b7-238ada5cebd2.html">donations to groups that support gun violence victims</a> in both <a href="https://cftexas.org/supportuvalde">communities surged</a>.</p>
<p>And, shortly after the May 2022 leak of the <a href="https://www.townandcountrymag.com/society/politics/a40218865/us-supreme-court-roe-v-wade-overturned-decision/">Supreme Court’s draft decision to overturn Roe v. Wade</a>, NARAL Pro-Choice America, an organization that advocates for access to abortion, saw a <a href="https://www.reuters.com/world/us/donations-us-abortion-rights-groups-clinics-surge-after-supreme-court-leak-2022-05-04/">1,400% increase in donations within 24 hours</a>. </p>
<p>Likewise, the Brigid Alliance, a nonprofit <a href="https://theconversation.com/abortion-funds-are-in-the-spotlight-with-the-end-of-roe-v-wade-3-findings-about-what-they-do-182636">abortion fund</a> that provides financial and logistical help for people seeking abortions, saw the <a href="https://www.pbs.org/newshour/nation/funding-increases-for-abortion-related-causes-as-rage-giving-continues">number of its donors quadruple</a> from May to July. The gifts ranged from $5 to $50,000.</p>
<h2>Growth following 2016 election</h2>
<p>Rage giving isn’t limited to guns or abortion. Nor is it new. </p>
<p>But there are many signs that the phenomenon grew ahead of, <a href="https://www.theringer.com/tech/2018/6/22/17494052/rage-giving-trump-immigration-twitter">during and after</a> the <a href="https://www.npr.org/2016/11/05/500782887/donald-trumps-road-to-election-day">heated 2016</a> and <a href="https://afpglobal.org/news/engagement-all-rage-philanthropy-amid-crisis">2020 presidential elections</a>. Many people who were concerned about immigration, civil rights and sexual assault and harassment during those highly polarized periods sought out opportunities to give to nonprofits and political action committees as <a href="https://www.bostonglobe.com/business/2016/11/21/rage-donate-becomes-anti-trump-balm/7t4pJvnlbfAW3A3NeItmyL/story.html">quick and easy ways to express their outrage</a>.</p>
<p>The ease and growth of online giving, <a href="https://institute.blackbaud.com/charitable-giving-report/online-giving-trends">up 42% in the three years ending in 2021</a>, makes it simpler for rage givers to express their outrage. There’s no longer a need to mail a check or make a phone call.</p>
<p>Rage giving is, to be sure, partisan in that anger and outrage can provoke political mobilization, action and higher voter turnout.</p>
<p>But nonprofits on both sides of the political and cultural divide have reaped windfalls from rage giving in recent years. <a href="https://www.bbc.com/news/world-us-canada-43884698">Giving to pro-gun organizations</a> like the National Rifle Association, for example, can surge when gun control measures are in the news –as is generally the case after mass shootings. </p>
<h2>More likely to be women and Democrats</h2>
<p>In 2017, we commissioned a survey that identified 520 people who said they had donated to a nonprofit of their choice after feeling <a href="https://doi.org/10.1017/9781108951036">unbridled anger during the 2016 presidential election</a>. Based on that data, we estimated that about 58% of these rage givers were women and 80% were white.</p>
<p>About 44% said they were Democrats, roughly 35% said they were Republicans and the remaining 21% identified as independent voters. Because the shares of Americans who <a href="https://news.gallup.com/poll/15370/party-affiliation.aspx">lean toward one major political party</a> or the other is more evenly matched, we found that, at that moment in time, Democrats were more likely to donate this way than more conservative Americans.</p>
<p>When thinking about the candidates in the 2016 presidential election and the stances each candidate takes on social and environmental issues, one rage giver from North Carolina said in response to our survey, “I’m just sick about it,” she said. “We’ve got to do something.”</p>
<p>We also found the surveyed rage donors were likely to be civically engaged – through behaviors such as volunteering, voting, contacting elected officials and participating in marches and protests. Rage giving, as a form of collective action, aligns with other helping behaviors by giving a voice to the underserved and unheard.</p>
<p>More research is needed to get a clearer picture of why certain people do this. But based on what we’ve learned so far, we believe that people who engage in rage giving see philanthropy as a type of civic engagement and that their gift, along with other donations, makes a difference.</p><img src="https://counter.theconversation.com/content/185841/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>These donors can experience an emotional release by channeling their feelings into something they consider positive.Jennifer A. Taylor, Associate Professor of Political Science, James Madison University Katrina Miller-Stevens, Associate Professor of Management, Colorado CollegeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1861862022-07-22T12:29:58Z2022-07-22T12:29:58ZHow to navigate self-managed abortion issues such as access, wait times and complications – a family physician explains<figure><img src="https://images.theconversation.com/files/474177/original/file-20220714-32290-129v78.jpg?ixlib=rb-1.1.0&rect=31%2C31%2C5260%2C3364&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">When abortion care is restricted, demand for abortion pills goes up.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/abortion-drug-pills-and-drinking-water-royalty-free-image/1163891983?adppopup=true">Peter Dazeley/The Image Bank via Getty Images</a></span></figcaption></figure><p>“Are these pills legit? If I send money, am I even going to get these pills?”</p>
<p>These are the kinds of questions people have when they are curious about ordering medication abortion pills online.</p>
<p>This process, often called “self-sourced <a href="https://theconversation.com/what-is-a-medication-or-medical-abortion-5-questions-answered-by-3-doctors-182646">medication abortion</a>,” refers to an individual finding or sourcing medications to induce an abortion on their own, without going through their primary care provider, OB-GYN or other clinic like Planned Parenthood. Globally, abortion pills <a href="https://doi.org/10.1016/S0020-7292(98)00195-7">might be found without prescriptions</a> at neighborhood pharmacies or by accessing local community networks. In the U.S., even prior to the fall of Roe v. Wade, someone could order abortion pills online. </p>
<p><a href="https://www.uwmedicine.org/bios/grace-shih">As a family physician</a> practicing in Washington, I expect that abortion care will remain legal in my state. Even so, in the setting of legal abortion, I have cared for people who are self-managing their abortion because they don’t have a nearby abortion provider, because they cannot get a timely appointment or because they want control of their abortion experience. </p>
<p>In a study done before Roe v. Wade was overturned, researchers estimated that 7% of U.S. women would attempt <a href="https://doi.org/10.1001/jamanetworkopen.2020.29245">self-managed abortion in their lifetime</a>. Research shows that when there are more restrictions around care, demand for online abortion pills increases. </p>
<p>For example, one study looked at <a href="https://doi.org/10.1001/jamanetworkopen.2022.1122">requests to a common online source of abortion pills</a> the week after enactment of <a href="https://doi.org/10.1056/NEJMp2207423">Texas’ Senate Bill 8</a> – legislation that banned abortion after the detection of embryonic cardiac activity. That study found a mean daily increase of 1,180% over the baseline before the legislation took effect. We can only expect a larger surge given the new legal landscape in the post-Roe world.</p>
<p>As more people look to the internet to find <a href="https://theconversation.com/abortion-pills-are-safe-to-prescribe-without-in-person-exams-new-research-finds-179622">abortion pills</a>, what can they do to avoid getting scammed and stay safe? Here are some resources and common questions people have about the process. </p>
<h2>How do you get abortion pills online?</h2>
<p>There are lots of places where you can get abortion pills online; however, not all sites have been vetted for legitimacy. One reliable “one-stop shop” is <a href="https://www.plancpills.org/">plancpills.org</a>. This is a private advocacy organization that provides information on how to get pills. It does not mail the pills itself, but identifies the options that are available depending on someone’s location as well as basic information like the cost, delivery time, age restrictions and financial assistance availability. It’s like <a href="https://www.goodrx.com/">GoodRx</a> for abortion pills. </p>
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<figcaption><span class="caption">Those considering abortion pills should plan to rest and remain at home on the day they take misoprostol.</span></figcaption>
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<h2>What are the abortion pills?</h2>
<p>There are two medications that are commonly used for medication abortion: <a href="https://www.webmd.com/drugs/2/drug-20222-325/mifepristone-oral/mifepristone-oral/details">mifepristone</a> and <a href="https://medlineplus.gov/druginfo/meds/a689009.html">misoprostol</a>. Mifepristone blocks the hormone progesterone and stops the pregnancy from continuing. Misoprostol is a prostaglandin – a compound that has hormone-like effects on the body – that helps soften and dilate the cervix to expel the pregnancy. </p>
<p>Some online abortion sites may offer the mifepristone pill with misoprostol pills, and others may only have misoprostol pills. Both options are <a href="https://theconversation.com/abortion-pills-are-safe-to-prescribe-without-in-person-exams-new-research-finds-179622">safe and highly effective</a>. </p>
<p>In the U.S., medication abortion is <a href="https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/020687s020lbl.pdf">approved by the Food and Drug Administration</a> as the combination of mifepristone with misoprostol. However, mifepristone can be difficult to obtain <a href="https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/mifeprex-mifepristone-information">because of prescribing restrictions</a>. </p>
<p>Misoprostol is more readily accessible and available over the counter in many countries. There are accepted protocols for both the <a href="https://www.reproductiveaccess.org/wp-content/uploads/2020/08/2022-06-How-to-Use-Abortion-Pills-Mife-and-Miso.pdf">mifepristone-plus-misoprostol abortion</a> and the <a href="https://www.reproductiveaccess.org/resource/mabfactsheet-miso/">misoprostol-only abortion</a> pills. </p>
<h2>What if I live in a state with restricted abortion access?</h2>
<p>You can still buy the pills in states with restricted abortion access, but it may take longer to get them and there may be some legal risks. There are several options for people living in states <a href="https://www.guttmacher.org/state-policy/explore/overview-abortion-laws">that have total bans on abortion</a>, like Texas, Oklahoma, South Dakota, Missouri, Mississippi, Arkansas and Alabama. </p>
<p>One option is <a href="https://aidaccess.org/">Aid Access</a>, a private organization with clinicians inside and outside the United States. When requests are made by people living in states with abortion bans, prescriptions are written by non-U.S. physicians and pills are mailed from international sources. Because of this process, it takes longer – two to three weeks versus two to three days – to receive the abortion pills. </p>
<p>Another option is ordering directly from online pharmacies. This means no prescription is required since no clinicians are involved; the process can be quicker, but it also may cost more (say, $200 to $400 compared to $100). </p>
<p>Finally, <a href="https://www.plancpills.org/mail-forwarding">some people use mail forwarding</a> as a way to get abortion pills to restricted states. For legal questions, people can seek free, confidential help on the Repro Legal Helpline <a href="https://www.reprolegalhelpline.org/sma-contact-the-helpline/">either online</a> or at 844-868-2812. </p>
<h2>Are the online pills safe?</h2>
<p>For the most part, yes. A 2017 study <a href="https://doi.org/10.1016/j.contraception.2017.09.016">investigated the process</a> of buying abortion pills from online sources, including verifying the chemical quality of the pills received. Most of the sources contained within 8% of the labeled active ingredient. </p>
<p>This study was <a href="https://gynuity.org/">conducted by researchers from Gynuity and Plan C</a>, which are nonprofit organizations dedicated to abortion research and advocacy. <a href="https://www.plancpills.org/">Plan C Pills</a> continues to check its sources, and only those that have been vetted and verified are included on its website. </p>
<p>In general, medication abortion is very safe. In fact, medication abortion pills are so safe and easy to use that a label prototype for over-the-counter medication abortion <a href="https://doi.org/10.1097/AOG.0000000000004757">has been studied</a>. </p>
<h2>What happens if you have a question once you have the pills?</h2>
<p>Depending on where you order the pills, you may have access to a clinician who works with the organization that mails out the pills. If no clinician is available or if you ordered directly from an online pharmacy, people can contact the <a href="https://www.mahotline.org/">M+A Hotline</a>, which is a text/phone-based hotline staffed by volunteer licensed clinicians, or <a href="https://abortionpillinfo.org/">Self-Managed Abortion Safe & Supported</a>, a global nonprofit where trained counselors answer questions through a secure web portal. </p>
<p>The bottom line is that self-managed medication abortion <a href="https://doi.org/10.1016/j.lana.2022.100200">is medically safe</a>, and there are many reliable resources available to help people through the process. As abortion restrictions increase in the U.S., abortion pills may become like any other internet commodity – just a click away.</p><img src="https://counter.theconversation.com/content/186186/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Grace Shih is part of a network of providers that supports people and providers with sexual and reproductive health questions.</span></em></p>Abortion pills are available online, and many of them are safe. But not all sites have been properly vetted for legitimacy.Grace Shih, Associate Professor of Family Medicine, School of Medicine, University of WashingtonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1858302022-06-30T12:22:39Z2022-06-30T12:22:39ZMore states will now limit abortion, but they have long used laws to govern – and sometimes jail – pregnant women<figure><img src="https://images.theconversation.com/files/471669/original/file-20220629-22-rdcjl0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Activists protest for the end of shackling pregnant women during birth in prison in New York in 2015.</span> <span class="attribution"><a class="source" href="https://mapi.associatedpress.com/v1/items/f50522d3e2584b00b7652bee417bd8f3/preview/AP090818071368.jpg?wm=api&tag=app_id=1,user_id=904438,org_id=101781">Yanina Manolova/Associated Press</a></span></figcaption></figure><p>It’s clear that the Supreme Court’s ruling in <a href="https://www.oyez.org/cases/2021/19-1392">Dobbs v. Jackson Women’s Health Organization</a> will make it harder for women to get an abortion across much of the United States. But there are other kinds of laws – not related to abortion – that already control the decisions women make during pregnancy.</p>
<p>In this scenario, a state concludes a pregnant woman’s conduct, mostly related to substance use, might harm the fetus they are carrying. These women are then forced into mandatory treatment or jail. Most of the women affected by these laws are poor, and disproportionately Black or Latina. </p>
<p>I am a <a href="https://law.utk.edu/directory/wendy-bach/">law professor</a> who studies poverty policy in the U.S. I think it is key to understand that the Dobbs ruling not only allows state legislatures to limit women’s ability to get an abortion, but it also invites state legislatures to pass more laws that control pregnant women’s behavior. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/471478/original/file-20220628-14253-pmgj2z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A pregnant woman in orange stands in a profile shot, holding her belly" src="https://images.theconversation.com/files/471478/original/file-20220628-14253-pmgj2z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/471478/original/file-20220628-14253-pmgj2z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=840&fit=crop&dpr=1 600w, https://images.theconversation.com/files/471478/original/file-20220628-14253-pmgj2z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=840&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/471478/original/file-20220628-14253-pmgj2z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=840&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/471478/original/file-20220628-14253-pmgj2z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1055&fit=crop&dpr=1 754w, https://images.theconversation.com/files/471478/original/file-20220628-14253-pmgj2z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1055&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/471478/original/file-20220628-14253-pmgj2z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1055&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A pregnant female inmate at the Western Massachusetts Regional Women’s Correctional Center in Chicopee poses for a portrait in March 2014.</span>
<span class="attribution"><a class="source" href="https://media.gettyimages.com/photos/pregnant-female-inmate-at-western-massachusetts-regional-womens-in-picture-id633693514?s=2048x2048">Dina Rudick/The Boston Globe via Getty Images</a></span>
</figcaption>
</figure>
<h2>States’ history of punishing women during pregnancy</h2>
<p>At least <a href="https://www.nationaladvocatesforpregnantwomen.org/arrests-and-prosecutions-of-pregnant-women-1973-2020/">40 states</a> have used a variety of laws to punish the behavior of pregnant women over the last five decades. These cases usually involve a woman whom the state believes is harming her fetus by taking drugs or abusing alcohol. </p>
<p>For example, as I describe in my <a href="https://www.cambridge.org/us/academic/subjects/law/socio-legal-studies/prosecuting-poverty-criminalizing-care?format=PB&isbn=9781108465533#contentsTabAnchor">book coming</a> out in September, Tennessee prosecuted and punished about 120 women from 2014 to 2016 for harming the fetuses they were carrying when they took narcotics during their pregnancies. </p>
<p>In total, scholars, journalists and activists <a href="https://www.nationaladvocatesforpregnantwomen.org/arrests-and-prosecutions-of-pregnant-women-1973-2020/">have documented</a> over 1,700 prosecutions and other interventions, like jailing a woman who refuses to enter treatment, against pregnant women from 1973 to 2020. </p>
<p>States have prosecuted women, in these cases, for <a href="https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3307889">assault</a>, <a href="https://www.propublica.org/article/when-the-womb-is-a-crime-scene">chemical endangerment</a>, child abuse and <a href="https://www.ktvu.com/news/california-supreme-court-rules-meth-using-mom-can-face-murder-charge-in-babys-stillborn-death">murder</a>. </p>
<p>Although in most cases these laws were originally passed to criminalize other people’s attacks against pregnant women, prosecutors have used these laws to prosecute pregnant women themselves.</p>
<p>While one might think that bringing prosecutions and jailing women to protect a fetus from her mother’s drug use might be an effective, if extreme, way to protect the fetus, virtually <a href="https://www.nationaladvocatesforpregnantwomen.org/medical_and_public_health_group_statements_opposing_prosecution_and_punishment_of_pregnant_women_revised_june_2021/">every</a> major medical organization disagrees. </p>
<p><a href="https://www.acog.org/clinical-information/policy-and-position-statements/statements-of-policy/2020/opposition-criminalization-of-individuals-pregnancy-and-postpartum-period#:%7E:text=ACOG%20believes%20that%20it%20is,the%20postpartum%20period%20(11).">Research shows that</a> incarcerating pregnant women because of substance use is not effective as a deterrent and can actually harm both the pregnant person and fetus. </p>
<p>One reason is that there is significant anecdotal evidence that jails and prisons lack <a href="https://www.prisonpolicy.org/blog/2019/12/05/pregnancy/#:%7E:text=All%20U.S.%20prisons%20and%20jails,receiving%20the%20care%20they%20need.">basic prenatal care services</a>. The vast majority of jails also do not provide adequate <a href="https://arrwip.org/projects/management-of-pregnant-people-with-opioid-use-disorder-in-jail/">health care services for</a> pregnant patients with substance use disorders. </p>
<p>Another reason is that women who know that they might be punished if they go to the doctor are likely to avoid the doctor, a result that can harm both mother and child.</p>
<p>Instead, the <a href="https://policysearch.ama-assn.org/policyfinder/detail/prenatal?uri=%2FAMADoc%2FHOD.xml-0-3705.xml">American Medical Association</a> and other expert groups recommend that the government spend more money setting up specialized treatment programs for pregnant and breastfeeding women with substance use disorders.</p>
<h2>Jailing pregnant women to protect their fetuses</h2>
<p>In addition to criminal prosecutions, there are at least two other kinds of state laws that let judges involuntarily commit and jail pregnant women. </p>
<p>First, judges in Tennessee have used state law to <a href="https://www.tennessean.com/story/news/crime/2017/02/04/small-town-tennessee-judge-opioid-crisis-personal/95359050/">jail pregnant women</a> who are on probation when the court has evidence that the woman is using drugs during pregnancy. </p>
<p>As one court staff person explained to me, when a criminal court judge finds out that a pregnant woman who is on probation has failed a drug test, the court issues an order putting her in jail. As that particular Tennessee court worker explained to me in 2018, “A lot of babies have been saved that way.” </p>
<p>Second, in <a href="https://docs.legis.wisconsin.gov/1997/related/acts/292">Wisconsin</a>, <a href="https://casetext.com/statute/south-dakota-codified-laws/title-34-public-health-and-safety/chapter-20a-treatment-and-prevention-of-alcohol-and-drug-abuse/section-34-20a-63-effective-712022-emergency-commitment-grounds">South Dakota</a> and <a href="https://law.justia.com/codes/minnesota/2018/chapters-245-267/chapter-253b/">Minnesota</a>, legislatures have authorized the involuntary commitment, either in medical facilities or jail, of pregnant women who use drugs or alcohol during pregnancy. </p>
<p>For example, in Wisconsin, <a href="https://docs.legis.wisconsin.gov/1997/related/acts/292">the state can investigate</a> the welfare of an “unborn child” and can order a woman to comply with drug treatment and services. If she refuses, the court can mandate that this woman is arrested and <a href="https://arrwip.org/projects/management-of-pregnant-people-with-opioid-use-disorder-in-jail/">jailed</a>. </p>
<p>Because child welfare records are confidential, we do not know precisely how many cases like these exist. In one court case, the state of Wisconsin revealed that, from 2006 to 2017, 467 women were found to have committed “unborn child abuse,” meaning that the state believed these women harmed their fetuses.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/471667/original/file-20220629-23-t8ai8r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Silhouettes of people outside the Supreme Court are shown, with one person holding a sign that says 'Protect'" src="https://images.theconversation.com/files/471667/original/file-20220629-23-t8ai8r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/471667/original/file-20220629-23-t8ai8r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/471667/original/file-20220629-23-t8ai8r.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/471667/original/file-20220629-23-t8ai8r.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/471667/original/file-20220629-23-t8ai8r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/471667/original/file-20220629-23-t8ai8r.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/471667/original/file-20220629-23-t8ai8r.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Abortion rights protesters stand outside the Supreme Court building on June 28, 2022, a few days after the Dobbs v. Jackson Women’s Health Organization decision was announced.</span>
<span class="attribution"><a class="source" href="https://media.gettyimages.com/photos/small-group-of-abortionrights-supporters-gather-in-front-of-the-on-picture-id1241597144?s=2048x2048">Nathan Howard/Getty Images</a></span>
</figcaption>
</figure>
<h2>Dobbs invites states to pass more laws like these</h2>
<p>In one sense, Dobbs has little impact on these kinds of laws. Roe v. Wade and the 1992 case that reinforced its precedent, <a href="https://www.oyez.org/cases/1991/91-744">Planned Parenthood v. Casey</a>, never stopped these prosecutions and interventions, and they would have continued even if the Supreme Court didn’t overturn these rulings. </p>
<p>On the other hand, it is clear that the Dobbs ruling grants state legislatures new license to pass laws in the name of fetal protection. </p>
<p>Prior to Dobbs, constitutional law balanced the rights of a pregnant woman to control her pregnancy against the state’s legitimate interest in the fetus. </p>
<p>That is why, under Roe and Casey, a woman’s interest in controlling her body outweighed the state’s interest in the fetus early in a woman’s pregnancy. As a pregnancy progressed, the balance shifted away from protecting the woman’s autonomy and toward protecting the state’s interest in the fetus. </p>
<p>But as Supreme Court Justices Stephen Breyer, Elena Kagan and Sonia Sotomayor <a href="https://www.supremecourt.gov/opinions/21pdf/19-1392_6j37.pdf">explain in their dissenting opinion</a> with the Dobbs ruling, “the Court discards that balance. It says that from the very moment of fertilization, a woman has no rights to speak of.”</p>
<p>So who will look out for the rights of either the mother or the fetus?</p>
<p>The Supreme Court is clear. As Justice Brett Kavanaugh explained in his <a href="https://www.supremecourt.gov/opinions/21pdf/19-1392_6j37.pdf">concurring opinion</a>, “those difficult moral and policy questions will be decided” not by the court, but “by the people and their elected representatives through the constitutional processes of democratic self-government.”</p>
<p>After Dobbs, as the dissenting judges explained, it seems the states have all the power they need to pass and enforce new laws that punish pregnant women, whether or not they want to get an abortion.</p><img src="https://counter.theconversation.com/content/185830/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Wendy Bach does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Tennessee and Wisconsin are among the states that can jail pregnant women because of illegal substance use, despite major medical groups saying that this practice isn’t effective.Wendy Bach, Professor of Law, University of TennesseeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1758112022-01-27T13:31:34Z2022-01-27T13:31:34ZThe moderate, pragmatic legacy of Stephen Breyer<figure><img src="https://images.theconversation.com/files/442841/original/file-20220126-26-16nbyan.jpg?ixlib=rb-1.1.0&rect=11%2C11%2C3739%2C2485&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A justice representing a kinder political age?</span> <span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/SupremeCourtBreyerRetire/322df6a5f075411fa0d7810abac23943/photo?Query=Stephen%20Breyer&mediaType=photo&sortBy=arrivaldatetime:desc&dateRange=Anytime&totalCount=473&currentItemNo=37">AP Photo/Steven Senne</a></span></figcaption></figure><p>Stephen Breyer will leave a legacy that reflects the Supreme Court he joined nearly three decades ago – less fractious and less partisan than the bench he is <a href="https://apnews.com/article/stephen-breyer-supreme-court-retirement-2f9c1f5da824e3b1ef25964205131fff">reportedly set to leave</a> at the end of the current term.</p>
<p>When Breyer was <a href="https://clinton.presidentiallibraries.us/items/show/36180">nominated by Democratic President Bill Clinton</a> in 1994, he was not a controversial choice. He was confirmed by an 87-9 vote in the Senate, garnering the support of <a href="https://news.bloomberglaw.com/us-law-week/breyers-strong-bipartisan-confirmation-a-relic-of-the-past">79% of Republicans</a>.</p>
<p>There were few surprises at his relatively uneventful <a href="https://lawreview.uchicago.edu/sites/lawreview.uchicago.edu/files/ConfirmationMessesOldAndNew.pdf">confirmation hearing</a>. By and large, senators knew what they were getting: a moderate liberal who took a pragmatic approach to judging.</p>
<p>For Breyer, this meant a healthy respect for precedent and endeavoring to understand the practical consequences of the court’s cases, including how they affect the general population.</p>
<h2>Breyer’s majority opinions</h2>
<p>Breyer joined a court that had just reaffirmed the right to abortion in 1992’s <a href="https://www.oyez.org/cases/1991/91-744">Planned Parenthood v. Casey</a>, and he consistently upheld the precedent set by that case and Roe v. Wade throughout his tenure. In 2000, he wrote the majority opinion in <a href="https://www.oyez.org/cases/1999/99-830">Stenberg v. Carhart</a>, invalidating a state law that criminalized “partial-birth” abortion. In more recent terms, his opinions in <a href="https://www.oyez.org/cases/2015/15-274">Whole Woman’s Health v. Hellerstedt</a> and <a href="https://www.oyez.org/cases/2019/18-1323">June Medical Services, LLC v. Russo</a>, in 2016 and 2020 respectively, struck down state hospital admission requirements for abortion clinic doctors.</p>
<p>As the court moved in a more conservative direction, particularly after the 2020 death of liberal Justice <a href="https://www.nytimes.com/2020/09/18/us/ruth-bader-ginsburg-dead.html">Ruth Bader Ginsburg</a>, Breyer forged an alliance with Chief Justice John Roberts at the Court’s <a href="https://www.theatlantic.com/ideas/archive/2022/01/stephen-breyer-retirement-supreme-court-biden/619331">pragmatic center</a>.</p>
<p>Together, they led the court to moderate rulings upholding the <a href="https://apnews.com/article/supreme-court-dismisses-obamacare-challenge-67cc2e9604a70b1b329c5f3b4177a688">Affordable Care Act</a> and the free-speech <a href="https://apnews.com/article/supreme-court-cursing-cheerleader-first-amendment-981374cd3adc0e73274d7d33c29a9e0e">rights of students</a>. </p>
<h2>Breyer’s dissents</h2>
<p>Breyer’s moderate, pragmatic approach to judging is also apparent in his dissents. For instance, in 2015’s <a href="https://www.oyez.org/cases/2014/14-7955">Glossip v. Gross</a>, Breyer argued that the death penalty was unconstitutional because it was not consistent with contemporary understandings of what constitutes “cruel and unusual punishment.”</p>
<p>To justify this, he pointed out that states were increasingly abandoning the death penalty, that support for the death penalty among the public was decreasing, and that the vast majority of members of the United Nations had ceased using the death penalty. </p>
<p>Being moderate didn’t mean that Breyer was without strong feelings. In the school integration case of <a href="https://www.oyez.org/cases/2006/05-908">Parents Involved in Community Schools v. Seattle School District No. 1</a>, which came before the court in 2007, Breyer read his dissent from the bench – a rare occurrence that <a href="https://www.minnesotalawreview.org/wp-content/uploads/2012/01/TimJohnson_MLR.pdf">signaled</a> his passion for the issue.</p>
<p>Breyer sharply criticized the majority’s decision to strike down voluntary integration policies aimed at achieving racial diversity in a student body. Lamenting what he viewed as a radical departure from precedent, Breyer wrote, “It is not often in the law that so few have so quickly changed so much.”</p>
<h2>Breyer’s Legacy</h2>
<p>Justice Breyer is a product of the era in which he was confirmed: a conservative America where only moderate Democrats were politically viable.</p>
<p>[<em>Over 140,000 readers rely on The Conversation’s newsletters to understand the world.</em> <a href="https://memberservices.theconversation.com/newsletters/?source=inline-140ksignup">Sign up today</a>.]</p>
<p>Clinton had considered several high-profile <a href="https://www.baltimoresun.com/news/bs-xpm-1994-04-07-1994097137-story.html">liberal politicians</a>, including Maine Senator George Mitchell and then-Interior Secretary Bruce Babbitt, for the Supreme Court seat left vacant after the retirement of Justice Harry Blackmun. But in the end, he opted for a moderate judge who was already on the bench.</p>
<p>Breyer’s pragmatic approach allowed him to reach consensus with his more conservative colleagues.</p>
<p>His expected departure reminds America that the era of consensus has largely passed.</p><img src="https://counter.theconversation.com/content/175811/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>There was little controversy when President Bill Clinton nominated Stephen Breyer to the bench in 1994. His tenure on the Supreme Court reflects those less partisan times.Paul M. Collins Jr., Professor of Legal Studies and Political Science, UMass AmherstArtemus Ward, Professor of Political Science, Northern Illinois UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1624762021-12-02T14:21:34Z2021-12-02T14:21:34ZHow a Supreme Court decision limiting access to abortion could harm the economy and women’s well-being<figure><img src="https://images.theconversation.com/files/461289/original/file-20220504-15-r3tbzx.jpg?ixlib=rb-1.1.0&rect=137%2C73%2C6905%2C4624&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The Supreme Court appears on the cusp of ending Roe v. Wade. </span> <span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/SupremeCourtAbortion/2194204e1a714554912fc438b10727d9/photo?Query=abortion&mediaType=photo&sortBy=arrivaldatetime:desc&dateRange=Anytime&totalCount=9770&currentItemNo=3">AP Photo/Jason DeCrow</a></span></figcaption></figure><p>A leaked draft <a href="https://www.politico.com/news/2022/05/02/supreme-court-abortion-draft-opinion-00029473">suggests the Supreme Court</a> <a href="https://theconversation.com/abortion-right-guaranteed-by-roe-will-be-replaced-by-state-power-if-the-supreme-court-adopts-the-leaked-alito-opinion-182379">is ready to overturn Roe v. Wade</a>, the landmark case that gave women the right to terminate a pregnancy.</p>
<p>But reproductive health isn’t <a href="https://www.guttmacher.org/united-states/abortion/demographics">just about abortion</a>, despite all the attention the procedure gets. It’s also about access to family planning services, contraception, sex education and much else – all of which <a href="https://www.scientificamerican.com/article/it-rsquo-s-time-to-end-the-war-on-women-rsquo-s-health/">have also come under threat</a> in recent years. </p>
<p><a href="https://iwpr.org/wp-content/uploads/2020/07/B379_Abortion-Access_rfinal.pdf">Such access lets women control the timing</a> and size of their families so they have children when they are financially secure and emotionally ready and can finish their education and advance in the workplace. After all, <a href="http://www.nwlc.org/sites/default/files/pdfs/reproductive_health_is_part_of_the_economic_health_of_women_5.29.15pdf.pdf">having children is expensive</a>, <a href="https://www.usda.gov/media/blog/2017/01/13/cost-raising-child">typically costing almost US$15,000</a> a year for a middle-class family. For low-income working families, <a href="https://americanprogress.org/article/working-families-spending-big-money-child-care/">child care costs alone</a> can eat up over a third of earnings. </p>
<p>And that’s why providing Americans with a full range of reproductive health options is good for the economy, at the same time as being essential to the financial security of women and their families. As <a href="https://law.ubalt.edu/faculty/profiles/gilman/">a law professor who represents people experiencing poverty</a>, I believe doing the opposite threatens not only the physical health of women but their economic well-being too.</p>
<h2>The economics of contraception</h2>
<p>A <a href="https://www.oyez.org/cases/1991/91-744">Supreme Court majority acknowledged</a> as much in 1992, stating in its Planned Parenthood of Southeastern Pennsylvania v. Casey decision:</p>
<blockquote>
<p>“The ability of women to participate equally in the economic and social life of the nation has been facilitated by their ability to control their reproductive lives.”</p>
</blockquote>
<p>But in recent years, the right to control their reproductive health has become <a href="https://www.ansirh.org/research/research/novel-study-identifies-27-large-us-cities-abortion-deserts">increasingly illusory</a> for many women, particularly the poor. </p>
<p>Given their focus on limiting access to abortion, you might assume that conservative politicians would be for policies that help women avoid unintended pregnancies. But <a href="https://www.vogue.com/article/anti-birth-control-movement">conservative attacks on birth control</a> <a href="https://www.salon.com/2019/08/20/why-are-republicans-taking-away-birth-control-because-they-dont-want-women-to-have-it">are escalating</a>, even though <a href="http://www.cdc.gov/nchs/data/nhsr/nhsr062.pdf">99% of sexually active women</a> of reproductive age have used <a href="https://www.guttmacher.org/fact-sheet/contraceptive-use-united-states">some form of it such as an intrauterine device, patch or pill</a> at least once.</p>
<p>In addition to its widely recognized health and autonomy benefits for women, contraception <a href="http://www.theatlantic.com/health/archive/2014/07/the-broader-benefits-of-contraception/373856">directly boosts the economy</a>. In fact, research shows access to the pill <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3684076/">is responsible</a> for a third of women’s wage gains since the 1960s. </p>
<p>And this benefit <a href="https://iwpr.org/wp-content/uploads/2020/07/Contraception-fact-sheet_final.pdf">extends to their kids</a>. Children born to mothers with access to family planning <a href="http://www.nber.org/papers/w19493.pdf">benefit from a 20% to 30% increase</a> in their own incomes over their lifetimes, as well as boosting college completion rates. </p>
<p>Not surprisingly, in a 2016 survey, <a href="https://www.urban.org/urban-wire/women-want-effective-birth-control">80% of women said birth control had a positive effect</a> on their lives, including 63% reporting that it reduces stress and 56% saying it helps them to keep working. </p>
<figure class="align-center ">
<img alt="two hands hold a plastic package that's been ripped open showing a container containing many little white and green pills" src="https://images.theconversation.com/files/461288/original/file-20220504-17-409ee2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/461288/original/file-20220504-17-409ee2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=458&fit=crop&dpr=1 600w, https://images.theconversation.com/files/461288/original/file-20220504-17-409ee2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=458&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/461288/original/file-20220504-17-409ee2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=458&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/461288/original/file-20220504-17-409ee2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=576&fit=crop&dpr=1 754w, https://images.theconversation.com/files/461288/original/file-20220504-17-409ee2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=576&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/461288/original/file-20220504-17-409ee2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=576&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Not everyone has equal access to effective birth control.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/TrumpBirthControl/04e57690d6e84317a1bd1698392fed3d/photo?Query=contraception&mediaType=photo&sortBy=arrivaldatetime:desc&dateRange=Anytime&totalCount=411&currentItemNo=9">AP Photo/Rich Pedroncelli</a></span>
</figcaption>
</figure>
<h2>Disparities in access</h2>
<p>Still, there is a class divide in contraception access, as evidenced by disparities in the 2011 rate of unintended pregnancies – the latest data available. </p>
<p>While the <a href="https://www.cdc.gov/reproductivehealth/contraception/unintendedpregnancy/index.htm">overall rate</a> fell to 45% that year from 51% in 2008, the figure for women living at or below the poverty line, although also decreasing, was <a href="https://www.guttmacher.org/sites/default/files/pdfs/pubs/FB-Unintended-Pregnancy-US.pdf">five times that of women</a> at the highest income level. </p>
<p>One reason for this disparity is the <a href="http://www.thenation.com/article/why-does-best-birth-control-cost-entire-months-wages/">cost of birth control</a>, particularly for the most effective, long-lasting forms. For instance, <a href="https://www.plannedparenthood.org/learn/birth-control/iud/how-can-i-get-an-iud">it typically costs women</a> over $1,000 for an IUD and the procedure to insert it, amounting to about <a href="http://dx.doi.org/10.1016/j.jadohealth.2013.01.012">one month’s full-time pay</a> for a minimum-wage worker lacking insurance coverage. </p>
<p>These costs are significant, given that the <a href="https://www.nytimes.com/2018/02/13/upshot/american-fertility-is-falling-short-of-what-women-want.html">average American woman will have</a> about two children and will thus need contraception for at least three decades of her life. Unfortunately, <a href="https://www.socialventurepartners.org/chicago/wp-content/uploads/sites/51/2013/04/Breaking-the-Cycle-of-Poverty-Expanding-Access-to-Family-Planning.pdf">publicly funded family planning</a> meets only 54% of the need, and these funding streams are under constant <a href="https://www.guttmacher.org/article/2020/06/seeing-whole-pattern-coordinated-federal-attacks-birth-control-coverage-and-access">attack by conservatives</a>.</p>
<p>Not surprisingly, <a href="http://www.scotusblog.com/2015/12/symposium-womens-compelling-need-for-contraception-met-by-insurers-not-objecting-employers/">health insurance makes a difference</a>, and women with coverage are much more likely to use contraceptive care. And yet about 6.2 million women <a href="https://www.cdc.gov/mmwr/volumes/70/wr/mm7025a2.htm">who need contraception lack insurance coverage</a>. </p>
<p>Further, this coverage can be denied to millions of employees and their dependents who work for employers claiming a religious or moral objection <a href="https://www.supremecourt.gov/opinions/19pdf/19-431_5i36.pdf">under a Supreme Court ruling in 2020</a>. </p>
<h2>Sex education and the economic ladder</h2>
<p>Another key to reproductive health – and one that isn’t discussed enough – is sexual education for teenagers. </p>
<p>For years, the public has spent up to $110 million a year on abstinence-only programs, which not only <a href="https://doi.org/10.1016/j.jadohealth.2005.10.006">fail to reduce teen birth rates</a> but also reinforce gender stereotypes and are rife with misinformation. Low-income minority teens <a href="http://scholarship.law.berkeley.edu/cgi/viewcontent.cgi?article=1084&context=bjalp">are particularly subject</a> to these programs.</p>
<p>Teens without knowledge about their sexual health <a href="https://www.guttmacher.org/news-release/2017/abstinence-only-until-marriage-programs-are-ineffective-and-harmful-young-people">are more likely</a> to get pregnant and less likely to work, spiraling them to the bottom of the economic ladder. </p>
<h2>Access to abortion</h2>
<p>Then there’s the issue of abortion. Let’s start with the cost.</p>
<p><a href="http://www.nwlc.org/sites/default/files/pdfs/reproductive_health_is_part_of_the_economic_health_of_women_5.29.15pdf.pdf">Half of women who obtain an abortion</a> pay more than one-third of their monthly income for the procedure.</p>
<p>The longer a woman must wait – either because state law requires it or she needs to save up the money, or both – costs rise significantly.</p>
<p>Studies show that women <a href="http://www.nytimes.com/2013/06/16/magazine/study-women-denied-abortions.html?_r=0">who cannot access abortion</a> are <a href="https://www.law.berkeley.edu/php-programs/centers/crrj/zotero/loadfile.php?entity_key=5GDWVH35">three times as likely</a> to fall into poverty as women who obtained abortions.</p>
<p>In addition to the financial burden, <a href="https://www.guttmacher.org/state-policy/explore/targeted-regulation-abortion-providers">many states are enacting laws</a> designed to limit abortion access. These laws hit low-income women particularly hard. Since Roe was decided, states have enacted 1,320 restrictions on abortion, including waiting periods, mandatory counseling sessions, and onerous restrictions on clinics. In 2021 alone, <a href="https://www.guttmacher.org/article/2021/07/state-policy-trends-midyear-2021-already-worst-legislative-year-ever-us-abortion">states passed 90 such laws</a>. </p>
<figure class="align-center ">
<img alt="A security guard opens the door to a brick building with a green hedge in front in Fort Worth, Texas. A sign on the wall says abortion is legal our clinic is open" src="https://images.theconversation.com/files/435348/original/file-20211202-13-i5vf8z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/435348/original/file-20211202-13-i5vf8z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=376&fit=crop&dpr=1 600w, https://images.theconversation.com/files/435348/original/file-20211202-13-i5vf8z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=376&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/435348/original/file-20211202-13-i5vf8z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=376&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/435348/original/file-20211202-13-i5vf8z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=473&fit=crop&dpr=1 754w, https://images.theconversation.com/files/435348/original/file-20211202-13-i5vf8z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=473&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/435348/original/file-20211202-13-i5vf8z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=473&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">In some states, abortion clinics are having a hard time staying open.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/SupremeCourt-Abortion/3803c31ca16044f580e5e3af65d8738c/photo?Query=abortion%20clinic&mediaType=photo&sortBy=arrivaldatetime:desc&dateRange=Anytime&totalCount=1244&currentItemNo=113">AP Photo/LM Otero</a></span>
</figcaption>
</figure>
<h2>Hyde and health</h2>
<p>Another way in which U.S. policy on abortions <a href="https://www.americanprogress.org/issues/women/news/2013/05/10/62875/how-the-hyde-amendment-discriminates-against-poor-women-and-women-of-color">exacerbates economic inequality, especially for women of color</a>, is through the ban on federal funding.</p>
<p>It has been so since the <a href="http://billmoyers.com/content/five-facts-you-should-know-about-the-hyde-amendment/">1976 enactment of the Hyde Amendment</a>, which prevents federal Medicaid funds from being used for abortions except in cases of rape or incest, or when the life of the mother is at risk. </p>
<p>Denying poor women coverage for abortion under Medicaid contributes to the unintended birth rates that are <a href="https://www.guttmacher.org/fact-sheet/unintended-pregnancy-united-states">seven times as high</a> for poor women as for high-income women. </p>
<p>If Roe v. Wade is overturned by the Supreme Court – the chief justice <a href="https://www.nytimes.com/live/2022/05/03/us/roe-wade-abortion-supreme-court/leaked-draft-of-supreme-court-ruling-signals-a-seismic-shift-in-american-politics-and-law?smid=url-copy">confirmed the leaked draft’s authenticity</a> but said the decision wasn’t final – poor women would be affected the most. Women who are denied abortions <a href="https://doi.org/10.2105/AJPH.2017.304247">are more likely to end up in poverty</a>, be unemployed and turn to public assistance. </p>
<p>By contrast, economists have established that the <a href="https://www.brookings.edu/research/what-can-economic-research-tell-us-about-the-effect-of-abortion-access-on-womens-lives/">legalization of abortion</a> led to improved educational, employment and earnings outcomes for women, as well as for their children. </p>
<p>Politicians cannot promise to grow the economy and simultaneously limit access to abortion, birth control and sexual education. America’s economic health and women’s reproductive health are linked.</p>
<p><em>This article was updated on May 4, 2022, to add a reference to the leaked draft of the upcoming Supreme Court ruling. It’s a revised version of an <a href="https://theconversation.com/how-limiting-womens-access-to-birth-control-and-abortions-hurts-the-economy-57546">article originally published</a> on April 27, 2016.</em></p><img src="https://counter.theconversation.com/content/162476/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michele Gilman does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>In past rulings, the court has acknowledged that there’s a connection between the ability of women to control their reproductive lives and the economic health of the nation.Michele Gilman, Venable Professor of Law, University of BaltimoreLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1706932021-11-02T16:09:25Z2021-11-02T16:09:25ZWhat the 100 nonprofits that raised the most money in 2020 indicate about charity today<figure><img src="https://images.theconversation.com/files/429453/original/file-20211031-21-n9eof2.jpg?ixlib=rb-1.1.0&rect=58%2C29%2C3813%2C1973&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Claire Babineaux-Fontenot, CEO of the national Feeding America anti-hunger network, meets with Jay Worrall, president of a Pennsylvania food bank.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/claire-babineaux-fontenot-ceo-of-feeding-america-and-jay-news-photo/1297455257">Ben Hasty/MediaNews Group/Reading Eagle via Getty Images</a></span></figcaption></figure><p><em>The Chronicle of Philanthropy has released a <a href="https://www.philanthropy.com/article/giving-to-top-charities-rose-nearly-3-7-in-2020-driven-by-big-gifts-from-the-wealthy">list of the nation’s 100 nonprofits</a> that garnered the most funding through charitable donations in 2020. These organizations received about US$1 out of every $11 donated over the course of the year. <a href="https://philanthropy.iupui.edu/people-directory/siddiqui-shariq.html">Shariq Siddiqui</a>, <a href="https://scholar.google.com/citations?hl=en&user=VYsdAEIAAAAJ">David Campbell</a> and <a href="https://scholar.google.com/citations?hl=en&user=gbNTcf0AAAAJ">Mirae Kim</a>, three scholars of philanthropy and nonprofits, weigh in on this ranking, what it indicates about donations during the COVID-19 pandemic and where they see charitable giving headed.</em></p>
<h2>What trends stand out?</h2>
<p><strong>Campbell:</strong> The $515 million that <a href="https://apnews.com/article/coronavirus-pandemic-lifestyle-united-states-health-hunger-2c509e7e1ce108c47287b42315e2a0c3">Feeding America</a> – a national network of food banks and other agencies that help people get enough to eat – received in 2020 marked a 354% increase from 2019 levels. That gain, the largest for any nonprofit, was no doubt due to the COVID-19 pandemic and the economic distress it caused.</p>
<p>But what most stands out to me across the board is brand loyalty. Many of the nonprofits that raised the most money in a year when so much changed are among the nation’s most prominent institutions in education, health care and international development.</p>
<p>For example, Johns Hopkins, Stanford and Harvard universities amassed $1.52 billion, $1.28 billion and $1.22 billion, respectively – landing them in fourth, fifth and sixth place. <a href="https://facts.stanford.edu/administration/finances/">That money</a> <a href="https://www.thecrimson.com/article/2020/2/26/donor-honor-roll/">usually flows</a> from <a href="https://www.vox.com/future-perfect/2018/11/19/18102994/michael-bloomberg-johns-hopkins-financial-aid-donation">wealthy alumni</a>.</p>
<p><a href="https://nccs.urban.org/publication/nonprofit-sector-brief-2019#type">In recent years</a>, only around 2% of all United States giving went to international development charities, so it is somewhat surprising to see that several nonprofits in that sector are big enough to have made the cut. The largest among the top 100 are Compassion International, World Vision and Save the Children. All three invite donors to make monthly payments to “<a href="https://doi.org/10.1093/wber/lhv081">sponsor</a>” children in developing countries, a process that often includes sending letters and exchanging photos.</p>
<p><strong>Kim:</strong> Many private colleges and universities, including several prominent schools, saw steep declines in donations. For example, gifts to Yale fell by 15.4%, to $550 million. Despite those reductions, nearly half of the 100 nonprofits drawing the most money through donations in 2020 were higher education institutions and hospitals. Nine of the top 20 were universities.</p>
<p><strong>Siddiqui:</strong> Poverty relief and health care were clearly big priorities for U.S. donors in 2020, a year that included the start of a <a href="https://apnews.com/article/coronavirus-pandemic-five-million-dead-memorials-acd5a25aabb50f203c8ee059803a1bec">historic pandemic</a>, which has so far cost 5 million lives, and a <a href="https://www.brookings.edu/research/11-facts-on-the-economic-recovery-from-the-covid-19-pandemic/">recession</a>. </p>
<p>I was surprised by the steep declines that many top-tier universities experienced because these schools <a href="https://insights.digitalmediasolutions.com/articles/higher-education-fundraising-2018">employ sophisticated and large fundraising teams</a> that help them attract and keep donors in good times and in downturns alike.</p>
<p><iframe id="fplbX" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/fplbX/6/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<h2>What concerns do you have?</h2>
<p><strong>Siddiqui:</strong> Planned Parenthood donations fell 13.8% to $510 million. That decline in support could potentially make it harder for <a href="https://www.kff.org/womens-health-policy/issue-brief/financing-family-planning-services-for-low-income-women-the-role-of-public-programs/">women to access health care</a>. Similarly, there was a decline of 29% to the Metropolitan Museum of Art, which obtained $234.5 million in donations in 2020. That reduction in funding speaks to a <a href="https://theconversation.com/federal-support-has-shored-up-nonprofits-during-the-coronavirus-pandemic-but-many-groups-are-still-struggling-156359">larger challenge faced by arts organizations</a>, which are <a href="https://www.ted.com/playlists/733/why_art_is_important_to_democracy">critical to democracy</a> in the U.S. </p>
<p><strong>Kim:</strong> It is somewhat disappointing to see only a few organizations that primarily fund communities of color on this list despite an increase in <a href="https://apnews.com/article/business-race-and-ethnicity-racial-injustice-philanthropy-b5e6e871d7e3419c43ef7aef46b7eb97">support for causes related to racial inequality</a>. </p>
<p>I am also troubled to see so few nonprofits led by people of color on this list. Some notable exceptions include the <a href="https://www.unitedway.org/the-latest/press/new-president-and-ceo">United Way</a>, <a href="https://www.plannedparenthoodaction.org/pressroom/alexis-mcgill-johnson-named-permanent-president-and-ceo-of-the-planned-parenthood-federation-of-america-and-the-planned-parenthood-action-fund-2">Planned Parenthood</a> and <a href="https://www.feedingamerica.org/about-us/leadership/claire-babineaux-fontenot">Feeding America</a>. But the vast majority are led by white people.</p>
<p>Many of these organizations, however, such as the <a href="https://www.msureporter.com/2021/10/14/16869/">Mayo Clinic</a>, the <a href="https://www.usm.edu/news/2021/release/oyster-production-grant.php">Nature Conservancy</a> and the <a href="https://newsroom.howard.edu/newsroom/article/15076/howard-university-joins-american-cancer-society-research-and-diversity">American Cancer Society</a>, have launched or expanded the scope of their racial equity initiatives.</p>
<p><strong>Campbell:</strong> When the Chronicle of Philanthropy released its list of <a href="https://theconversation.com/what-the-25-billion-the-biggest-us-donors-gave-in-2020-says-about-high-dollar-charity-today-154466">the top 50 donations of 2020</a>, racial justice and social equity were clear themes. Yet despite a <a href="https://theconversation.com/racial-justice-giving-is-booming-4-trends-145526">surge in gifts</a> to historically Black colleges and universities, none of the 44 higher education institutions that made this list is an HBCU.</p>
<h2>What do you expect to see for 2021 and beyond?</h2>
<p><strong>Siddiqui:</strong> As life in the U.S. and the rest of the world continues to get closer to normal, with lower levels of COVID-19 and a healthier economy, I believe that the changes in giving that occurred during the pandemic are likely to recede. As a result, I predict that colleges and universities, hospitals and other institutions that employ large, experienced fundraising teams will raise more money, and minority-led institutions will continue to be left out.</p>
<p><strong>Kim:</strong> A recent <a href="https://www.urban.org/partnering-understand-long-term-trends-nonprofit-organization-activities-and-needs">Urban Institute report</a> I worked on found that charitable giving to nonprofits led by whites was more likely to rise than for groups led by people of color from 2015 to 2019. That distinction vanished in 2020, when about 46% of all nonprofits, regardless of whether or not they were led by people of color, received less money through donations. We believe this change probably reflects a <a href="https://theconversation.com/racial-justice-giving-is-booming-4-trends-145526">stronger focus by donors</a> and nonprofit leaders on organizations led by people of color due the public outcry that followed the death of George Floyd.</p>
<p><strong>Campbell:</strong> It can be hard to spot fundraising trends based on data derived from a single year because one-time gifts can distort the picture. One example is the Foundation for the Carolinas, a community foundation based in Charlotte, North Carolina. Giving to this foundation shot up by 236% in 2020, the second-highest pace on this list. This abrupt change appears to be largely due to <a href="https://www.philanthropy.com/article/filling-a-void-on-the-right/">the support of a single donor</a>, <a href="https://www.politico.com/magazine/politico50/2015/jay-faison/">Jay Faison</a> – an entrepreneur who made a fortune in the video surveillance equipment industry.</p>
<p>Likewise, the nation’s economic circumstances are changing. So I don’t know whether or not Feeding America will continue getting the increased level of support it saw in 2020.</p>
<p>[<em>Over 110,000 readers rely on The Conversation’s newsletter to understand the world.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=100Ksignup">Sign up today</a>.]</p><img src="https://counter.theconversation.com/content/170693/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Shariq Siddiqui receives funding from Waraich Family Fund, The John Templeton Foundation, Islamic Relief USA, Muslim Legal Fund of America, Mirza Family Foundation, Hamzavi Family Foundation, Pillars Fund, Indian American Muslim Council and International Strategy and Policy Institute. </span></em></p><p class="fine-print"><em><span>David Campbell is vice chair of the board of the Conrad and Virginia Klee Foundation. </span></em></p><p class="fine-print"><em><span>Mirae Kim previously received research grants from the Generosity Commission, a project of the Giving Institute and Giving USA Foundation and Charles Koch Foundation. One of her current research projects is funded by the National Science Foundation Human Networks and Data Science – Infrastructure Program. Mirae Kim is affiliated with Independent Sector as a Visiting Scholar 2021-2022. She is also a non-paid, elected board member of the Association for Research on Nonprofit Organizations and Voluntary Action (ARNOVA).</span></em></p>The Chronicle of Philanthropy’s latest ranking indicates that the coronavirus and heightened awareness about racism made a difference, but not necessarily a lasting one.Shariq Siddiqui, Assistant Professor & Director of the Muslim Philanthropy Initiative, IUPUIDavid Campbell, Associate Professor of Public Administration, Binghamton University, State University of New YorkMirae Kim, Associate Professor of Nonprofit Studies, George Mason UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1699252021-10-28T12:32:33Z2021-10-28T12:32:33ZThe erosion of Roe v. Wade and abortion access didn’t begin in Texas or Mississippi – it started in Pennsylvania in 1992<figure><img src="https://images.theconversation.com/files/427608/original/file-20211020-17-1fteqi6.jpg?ixlib=rb-1.1.0&rect=0%2C25%2C4219%2C2787&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Demonstrators in Austin march at the Texas State Capitol in just one of many rallies held across the U.S. to protest the state's new abortion law.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/demonstrators-rally-against-anti-abortion-and-voter-news-photo/1235651508?adppopup=true">Montinique Monroe/Getty Images News via Getty Images</a></span></figcaption></figure><p>Abortion rights are more vulnerable to Supreme Court reversal now than at any time since the court legalized the procedure in its landmark 1973 ruling <a href="https://www.oyez.org/cases/1971/70-18">Roe v. Wade</a>.</p>
<p>The court is set to weigh in on abortion restrictions from at least two states this term. The first is <a href="https://www.texastribune.org/2021/08/31/texas-abortion-law-supreme-court/">a Texas law effectively outlawing abortions after six weeks</a>. The second is <a href="https://www.npr.org/2021/05/17/997478374/supreme-court-to-review-mississippi-abortion-ban">a Mississippi law barring abortions after 15 weeks</a>. </p>
<p>On Oct. 22, 2021, the Supreme Court upheld <a href="https://www.texastribune.org/2021/10/14/texas-abortion-restrictions-appeal/">a Fifth Circuit Court of Appeals ruling allowing the Texas law to go into effect while the case is being litigated</a>. </p>
<p>The court will hold oral arguments about <a href="https://www.scotusblog.com/2021/10/court-wont-block-texas-abortion-ban-but-fast-tracks-cases-for-argument-on-nov-1/">specific elements</a> of the Texas law on Nov. 1. The court is scheduled to hear arguments on the constitutionality of the Mississippi law on <a href="https://www.texastribune.org/2021/10/05/texas-mississippi-abortion-laws-supreme-court/">Dec. 1, 2021</a>.</p>
<p>Many discussions about these cases focus on the possibility that the court will specifically dismantle the precedent established in Roe v. Wade. In reality, the protections established under Roe were already limited in 1992 in a case called <a href="https://www.oyez.org/cases/1991/91-744">Planned Parenthood v. Casey</a>. What’s more, Casey has given conservative courts ample room to further limit abortion protections. </p>
<p>The Fifth Circuit, <a href="https://www.wsj.com/articles/conservative-appeals-court-is-prime-venue-for-biden-era-litigation-11634907602">among the nation’s most conservative courts</a>, is a major player in the current fight over abortion restrictions. As the appellate court overseeing federal cases involving Texas and Mississippi, its interpretation of Casey will carry significant influence in the upcoming abortion cases. </p>
<figure class="align-center ">
<img alt="Four people face away from the camera holding up signs that read 'Courageously Abolishing Abortion'" src="https://images.theconversation.com/files/427617/original/file-20211020-19039-q1cp27.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/427617/original/file-20211020-19039-q1cp27.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/427617/original/file-20211020-19039-q1cp27.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/427617/original/file-20211020-19039-q1cp27.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/427617/original/file-20211020-19039-q1cp27.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/427617/original/file-20211020-19039-q1cp27.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/427617/original/file-20211020-19039-q1cp27.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Anti-abortion activists rally in Austin, Texas.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/pro-life-activists-continue-to-descend-on-the-capitol-news-photo/539703350?adppopup=true">Robert Daemmrich Photography Inc/Corbis Historical via Getty Images</a></span>
</figcaption>
</figure>
<h2>It’s not all about Roe</h2>
<p>Roe v. Wade established constitutional protections for individuals seeking abortions, placing the right to choose an abortion within a broader and fundamental “<a href="https://www.reuters.com/article/us-usa-court-abortion-roevwade-explainer/explainer-supreme-courts-roe-v-wade-decision-hinged-on-womens-right-to-privacy-idUSKCN26E1LU">right to privacy</a>.” Importantly, Roe also established an explicit framework for implementing those protections, based entirely on the trimesters in a pregnancy. </p>
<p>Under Roe, states could not enact any legislation interfering with a person’s decision to seek an abortion during the first three months of a pregnancy. The decision on whether to have an abortion existed entirely between the pregnant individual and her health care provider. </p>
<p>States could enact legislation regarding abortions during the second three-month period, but only to protect the health of the woman seeking the abortion. Laws intervening on behalf of the fetus were limited to the third trimester or final three months. It was at that point, argued the court, that one could reasonably expect a fetus to be able to live outside the womb, entitling the state to legislate protections.</p>
<p>That framework remained in place for 16 years until, in 1989, Pennsylvania Gov. Bob Casey Sr. – an anti-abortion Democrat – signed into law the <a href="https://www.cityandstatepa.com/content/continuing-ramifications-pas-landmark-scotus-abortion-ruling">Pennsylvania Abortion Control Act</a>. The legislation imposed a range of restrictions on abortion access. These included a 24-hour waiting period for patients to give their fully informed consent, spousal notification requirement and parental consent for pregnant minors. </p>
<p>Planned Parenthood sued the state, arguing that the law violated the central elements of Roe by impeding a woman’s ability to seek an abortion during the first trimester. The case made its way up to the Supreme Court. </p>
<h2>States get more control</h2>
<p>In <a href="https://www.oyez.org/cases/1991/91-744">Planned Parenthood v. Casey</a>, the Supreme Court upheld all but one main provision in the new law, the spousal notification requirement. In the decision, the court still claimed its commitment to “<a href="https://supreme.justia.com/cases/federal/us/505/833/">the right of the woman to choose to have an abortion before viability</a>.” Yet the ruling allowed states to regulate that choice at any point as long as they did not impose an “undue burden” on access to abortion services. </p>
<p>Roe had given women an unmitigated first-trimester right to choose. Casey rendered abortion rights contingent on and subject to state control at any point during a pregnancy. </p>
<p>The new “undue burden” framework provided two avenues for states seeking to limit access to abortions. </p>
<p>First, it widened the timeline for intervention by the state. Under Roe, courts would treat any regulatory constraints on first-trimester abortions as suspect. Under Casey, states could now far more easily regulate abortions at any time during a person’s pregnancy.</p>
<p>Second, Casey shifted the requirements for anti-abortion states and abortion-rights advocates when arguing their positions in court. For one, it reduced the requirements that states had to meet to uphold abortion restrictions. Under Roe’s framework, states regulating abortions during the first trimester needed to prove to the court that they had a compelling reason for limiting a woman’s right to choose. Casey removed that barrier. Casey’s “undue burden” framework also required individuals suing states to prove that the policies imposed significant challenges to abortion access. </p>
<p>In effect, under Casey, any abortion regulation would now be presumed constitutional unless someone could prove that it imposed undue and significant burdens on a woman’s ability to access an abortion. </p>
<p>In 2015, the Fifth Circuit revisited and reinvigorated Casey when reviewing a Texas law restricting abortions, in <a href="https://scholar.google.com/scholar_case?case=14192682821420050675&hl=en&as_sdt=6&as_vis=1&oi=scholarr">Whole Women’s Health v. Cole</a>. According to abortion-rights advocates, the Texas law imposed costly restrictions on existing abortion providers that would have forced most clinics in the state to close. The Fifth Circuit, relying on Casey, upheld the law. It argued that regulating abortions before the third trimester is unconstitutional only if it places “a substantial obstacle in the path of a woman seeking an abortion” or if it “<a href="https://scholar.google.com/scholar_case?case=14192682821420050675&hl=en&as_sdt=6&as_vis=1&oi=scholarr">serves no purpose other than to make abortions more difficult</a>.” </p>
<p>[<em>Over 115,000 readers rely on The Conversation’s newsletter to understand the world.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=100Ksignup">Sign up today</a>.]</p>
<p>Three years later <a href="https://www.oyez.org/cases/2015/15-274">the Supreme Court overturned the Texas law in a 5-3 decision</a>, invalidating the Fifth Circuit’s reasoning. However, two justices in the majority – Justices Ruth Bader Ginsburg and Anthony Kennedy – are no longer on the court. <a href="https://www.npr.org/2020/09/18/100306972/justice-ruth-bader-ginsburg-champion-of-gender-equality-dies-at-87">Ginsburg died in 2020</a> and <a href="https://www.cnn.com/2018/06/27/politics/anthony-kennedy-retires/index.html">Kennedy retired in 2018</a>. Donald Trump filled their vacancies, along with a third left by the late Justice Scalia, with <a href="https://www.voanews.com/a/usa_trumps-lasting-legacy-conservative-supermajority-supreme-court/6199935.html">three conservative justices</a>. Their addition to the court places the Fifth Circuit’s reading of Casey back in play at a pivotal moment in abortion politics.</p><img src="https://counter.theconversation.com/content/169925/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alison Gash does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A Supreme Court decision in a case called Planned Parenthood v. Casey opened the door to state laws restricting availability of abortions.Alison Gash, Associate Professor of Political Science, University of OregonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1677552021-09-22T12:58:35Z2021-09-22T12:58:35ZHow the Satanic Temple is using ‘abortion rituals’ to claim religious liberty against the Texas’ ‘heartbeat bill’<figure><img src="https://images.theconversation.com/files/422452/original/file-20210921-23-x5k5cz.jpg?ixlib=rb-1.1.0&rect=44%2C295%2C4928%2C2707&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Two women hold mock pro-life signs in what they call an 'Abortrait room' at the Satanic Temple’s headquarters to protest abortion laws.
</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/mercy-maelica-and-joy-davenport-hold-up-pro-life-signs-in-a-news-photo/1174663556?adppopup=true">Joseph Prezioso / AFP via Getty images</a></span></figcaption></figure><p>Texas’s controversial anti-abortion law known as the “Heartbeat Bill” went into effect at midnight on Sept. 1, 2021. Less than 24 hours later, the U.S. Supreme Court declared it would not <a href="https://www.texastribune.org/2021/09/01/texas-abortion-clinic-follow-new-law/">block the law</a>. </p>
<p><a href="https://www.houstonchronicle.com/politics/texas/article/Satanic-Temple-texas-abortion-law-16441269.php">In response</a>, The Satanic Temple, a nontheistic group that has been recognized by <a href="https://religionnews.com/2019/04/25/the-satanic-temple-is-a-real-religion-says-irs/">the IRS</a> as a religion, announced that it would fight back by invoking the Religious Freedom Restoration Act, or RFRA, to demand exemption from abortion restrictions on religious grounds. RFRA laws, which came into effect in 1993, restrict the government’s ability to burden religious practices.</p>
<p>Like the Heartbeat Bill itself, The Satanic Temple’s efforts to circumvent abortion restrictions on religious grounds involve a creative and complicated legal strategy. As a <a href="https://global.oup.com/academic/product/speak-of-the-devil-9780190948498?cc=us&lang=en&">scholar</a> who studies the ways in which The Satanic Temple’s provocations affect public debates about religious freedom, I anticipate their latest legal argument will challenge some assumptions about RFRA and the freedoms it was designed to protect.</p>
<h2>The Heartbeat Bill</h2>
<p>In the pivotal 1973 abortion case <a href="https://www.oyez.org/cases/1971/70-18">Roe v. Wade</a> and <a href="https://www.oyez.org/cases/1991/91-744">Planned Parenthood v. Casey</a> in 1992, the Supreme Court established that abortion is a <a href="https://www.law.cornell.edu/constitution-conan/amendment-14/section-1/abortion">Constitutional right</a>. However, states can still pass laws that severely restrict access to abortion. The question is how severely. </p>
<p>Texas’s new law was designed to <a href="https://www.texasmonthly.com/news-politics/meet-the-legal-strategist-behind-the-texas-abortion-ban/">effectively shut down</a> all abortion while protecting the state from judicial review.</p>
<p>First, the bill bans abortion after six weeks – the point at which <a href="https://www.texastribune.org/2021/09/02/texas-abortion-heartbeat-bill/">Texas lawmakers claim</a> a fetus’s heartbeat can be detected. Most women are <a href="https://www.scientificamerican.com/article/the-absurd-pregnancy-math-behind-the-lsquo-six-week-rsquo-abortion-ban/">not aware</a> they are pregnant before six weeks, and Texas abortion providers estimate <a href="https://www.texastribune.org/2021/09/01/texas-abortion-clinic-follow-new-law/">85% of abortions</a> in the state are performed after this period.</p>
<p>Second, the law allows anyone to sue those they can accuse of “aiding and abetting” an abortion for US$10,000. Critics of the law claim this is an <a href="https://www.washingtonpost.com/opinions/2021/07/24/heres-what-makes-texass-heartbeat-abortion-bill-uniquely-dangerous/">intimidation tactic designed to threaten the clinics</a> with so much potential liability that legal abortion becomes impossible. </p>
<p>But outsourcing enforcement to the public is also intended to protect the state. Proponents of the bill claim that since no state official is enforcing the law, abortion providers have <a href="https://www.acslaw.org/expertforum/bypassing-the-texas-two-step-to-save-reproductive-right/">no one to sue</a>.</p>
<h2>The Religious Freedom Restoration Act</h2>
<p>The 1990 Supreme Court case <a href="https://www.oyez.org/cases/1989/88-1213">Employment Division v. Smith</a> considered arguments that a member of the Native American Church had a religious right to use peyote, a controlled substance. </p>
<p>The court ruled that freedom of religion was no excuse from compliance with a generally applicable law – a law that applies equally to everyone and does not single out specific groups. With <a href="https://www.aclu-or.org/en/cases/smith-v-employment-division">this decision</a>, it appeared that the free exercise of religion guaranteed in the First Amendment meant very little.</p>
<p>In response, Congress wrote the <a href="https://www.congress.gov/bill/103rd-congress/house-bill/1308#:%7E:text=Religious%20Freedom%20Restoration%20Act%20of%201993%20%2D%20Prohibits%20any%20agency%2C%20department,government%20may%20burden%20a%20person's">Religious Freedom Restoration Act</a>, which was signed into law in 1993.</p>
<p>Under RFRA, the government cannot burden the free exercise of religion unless: 1) it has a compelling reason for doing so, and 2) the government acts in the least restrictive way possible to achieve its purpose. </p>
<p>Four years later, in <a href="https://www.oyez.org/cases/1996/95-2074">Boerne v. Flores</a>, the Supreme Court ruled that RFRA applied only to the federal government and not to individual states. So <a href="https://www.ncsl.org/research/civil-and-criminal-justice/state-rfra-statutes.aspx">many states</a>, including Texas, passed similar legislation, sometimes called “mini-RFRAs.”</p>
<p>In 2014, the Supreme Court ruled in <a href="https://www.oyez.org/cases/2013/13-354">Burwell v. Hobby Lobby</a> that under RFRA, the federal government could not require the Christian company Hobby Lobby to fund insurance that provided their employees with certain forms of birth control. <a href="https://www.theatlantic.com/politics/archive/2014/07/satanists-troll-the-hobby-lobby-decision/375268/">This decision</a> inspired The Satanic Temple by linking the question of religious liberty with that of reproductive rights.</p>
<h2>The Satanic Temple and RFRA</h2>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/422207/original/file-20210920-20-cbf8cs.jpg?ixlib=rb-1.1.0&rect=12%2C18%2C4013%2C2975&q=45&auto=format&w=1000&fit=clip"><img alt="A statue of Baphomet, a winged-goat creature, installed by The Satanic Temple, a group of atheistic Satanists." src="https://images.theconversation.com/files/422207/original/file-20210920-20-cbf8cs.jpg?ixlib=rb-1.1.0&rect=12%2C18%2C4013%2C2975&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/422207/original/file-20210920-20-cbf8cs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/422207/original/file-20210920-20-cbf8cs.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/422207/original/file-20210920-20-cbf8cs.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/422207/original/file-20210920-20-cbf8cs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/422207/original/file-20210920-20-cbf8cs.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/422207/original/file-20210920-20-cbf8cs.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The Satanic Temple’s seven tenets include the belief that one’s body is subject to one’s own will alone.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/SatanicTemple/fc28a9277fc6499dab6fb9281368d0e2/photo?Query=satanic&mediaType=photo&sortBy=&dateRange=Anytime&totalCount=208&currentItemNo=4">AP Photo/Hannah Grabenstein</a></span>
</figcaption>
</figure>
<p>The Satanic Temple <a href="https://theconversation.com/what-the-satanic-temple-is-and-why-its-opening-a-debate-about-religion-131283">began in 2013</a> and has launched a number of political actions and lawsuits related to the separation of church and state. <a href="https://thesatanictemple.com/pages/find-a-congregation">Texas is home to four congregations</a> of The Satanic Temple, more than any other state.</p>
<p>Although The Satanic Temple does not believe in or worship a literal Satan, they revere Satan as described in the works of English poet John Milton and the <a href="https://www.palgrave.com/gp/book/9781403911827">Romantic movement</a>, an intellectual movement that originated in late 18th-century Europe, as a powerful symbol of rebellion against authority. </p>
<p>The Satanic Temple’s <a href="https://thesatanictemple.com/blogs/the-satanic-temple-tenets/there-are-seven-fundamental-tenets">seven tenets</a> include the belief that “one’s body is inviolable, subject to one’s own will alone.” It interprets state restrictions on abortion access as a burden on this sincerely held religious belief. </p>
<p>In 2015, The Satanic Temple began a series of lawsuits against the state of Missouri, where women seeking abortions must view sonograms and then <a href="https://dss.mo.gov/fsd/a2a/files/Missouri-Informed-Consent-Booklet.pdf">review a booklet</a> stating, “The life of each human being begins at conception. Abortion will terminate the life of a separate, unique, living human being.” After this, the women must spend 72 hours considering their decision before finally receiving an abortion.</p>
<p>The Satanic Temple argued that this practice was an unconstitutional effort by the state to impose its religious views onto vulnerable women. Furthermore, it claimed that under Missouri’s RFRA law, Satanic women could not be forced to comply with these procedures. Instead of answering whether RFRA protected members of The Satanic Temple from abortion restrictions, the court dismissed these cases on procedural grounds. </p>
<p>The Missouri Supreme Court ruled that since the plaintiff, a woman known as “Mary Doe,” was <a href="https://www.seattletimes.com/nation-world/nation-politics/satanic-temples-missouri-abortion-law-challenge-dismissed/">no longer pregnant</a> by the time her case wound its way through the courts, she no longer needed an abortion and therefore had no legal standing to sue. The Satanic Temple appealed this ruling to the U.S. Supreme Court, which <a href="https://www.supremecourt.gov/orders/courtorders/112320zor_7l48.pdf">declined to hear it</a>.</p>
<p>To prevent similar rulings, ministers for The Satanic Temple created an “<a href="https://religiondispatches.org/satanic-temples-satanic-abortion-ritual-may-challenge-states-anti-abortion-laws/">abortion ritual</a>,” in which a woman affirms her own autonomy, obtains an abortion, and then concludes the ritual. </p>
<p>Since abortion is part of the ritual, The Satanic Temple argues, subjecting a woman to a waiting period is akin to the government interfering with a baptism or communion. In February 2021, The Satanic Temple filed a <a href="https://thesatanictemple.com/pages/texas-lawsuit">new lawsuit</a> against Texas, arguing that the state was violating the religious liberty of its new plaintiff, referred to as “Ann Doe.”</p>
<h2>The devil is in the details</h2>
<p>The Satanic Temple raises <a href="https://theconversation.com/what-the-satanic-temple-is-and-why-its-opening-a-debate-about-religion-131283">important questions</a> about what counts as a religion. Opponents of the group argue that abortion is a medical procedure, not a protected religious practice. But The Satanic Temple’s lawyer, Matthew Kezhaya, points to a 2009 case, <a href="https://caselaw.findlaw.com/tx-supreme-court/1347663.html">Barr v. City of Sinton</a>, in which Texas pastor Richard Barr was told the halfway house he operated violated a zoning ordinance. </p>
<p>The Texas Supreme Court ruled that excluding Barr’s halfway house from the city violated Texas’s RFRA law. Key to this argument was the court’s statement that, “The fact that a halfway house can be secular does not mean that it cannot be religious.” Likewise, Kezhaya argues, abortion can be both secular and religious, depending on context.</p>
<p>Kezhaya also disagrees that outsourcing the enforcement of abortion to private lawsuits makes the state of Texas immune to judicial review. He compared this situation to “<a href="https://www.dcpolicycenter.org/publications/racially-restrictive-covenants-bloomingdale/">racially restrictive covenants</a>” of the Jim Crow era in which white residents signed legal agreements never to sell or rent their homes to African Americans. </p>
<p>The Supreme Court initially declined to hear cases challenging these covenants because they were considered private contracts. But in 1948, it ruled that a court enforcing these contracts was a state action that violated the 14th Amendment.</p>
<p>The Satanic Temple also has an even more creative strategy. The Food and Drug Administration, which controls the distribution of the abortion pills mifepristone and misoprostol, is subject to the federal RFRA law. <a href="https://thetexan.news/wp-content/uploads/2021/09/Satanic-Temple-FDA-Letter.pdf">The Satanic Temple sent a letter</a> to the FDA explaining that its prescription requirements illegally burden their abortion ritual. Currently, these drugs are only available with a doctor’s prescription, and the doctor must adhere to any state restrictions before providing them.</p>
<p>The Satanic Temple proposed an accommodation in which Satanic women can obtain a doctor’s note indicating only that these medications are safe for them to use, and then receive medication directly from The Satanic Temple rather than a state-approved provider. </p>
<p>In an interview with me in September 2021, Kezhaya, The Satanic Temple’s lawyer, admitted this was experimental territory. Assuming a court approved this accommodation, it could legally make The Satanic Temple a pharmacy, in addition to a religious entity, because it would be distributing controlled medications.</p>
<h2>Is RFRA a “loophole?”</h2>
<p>The Satanic Temple’s opponents claim it is abusing RFRA and using it as a “loophole” to circumvent the law. However, Lucien Greaves, a co-founder of The Satanic Temple, counters that RFRA was always intended to protect religious minorities from the government. If anyone is abusing it, he claims, it is companies like Hobby Lobby that invoked it to restrict the choices of their employees.</p>
<p>Critics of RFRA, such as legal scholar Marci Hamilton, warn that religious exemptions can turn the law into “<a href="https://verdict.justia.com/2014/08/07/circle-starts-close">Swiss cheese</a>.” In other words, there could be so many religious loopholes that laws become meaningless. Whether or not this is a serious concern, it is certainly true that RFRA must not benefit <a href="https://www.salon.com/2014/06/30/here_are_the_highlights_of_justice_ginsburgs_fiery_hobby_lobby_dissent/">only the Christian majority</a>. </p>
<p>This is why constitutional law professor <a href="https://www.sup.org/books/title/?id=27312">Jay Wexler</a> has encouraged the work of groups like The Satanic Temple, stating, “Only by insisting on exercising these rights can Muslims, Hindus, Buddhists, atheists and everybody else ensure that the Court’s new religious jurisprudence does not result in a public space occupied exclusively by Christian messages and symbols. At stake is nothing less than our national public life.”</p>
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<p class="fine-print"><em><span>Joseph P. Laycock does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The Satanic Temple, a nontheistic group, is invoking the Religious Freedom Restoration Act to challenge Texas’ new anti-abortion law.Joseph P. Laycock, Assistant Professor of Religious Studies, Texas State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1425302020-07-16T18:45:28Z2020-07-16T18:45:28ZPro-choice movement’s big win at Supreme Court might really have been a loss<figure><img src="https://images.theconversation.com/files/347355/original/file-20200714-139969-1fxrjzm.jpg?ixlib=rb-1.1.0&rect=7%2C0%2C5174%2C3465&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Anti-abortion demonstrators pray outside the Supreme Court building on July 8, 2020, while they wait for a ruling.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/anti-abortion-demonstrators-pray-in-front-of-the-u-s-news-photo/1255027472">Chip Somodevilla/Getty Images</a></span></figcaption></figure><p>When the Supreme Court handed down its ruling <a href="https://www.oyez.org/cases/2019/18-1323#!">striking down a Louisiana law</a> that would have limited abortion access in that state, progressives celebrated. Their reasoning on June 29 was simple: By joining the court’s liberal justices, Chief Justice John Roberts had proven his commitment to the <a href="https://www.washingtonpost.com/outlook/how-supreme-court-could-overturn-roe/2020/07/01/51fe4a2c-bb1e-11ea-80b9-40ece9a701dc_story.html">principle of precedent</a>.</p>
<p>But the court had also sent several cases – all big wins for abortion rights – back to lower courts for <a href="https://www.scotusblog.com/2020/07/justices-grant-new-cases-send-indiana-abortion-cases-back-for-a-new-look/">reconsideration</a>.</p>
<p>Those moves, and a closer look at <a href="https://www.oyez.org/cases/2019/18-1323#!">the decision in the Louisiana case</a>, called June Medical v. Russo, made it far less clear who won. In my recent book “<a href="https://doi.org/10.1017/9781108653138">Abortion and the Law in America: Roe v. Wade to the Present</a>,” I explore the history of the incremental attack on abortion that June Medical has supercharged. People who object to the <a href="https://www.oyez.org/cases/1971/70-18">landmark 1973 Roe ruling</a> legalizing abortion have long planned to deal the decision a <a href="https://www.nytimes.com/2018/08/30/opinion/brett-kavanaugh-abortion-rights-roe-casey.html">death of a thousand cuts</a>, and June Medical makes that much easier. </p>
<h2>What comes next</h2>
<p>There is no shortage of abortion cases that might well land at the Supreme Court next – at least 16 are already in the <a href="https://www.nytimes.com/2020/06/29/us/june-medical-supreme-court.html">pipeline</a>. Let’s start with the ones that the court just sent back for reconsideration. The 7th Circuit Court of Appeals now has to take a second look at its decisions striking down two restrictions in Indiana.</p>
<p>One required abortion providers to show a pregnant woman her ultrasound, let her listen to her fetus’s heartbeat and then wait 18 hours before having an abortion – unless the <a href="https://codes.findlaw.com/in/title-16-health/in-code-sect-16-34-2-1-1.html">patient</a> <a href="https://thehill.com/homenews/399036-federal-court-upholds-ruling-that-blocks-indiana-ultrasound-abortion-law">refused in writing</a>.</p>
<p>The second state law beefed up the restrictions that applied to minors, requiring a judge to notify a young woman’s parents even when a court had already found that abortion would be in her best interests – or that she was mature enough to make <a href="https://www.indystar.com/story/news/health/2019/08/28/parental-consent-abortions-minors-ruled-unconstitutional-indiana-law-planned-parenthood-aclu/2139648001/">her own decision</a>.</p>
<p>Telling the lower court to look again at the case and reach a better result usually means the court was wrong – signaling that the <a href="http://www.dorfonlaw.org/2020/07/scotus-abortion-gvrs-suggest-june.html">regulations are likely constitutional</a>. It also indicates that Chief Justice Roberts actually relaxed the rules governing abortion restrictions and just made it much easier for states to pass them. But the Indiana cases are not the only ones likely to land at the Supreme Court.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/347357/original/file-20200714-54-6glzgu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/347357/original/file-20200714-54-6glzgu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/347357/original/file-20200714-54-6glzgu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=335&fit=crop&dpr=1 600w, https://images.theconversation.com/files/347357/original/file-20200714-54-6glzgu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=335&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/347357/original/file-20200714-54-6glzgu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=335&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/347357/original/file-20200714-54-6glzgu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=421&fit=crop&dpr=1 754w, https://images.theconversation.com/files/347357/original/file-20200714-54-6glzgu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=421&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/347357/original/file-20200714-54-6glzgu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=421&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A 1992 protest on the National Mall in Washington, D.C. called for the Supreme Court to preserve women’s right to get an abortion.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/elevated-view-of-attendees-at-the-march-for-womens-lives-news-photo/640033280">Mark Reinstein/Corbis via Getty Images</a></span>
</figcaption>
</figure>
<h2>The aftermath of June Medical</h2>
<p>Since the court’s 1992 ruling in <a href="https://www.oyez.org/cases/1991/91-744">Planned Parenthood v. Casey</a>, the ultimate question in abortion cases is whether any particular law unduly burdens a woman’s right to abortion. </p>
<p>Before this most recent decision in June Medical, courts answering that question had to <a href="https://supreme.justia.com/cases/federal/us/579/15-274/#tab-opinion-3590956">balance the costs and benefits of abortion restrictions</a>. That meant that useless laws often failed challenges in court. In 2016, for example, the court <a href="https://www.oyez.org/cases/2015/15-274">struck down a law</a> requiring abortion clinics to meet the standards set for ambulatory surgical centers. </p>
<p>A Supreme Court majority saw no point to the law. After all, many early abortions required a woman to take pills, not have surgery. And even when a woman did suffer complications after an abortion, that usually happened much later, and well after she had left a clinic. The decision told legislators who wanted to restrict abortion they needed to prove that their laws served a useful purpose.</p>
<p>Roberts changed all that in June Medical. Now, the court will no longer consider whether a law has any benefit. And Roberts seems to have a very different – and much narrower – idea about what a burden is. </p>
<p>That may well mean that it will be harder for women to prove that an abortion restriction – rather than some other force – caused an abortion clinic to close and thereby caused an undue burden. It may mean that the court no longer cares if a woman has to travel hundreds of miles or leave the state to get an abortion, or if she receives a lower quality of care as the result of an existing law. Roberts has seemed skeptical that these burdens cross the line. As the court’s new <a href="https://www.nytimes.com/2020/06/30/us/john-roberts-supreme-court.html">swing justice</a>, his opinion on the matter will be the one that counts.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/347359/original/file-20200714-139820-18r1y6s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/347359/original/file-20200714-139820-18r1y6s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/347359/original/file-20200714-139820-18r1y6s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/347359/original/file-20200714-139820-18r1y6s.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/347359/original/file-20200714-139820-18r1y6s.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/347359/original/file-20200714-139820-18r1y6s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/347359/original/file-20200714-139820-18r1y6s.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/347359/original/file-20200714-139820-18r1y6s.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The debate about abortion rights is both national and individual, as seen here in Jackson, Mississippi, on March 25, 2020.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Virus-Outbreak-Mississippi-Abortion/0836f0e902b544df887cce0a28a91769/9/0">AP Photo/Rogelio V. Solis</a></span>
</figcaption>
</figure>
<h2>Alternative anti-abortion strategies</h2>
<p>Several other restrictions bear watching. Seventeen states ban abortions after 20 weeks, based on the hotly contested theory that <a href="https://www.nytimes.com/2013/09/17/health/complex-science-at-issue-in-politics-of-fetal-pain.html">fetal pain becomes possible at that point in pregnancy</a>. Others outlaw dilation and evacuation, <a href="https://www.guttmacher.org/gpr/2017/02/de-abortion-bans-implications-banning-most-common-second-trimester-procedure">the most common procedure after the first trimester</a>. Both types of laws build on abortion foes’ last major win, <a href="https://www.law.cornell.edu/supct/html/05-380.ZS.html">Gonzales v. Carhart</a>, a 2007 decision upholding a federal ban on dilation and extraction, a specific technique that Congress called partial-birth abortion.</p>
<p>In Gonzales, the court claimed that whenever there was scientific uncertainty, lawmakers had more freedom to maneuver. Now, abortion foes use scientific uncertainty to justify much broader restrictions. That leeway could give Roberts the kind of cover he needs to chip away at abortion rights. Rather than ignoring precedent, the court could claim to extend it, all while continuing down a path to eliminating Roe.</p>
<p>Recently, states have bet on laws that bring together abortion politics and explosive questions about racial justice. <a href="https://abcnews.go.com/Health/wireStory/mississippi-bans-abortion-based-race-sex-genetic-issues-71569004">Mississippi</a> and <a href="https://www.tennessean.com/story/news/politics/2020/06/19/tennessee-six-week-abortion-ban-fetal-heartbeat-down-syndrome/3214947001/">Tennessee</a> became the latest states to ban abortions based on the fetus’s race, sex or disability. The Supreme Court <a href="https://www.oyez.org/cases/2018/18-483">dodged considering the legality of one</a> of these laws, allowing the issue to percolate longer in the lower courts.</p>
<h2>Overturning Roe?</h2>
<p>It’s still possible that the court would uphold a far more sweeping ban. Last year, after President Donald Trump seemed to have created a conservative Supreme Court majority, states rushed to pass laws outlawing abortion <a href="https://www.nytimes.com/interactive/2019/us/abortion-laws-states.html">at the sixth week of pregnancy</a>, when a doctor could detect fetal cardiac activity. </p>
<p>To uphold such a law, the court would have to overturn Roe and Casey, which both prohibit any abortion ban before viability. But red state lawmakers want to force the court to reconsider Roe. Roberts declined to overturn either one in June Medical, but he stressed that no one had asked <a href="https://slate.com/news-and-politics/2020/06/john-roberts-abortion-june-medical.html">him to</a>. He might be game if the question comes up directly. And I believe it’s only a matter of time until someone makes a specific request.</p>
<p>June Medical doesn’t look to me like a win for abortion rights. The fate of Roe is more uncertain than ever. In my view, the threats to abortion have hardly diminished, and John Roberts, the deciding vote in June Medical, may well be the one to carry them out.</p><img src="https://counter.theconversation.com/content/142530/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mary Ziegler does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>People who object to the landmark 1973 Roe v. Wade ruling legalizing abortion have fought it for years. A recent Supreme Court decision makes the fight much easier.Mary Ziegler, Stearns Weaver Miller Professor, College of Law, Florida State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1126812019-03-19T23:01:15Z2019-03-19T23:01:15ZTrump and Pence turning back progress on access to birth control and a woman’s right to choose<figure><img src="https://images.theconversation.com/files/263485/original/file-20190312-86678-5qf39.png?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Women and men sitting with baby carriages in 1916 in front of The Sanger Clinic in Brooklyn, considered the first Planned Parenthood clinic.</span> <span class="attribution"><span class="source">New York World-Telegram and the Sun Newspaper Photograph Collection/Library of Congress</span></span></figcaption></figure><p>Last month, the U.S. administration officially announced its intention to block federal family planning funds for organizations that provide abortion referrals. <a href="https://thehill.com/policy/healthcare/375852-pence-says-abortion-will-end-in-us-in-our-time">President Donald Trump and his anti-choice Vice-President Mike Pence first presented the idea last spring</a>. </p>
<p>If successful, it would mean a dramatic drop in funding for Planned Parenthood and restricted access for individuals to health services at Planned Parenthood clinics. There is nothing original about this policy move: it is old and tired. It is also harmful to the citizens of the United States. </p>
<p>Planned Parenthood is a <a href="https://100years.plannedparenthood.org">century-old organization</a>, based on the <a href="https://www.plannedparenthood.org/about-us/who-we-are/our-history">first contraception clinic in Brooklyn, N.Y.</a> Founded by public health nurse Margaret Sanger, her sister Ethel Byrne and activist Fania Mindell in 1916, it was the inspiration for the Planned Parenthood Federation of America formed decades later. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/264661/original/file-20190319-60969-1wcgoi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/264661/original/file-20190319-60969-1wcgoi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=388&fit=crop&dpr=1 600w, https://images.theconversation.com/files/264661/original/file-20190319-60969-1wcgoi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=388&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/264661/original/file-20190319-60969-1wcgoi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=388&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/264661/original/file-20190319-60969-1wcgoi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=487&fit=crop&dpr=1 754w, https://images.theconversation.com/files/264661/original/file-20190319-60969-1wcgoi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=487&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/264661/original/file-20190319-60969-1wcgoi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=487&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">U.S. Vice-President Mike Pence is telling anti-abortion advocates that Donald Trump is keeping his word on opposing abortion, calling him the ‘most pro-life president in American history.’</span>
<span class="attribution"><span class="source">(AP Photo/Mark Humphrey)</span></span>
</figcaption>
</figure>
<p>Planned Parenthood occupies a central role in the provision of comprehensive sexuality education and reproductive services for American women. </p>
<p>Approximately 20 per cent of women in the U.S. will rely on a service performed by Planned Parenthood in her lifetime. Nearly half of its client base is related to sexually transmitted infection (STI) testing and treatment, with another 27 per cent for contraception. </p>
<p>This means about three-quarters of Planned Parenthood Federation’s caseload is related to sexual health. <a href="https://www.plannedparenthood.org/uploads/filer_public/4a/0f/4a0f3969-cf71-4ec3-8a90-733c01ee8148/190124-annualreport18-p03.pdf">Only three per cent of its client base visits it for abortion-related services</a>. </p>
<p>At least 60 per cent of Planned Parenthood clients <a href="https://www.istandwithpp.org/defund-defined">use either Medicaid funding or Title X</a>.</p>
<h2>Title X</h2>
<p>Designed in 1970, and supported by both Democrats and Republicans (and Republican President Richard Nixon) to prioritize the needs of low-income families or uninsured people, Title X is the only federal grant program that provides individuals with comprehensive family planning and related preventive health services.</p>
<p><a href="https://www.guttmacher.org/gpr/2000/08/title-x-gag-rule-formally-repealed">Title X “requires counsellors in federally funded family planning clinics to provide a woman facing an unintended pregnancy with non-directive counselling on all of her options and with referrals for services upon request.”</a></p>
<p>In the U.S., it has been the most comprehensive and effective source of public funds for reproductive rights care. Unlike the more <a href="https://www.guttmacher.org/gpr/2001/02/title-x-three-decades-accomplishment">restrictive Medicaid health-care program for those below the poverty line</a>, Title X has no eligibility criteria. </p>
<p>Almost half (42 per cent) of clients accessing Title X-funded clinics have no health insurance, 38 per cent are covered by Medicaid and 19 per cent have private health insurance, according to the <a href="https://www.nationalfamilyplanning.org/title-x_title-x-key-facts">National Family Planning and Reproductive Health Association</a>. More than 50 per cent of Title X patients identify as Black or Latino.</p>
<h2>Recycling old policies</h2>
<p>Trump and Pence have recycled a policy fragment from the end days of the Reagan administration. </p>
<p>In 1988, the secretary of health issued a new regulation that prohibited Title X projects from engaging in counselling, referrals or activities that advocated abortion as a method of family planning. That 1988 law required all Title X projects <a href="https://www.law.cornell.edu/supremecourt/text/500/173">“to maintain an objective integrity and independence from the prohibited abortion activities by the use of separate facilities, personnel and accounting records.”</a> </p>
<p>During the conservative Congresses of the 1980s and 1990s, Title X family planning funding suffered severe cuts. By 1999, taking inflation into account, <a href="https://www.guttmacher.org/gpr/2001/02/title-x-three-decades-accomplishment">the program’s funding level was 60 per cent lower than it was in 1979</a>. </p>
<p>But even with the funding cuts, as of 2016, Title X funded 91 family-planning service grantees, of which 43 were non-profit clinics such as Planned Parenthood.</p>
<p>In 1988, after the first iteration of the <a href="https://www.guttmacher.org/gpr/2000/08/title-x-gag-rule-formally-repealed">anti-Title X domestic “gag rule” was announced</a>, a coalition of pro-choice groups, including Planned Parenthood, challenged it in court. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/264663/original/file-20190319-60949-18aduk8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/264663/original/file-20190319-60949-18aduk8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/264663/original/file-20190319-60949-18aduk8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/264663/original/file-20190319-60949-18aduk8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/264663/original/file-20190319-60949-18aduk8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/264663/original/file-20190319-60949-18aduk8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/264663/original/file-20190319-60949-18aduk8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Hundreds of abortion rights supporters gathered at the Indiana Statehouse in Indianapolis two years ago to protest one of the most restrictive anti-abortion laws signed by then Gov. Mike Pence.</span>
<span class="attribution"><span class="source">(Mykal McEldowney/The Indianapolis Star/AP)</span></span>
</figcaption>
</figure>
<p>Unfortunately, the Supreme Court’s 1991 Rust v. Sullivan decision granted deference to the secretary’s interpretation of Title X, citing “lack of Congressional intent in the legislative history.” </p>
<p>In affirming the District Court’s grant of summary judgment to the secretary, <a href="https://www.law.cornell.edu/supremecourt/text/500/173">the Court of Appeals held that the regulations were a permissible construction of the statute and consistent with the First and Fifth Amendments</a>.</p>
<p>After the Rust vs. Sullivan decision, both houses of Congress voted to overturn the domestic gag rule. However, <a href="https://www.guttmacher.org/gpr/2000/08/title-x-gag-rule-formally-repealed">President George H.W. Bush vetoed the vote</a>. </p>
<p>In January 1993, in his first week in office, President Bill Clinton repealed it and the restrictive interpretation never had a chance to become fully implemented. However, both Pence and Trump wish to reactivate it now. </p>
<p>Given the Supreme Court precedent and the current makeup of the Supreme Court, it is likely this iteration of the domestic gag rule will become policy. </p>
<p>While pro-choice groups have already announced challenges, the court’s history of interpretation on the gag rule doesn’t bode well for those supporting reproductive choices and access for all.</p><img src="https://counter.theconversation.com/content/112681/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Melissa Haussman has received funding in the past from the International Council of Canadian Studies.She has volunteered for the Democratic Party in the US and the Liberal party in Canada.</span></em></p>The Trump administration’s proposal to block federally funded organizations from providing comprehensive reproductive health care will deprive millions of people access to sexual health services.Melissa Haussman, Professor of Political Science, Carleton UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1124912019-03-04T11:39:23Z2019-03-04T11:39:23ZAbortions rise worldwide when US cuts funding to women’s health clinics, study finds<figure><img src="https://images.theconversation.com/files/261709/original/file-20190301-110123-wpcogy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A billboard built by sex education advocates outside Mexico's National Population Council office, in Mexico City, warns that 'being a mother is not child's play.' (May 29, 2014)
</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Mexico-Teen-Pregnancy/4c057493e7914cbd831308d25ce1701b/32/0">AP Photo/Rebecca Blackwell</a></span></figcaption></figure><p>Advancing Republican efforts to <a href="https://www.nytimes.com/2019/02/22/health/trump-defunds-planned-parenthood.html">reduce access to abortion</a>, Secretary of State Mike Pompeo <a href="https://www.nytimes.com/2019/03/26/us/politics/state-department-abortion-funding.html">announced</a> on March 26 that the Trump administration will further restrict federal funding to health providers abroad that perform, promote or even talk about abortions.</p>
<p>The move expands the “<a href="https://theconversation.com/trumps-global-gag-order-5-questions-answered-77838">global gag rule</a>” Trump imposed in 2017. It substantially expands the number of <a href="https://pai.org/newsletters/absolutely-deplorable-trump-administrations-ggr-interpretation-represents-massive-overreach/">groups affected</a> by cutting funding to any organization with a foreign partner that provides abortions – even if those overseas groups are not, themselves, U.S. government-funded. </p>
<p>First implemented under Ronald Reagan in 1984, the global gag rule has been <a href="https://www.amfar.org/articles/on-the-hill/older/president-obama-reverses-%E2%80%9Cglobal-gag-rule%E2%80%9D/">rescinded by every Democrat</a> and reinstated by every Republican to occupy the Oval Office, reflecting the partisan nature of abortion.</p>
<p>Supporters of the global gag rule say defunding abortion providers will <a href="https://lifedefender.org/2017/06/5-reasons-why-defunding-planned-parenthood-is-crucial/">reduce abortions</a>. However, <a href="https://www.scielosp.org/scielo.php?pid=S0042-96862011001200010&script=sci_arttext&tlng=en">researchers from Stanford University</a> in 2011 found that this U.S. policy actually made women in sub-Saharan Africa twice as likely to have an abortion.</p>
<h2>Gag rule increases abortions in Latin America and Africa</h2>
<p>My <a href="https://smlr.rutgers.edu/news/study-global-gag-rule-increased-abortion-rates-some-regions">recent study</a>, published in November 2018, confirms those findings in Africa and shows that the global gag rule had an even greater effect in Latin America. </p>
<p>Analyzing abortion data from 51 developing countries between 2001 and 2008 – which encompassed the reproductive decisions of about 6.3 million women – I found that women in Latin America were three times more likely to have an abortion while the global gag rule was in effect. </p>
<p>Reflecting this impact, the percentage of pregnancies in Latin America that <a href="https://www.sciencedirect.com/science/article/pii/S0140673616303804">ended in abortion</a> rose from 23 percent in 1994, under the Clinton administration, to 32 percent by 2010, after two terms of the Bush administration.</p>
<p>In the United States, where abortion is legal nationwide, about <a href="https://www.cdc.gov/reproductivehealth/data_stats/abortion.htm">18 to 23 percent of pregnancies</a> end in abortion.</p>
<h2>How a US law hurts women abroad</h2>
<p>Funding cuts under the global gag rule cause health care staff reductions, clinic closures and contraceptive shortages. Without family planning counseling and birth control, there are more unintended pregnancies – and, consequently, more abortions. </p>
<p>Numerous <a href="https://www.guttmacher.org/infographic/2016/restrictive-laws-do-not-stop-women-having-abortions">studies</a> confirm that making abortions harder to get doesn’t stop them from happening. It just makes them less safe, because the procedure is not necessarily performed in sterile facilities by qualified doctors. </p>
<p><iframe id="t73Yb" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/t73Yb/1/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>Latin America, a heavily Catholic region, has the <a href="https://theconversation.com/in-latin-america-is-there-a-link-between-abortion-rights-and-democracy-85444">world’s most restrictive abortion laws</a>. Six countries, including Honduras, Nicaragua and El Salvador, <a href="http://derechosdelamujer.org/wp-content/uploads/2017/07/CRR-Mapa-Aborto-AL-2016.pdf">completely ban abortion</a>. Others permit it only in extreme cases like rape, incest or maternal health. </p>
<p>Latin America also has the world’s highest rate of illicit abortions, according to a <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)31794-4/fulltext">2017 study</a> in The Lancet. Seventy-five percent of all abortions in Latin America are performed illegally.</p>
<p>Since Trump reinstated the global gag rule in 2017, health workers <a href="https://www.amfar.org/Issue-Brief-The-Effect-of-the-Expanded-Mexico-City-Policy/">in developing countries</a> have reported drastic <a href="http://www.genderhealth.org/files/uploads/change/publications/Prescribing_Chaos_in_Global_Health_full_report.pdf">reductions</a> in the availability of contraception, teen sex education and family planning services.</p><img src="https://counter.theconversation.com/content/112491/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Yana Rodgers does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The White House will expand a law that cuts funding to abortion providers abroad. When the Bush-era ‘global gag rule’ was last in effect, abortion rates tripled in Latin America and doubled in Africa.Yana Rodgers, Professor of Labor Studies, Rutgers UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1103392019-01-27T19:43:34Z2019-01-27T19:43:34ZIs the future of abortion online?<figure><img src="https://images.theconversation.com/files/255461/original/file-20190124-196225-650k1q.jpg?ixlib=rb-1.1.0&rect=0%2C15%2C1500%2C907&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Women in Mexico City carry a banner reading "Legal and safe abortion across Mexico" during the commemoration of the International Day for the Elimination of Violence Against Women (November 25, 2018).
</span> <span class="attribution"><span class="source">Ronaldo Schemidt/AFP</span></span></figcaption></figure><p>While the abortion debate continues worldwide, even in countries where it has long been legal, new drugs and online telemedicine services could provide access to safe abortion beyond borders and laws.</p>
<p>Since the <a href="https://www.ourbodiesourselves.org/book-excerpts/health-article/a-brief-history-of-birth-control/">early days of the birth-control movement</a>, scientific research and development have contributed significantly to increase the range of options available for managing human fertility and giving women autonomy over their own bodies. One of the most remarkable changes in recent years is medical abortion, a <a href="http://apps.who.int/iris/bitstream/handle/10665/70914/9789241548434_eng.pdf">non-surgical method for terminating pregnancies</a>. It involves the use of prescription drugs such as Misoprostol and Mifepristone (also known as RU-486), which was <a href="https://openarchive.ki.se/xmlui/handle/10616/41984">developed in France and approved for use in 1989</a>.</p>
<p>Long before the scientific interest in these drugs, however, it was women themselves who first discovered their potential. In Brazil, where abortion is legal only in cases of rape and to save the woman’s life, misoprostol was registered for the treatment of ulcers. The label warned women not to use the pills in case of pregnancy. Understanding the implications, <a href="https://www.tandfonline.com/doi/abs/10.1016/0968-8080(93)90006-F">women started to take misoprostol to induce abortions</a> and its use quickly spread.</p>
<p>Medical abortion is a common practice today and has been shown to be effective for <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3766037/">98.3% for women in early pregnancies</a>. The procedure mimics miscarriage and is preferred by many women on the grounds that it is <a href="https://www.plannedparenthood.org/learn/abortion/the-abortion-pill">less invasive</a>. Given the low risk of complications and high success rate of medical abortions, the <a href="http://apps.who.int/iris/bitstream/handle/10665/70914/9789241548434_eng.pdf">World Health Organisation</a> has stated that they do not need to take place in a hospital or clinic.</p>
<p>Home use of abortion pills became legal in <a href="https://news.sky.com/story/women-in-england-able-to-take-abortion-pill-at-home-11481103">Scotland and Wales in 2017</a>, and in August 2018, England followed suit. The US organisation <a href="https://www.plannedparenthood.org/learn/abortion/the-abortion-pill">Planned Parenthood</a> states that: </p>
<blockquote>
<p>“Which kind of abortion you choose all depends on your personal preference and situation. With medical abortion, some people like that you don’t need to have a procedure in a doctor’s office. You can have your medical abortion at home or in another comfortable place that you choose.”</p>
</blockquote>
<h2>Carrying the abortion battle online</h2>
<p>Combining the advent of medical abortion with communication technologies, telemedicine services can provide access to safe abortion worldwide. Run by medical doctors, social workers and even volunteers, such platforms not only furnish women with medical abortion pills, but they also provide counselling and assistance throughout and even after the procedure.</p>
<p><a href="https://www.womenonweb.org/">Women on Web</a> was established in 2006 by a Dutch doctor, <a href="https://www.womenonwaves.org/en/page/2896/rebecca-gomperts%20--%20md%20--%20mpp%20--%20phd">Rebecca Gomperts</a>, who has previously and famously organised <a href="https://www.womenonwaves.org/en/page/493/abortion-on-our-ship">abortion ship campaigns</a> in countries where access to abortion is restricted. Celebrating the 10th anniversary of the website in 2016, the Women on Web community stated that over the past 10 years, more than 200,000 women from over 140 countries received consultation through their website and approximately 50,000 women obtained medical-abortion supplies for home use.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/255455/original/file-20190124-196215-1dzwjbd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/255455/original/file-20190124-196215-1dzwjbd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/255455/original/file-20190124-196215-1dzwjbd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/255455/original/file-20190124-196215-1dzwjbd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/255455/original/file-20190124-196215-1dzwjbd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/255455/original/file-20190124-196215-1dzwjbd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/255455/original/file-20190124-196215-1dzwjbd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Abortion pills, Mifepristone and Misoprostol.</span>
<span class="attribution"><span class="source">Women on Web</span></span>
</figcaption>
</figure>
<p>Since Women on Web was launched, telemedicine services that provide abortion care to those living in restrictive settings have proliferated. Even in countries where abortion is restricted by law, these services were able to operate as the custom regulations in most countries <a href="https://www.womenonweb.org/en/page/523/questions-and-answers-overview">allow women to receive prescription medicine for individual use</a>. By navigating around restrictive laws, such organisations have been able to provide safe abortions beyond laws and borders. Several studies have been conducted on the use of telemedicine abortion services, and they concluded that it is <a href="https://www.bmj.com/content/357/bmj.j2011">safe and effective</a> and that outcomes are in the <a href="https://www.ncbi.nlm.nih.gov/pubmed/18637010">same range as the termination of pregnancy provided in outpatient settings</a>. A <a href="https://www.ansirh.org/news/receiving-medication-abortion-through-telemedicine-safe-person">US-based study</a> puts forth that insofar the findings are “sufficiently large to be able to conclude that telemedicine provision of medication abortion is as safe as abortion in person.” It can thus be argued that telemedicine revolutionises access to safe abortions, while <a href="https://www.ncbi.nlm.nih.gov/pubmed/28780241">“putting abortion pills into women’s hands”</a>.</p>
<p>On the other side of the spectrum, rights advocates also warn against <a href="https://www.womenonwaves.org/en/page/974/warning%20--%20fake-abortion-pills-for-sale-online">fake abortion websites and scams</a>. Researchers also underline that telemedicine might be <a href="https://www.bmj.com/content/357/bmj.j2011">more applicable to the context of developed countries</a>, where women have better access to quality care in rare cases of complications. Reproductive-rights activists have asserted that telemedicine prescriptions could <a href="https://www.politico.com/story/2018/07/29/abortion-rights-technology-telemedicine-prescriptions-693328">undercut abortion restrictions</a> and help <a href="https://www.wired.com/story/telemedicine-could-help-fill-the-gaps-in-americas-abortion-care/">fill in the gap in abortion care</a>.</p>
<p>As abortion debates continue to revolve around different socio-political and religious realms, the <a href="https://www.bostonglobe.com/ideas/2018/08/31/the-abortion-debate-doesn-change-but-science-abortion-does/smHRPvw5XDkTXzMUrADawK/story.html">science of abortion has developed tremendously</a>. While abortion rights continue to be restricted in many countries around the world, research has shown that the sitution has already changed thanks to feminist activism, medical advances and telemedicine services.</p><img src="https://counter.theconversation.com/content/110339/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Hazal Atay a reçu des financements de la Commission européenne dans le cadre d'Actions Marie Skłodowska-Curie. </span></em></p>While the abortion debate continues worldwide, even in countries where it has long been legal, new drugs and telemedicine services could provide access to safe abortion beyond borders and laws.Hazal Atay, Ph.D candidate, INSPIRE Marie Skłodowska-Curie Fellow, Sciences Po Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1035132018-10-25T10:47:38Z2018-10-25T10:47:38ZTanzanian president bluntly attacks contraception, saying high birth rates are good for economy<figure><img src="https://images.theconversation.com/files/242116/original/file-20181024-71038-17f0kw4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Tanzania was one of the first sub-Saharan African nations to embrace family planning as a national development priority.</span> <span class="attribution"><a class="source" href="https://www.africom.mil/Img/5029/Super/US-AFRICOM-Photo">US Air Force</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>Tanzanian President John Magufuli has <a href="https://www.cnn.com/2018/09/25/africa/tanzania-suspends-family-planning-advert-intl/index.html">suspended</a> advertising by family planning organizations until further review, raising outcry among human rights groups and <a href="http://www.africanews.com/2018/09/21/is-magufuli-bullying-tanzania-s-health-ministry-as-family-planning-ads-are//">causing unrest</a> within Tanzania’s health ministry. </p>
<p>The move came weeks after Magufuli made <a href="https://www.kff.org/news-summary/tanzania-president-magufuli-calls-for-citizens-to-stop-using-birth-control-to-increase-population/">international headlines</a> for inflammatory comments calling <a href="http://www.thecitizen.co.tz/News/Magufuli-advises-against-birth-control/1840340-4751990-4h8fqpz/index.html">women who use contraception</a> “lazy” and saying that he does “not see any need for birth control in Tanzania,” one of the <a href="https://www.statista.com/statistics/264687/countries-with-the-highest-population-growth-rate/">world’s fastest-growing countries</a>. </p>
<p>Amnesty International <a href="https://www.amnesty.org/en/latest/news/2018/09/tanzania-decision-to-pull-family-planning-ads-an-attack-on-sexual-and-reproductive-rights/">denounced</a> Magufuli’s stance as an attack on the sexual and reproductive rights of Tanzanian women.</p>
<p>Tanzania has a history of promoting family planning, making Magufuli’s sudden opposition to birth control surprising.</p>
<p>But, as my <a href="https://womenalsoknowhistory.com/individual-scholar-page/?pdb=2328">demographic research</a> shows, Magufuli is not the only world leader questioning longstanding population control policies.</p>
<h2>Development and fertility</h2>
<p>Magufuli, who took office in 2015, earned the nickname “The Bulldozer” during his previous two decades in Tanzanian politics. </p>
<p>His administration garnered <a href="https://theconversation.com/magufuli-has-been-president-for-two-years-how-hes-changing-tanzania-86777">early popular support</a> in the East African nation for dismissing corrupt public officials and reorienting government spending, particularly toward anti-cholera operations and other public health services. </p>
<p>But he has also <a href="https://www.economist.com/middle-east-and-africa/2016/05/26/government-by-gesture">made undemocratic moves</a>, shutting down <a href="https://www.washingtonpost.com/news/monkey-cage/wp/2016/01/25/tanzania-loves-its-new-anti-corruption-president-why-is-he-shutting-down-media-outlets/?utm_term=.12c01bc712ca">newspapers critical of his administration</a> and undermining judicial independence. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/242117/original/file-20181024-71020-eb6g5d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/242117/original/file-20181024-71020-eb6g5d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=405&fit=crop&dpr=1 600w, https://images.theconversation.com/files/242117/original/file-20181024-71020-eb6g5d.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=405&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/242117/original/file-20181024-71020-eb6g5d.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=405&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/242117/original/file-20181024-71020-eb6g5d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=509&fit=crop&dpr=1 754w, https://images.theconversation.com/files/242117/original/file-20181024-71020-eb6g5d.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=509&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/242117/original/file-20181024-71020-eb6g5d.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=509&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Magufuli is known for his fiery rhetoric.</span>
<span class="attribution"><a class="source" href="http://pictures.reuters.com/C.aspx?VP3=SearchResult&VBID=2C0BXZFVNYSAE&SMLS=1&RW=1264&RH=744&POPUPPN=24&POPUPIID=2C0BF1OH3B26M">Reuters/Sadi Said</a></span>
</figcaption>
</figure>
<p>Many Tanzanians, especially young people and urbanites, have lost patience with his strongman tactics, <a href="http://www.theeastafrican.co.ke/news/ea/Tanzania-John-Magufuli-popularity-falls/4552908-4649482-12a4cwv/index.html">polling shows</a>.</p>
<p>Now his sudden opposition to birth control has raised concern that Tanzanian women could lose access to contraception. </p>
<p>Since the Industrial Revolution, economic development worldwide has <a href="https://www.nature.com/articles/nature08230">closely correlated</a> with lowering birth rates.</p>
<p>In Africa, the United Nations has <a href="http://www.un.org/popin/icpd/conference/bkg/pop.html">documented</a> a relationship between high population growth and lower quality of life. High fertility can exacerbate poverty and strain resource-strapped governments’ ability to provide public services like health care and education. </p>
<p>African leaders have generally <a href="http://www.un.org/en/development/desa/population/publications/pdf/policy/Compendium/Volume%20II/j_Chapter%205.pdf">acknowledged</a> the connection between demography and development, though their demographic policies have varied. Tanzania, a British colony until 1961, was one of the first countries in sub-Saharan Africa to embrace family planning. </p>
<p>In 1959, the <a href="http://www.umati.or.tz/index.php/who-we-are/about-umati">Family Planning Association of Tanzania</a> – now a <a href="https://www.ippf.org/about-us/member-associations/tanzania">member</a> of the International Planned Parenthood Federation – was founded to offer sexual education and contraception, though not abortion services.</p>
<p>At the time, the average Tanzanian woman had <a href="https://data.worldbank.org/indicator/SP.DYN.TFRT.IN?locations=TZ">almost seven</a> children. Cultural attitudes varied among the country’s <a href="https://www.africa.upenn.edu/NEH/tethnic.htm">100-plus</a> ethnic groups, but children were generally seen a status symbol and a source of labor for the majority who practiced subsistence farming and herding. </p>
<p>Tanzania’s first president, <a href="https://www.britannica.com/biography/Julius-Nyerere">Julius Nyerere</a>, emphasized social and economic development as the basis for his policy agenda. He called his plan “Ujamaa,” which means “familyhood” in Swahili, Tanzania’s national language. </p>
<p><iframe id="pipQF" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/pipQF/1/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>By choosing that term, Nyerere wanted to stress the connection between the newly sovereign nation and the families at its core.</p>
<p>In a 1969 speech introducing his <a href="https://books.google.com/books?id=i9fLugEACAAJ&dq=tanzania+second+five+year+development+plan&hl=en&sa=X&ved=0ahUKEwiTgeOZtZreAhWQq1kKHV3FDN0Q6AEIMDAC">blueprint for development in Tanzania</a>, Nyerere urged citizens to “put emphasis on caring for children and the ability to look after them properly, rather than thinking only about the numbers of children and the ability to give birth.”</p>
<h2>Tanzania’s Catholic champion of birth control</h2>
<p>President Nyerere was Catholic, like roughly <a href="http://globalreligiousfutures.org/countries/tanzania#/?affiliations_religion_id=0&affiliations_year=2010&region_name=All%20Countries&restrictions_year=2016">one-third</a> of Tanzania’s population. Then, as now, the Vatican officially opposed birth control. </p>
<p>But Nyerere rallied prominent local Catholic bishops around his efforts to link development and family planning. </p>
<p>“Nobody should have a single child unless he or she is able to take care of it,” said the late Tanzanian Bishop Fortunatus Lukanima in an <a href="https://www.diva-portal.org/smash/get/diva2:275035/FULLTEXT01.pdf">interview</a> after his retirement in 1998. “Let’s discuss family planning, condoms, birth control and so on.”</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/242118/original/file-20181024-71038-1g773bv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/242118/original/file-20181024-71038-1g773bv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/242118/original/file-20181024-71038-1g773bv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=479&fit=crop&dpr=1 600w, https://images.theconversation.com/files/242118/original/file-20181024-71038-1g773bv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=479&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/242118/original/file-20181024-71038-1g773bv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=479&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/242118/original/file-20181024-71038-1g773bv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=602&fit=crop&dpr=1 754w, https://images.theconversation.com/files/242118/original/file-20181024-71038-1g773bv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=602&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/242118/original/file-20181024-71038-1g773bv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=602&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Tanzania’s first president, Julius Nyerere (center) saw reduced fertility as key to Tanzania’s future as a sovereign nation.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:The_National_Archives_UK_-_CO_1069-164-60.jpg">UK National Archives</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Nyerere’s government also enlisted Muslim religious leaders to promote family planning in Tanzania’s predominantly Muslim coastal areas. </p>
<p>After he stepped down in 1985, consecutive administrations have continued to <a href="https://www.usaid.gov/documents/1860/tanzania-2014-family-planning-fact-sheet">support family planning</a> and pass national population policies aimed at <a href="https://extranet.who.int/nutrition/gina/sites/default/files/TZA%202006%20National%20Population%20Policy.pdf">lowering Tanzania’s fertility rates</a>.</p>
<p>Despite these efforts, Tanzania still has one of the <a href="https://www.statista.com/statistics/264687/countries-with-the-highest-population-growth-rate/">world’s highest birth rates</a>. The average Tanzanian woman has five children, double the <a href="https://ourworldindata.org/fertility-rate">global average</a>.</p>
<p>Tanzania’s population has grown from around 10 million at independence in 1961 to almost <a href="http://www.worldometers.info/world-population/tanzania-population/">60 million</a> today. That’s triple the growth rate of the United States, double that of China and above even Nigeria, Africa’s most populous country.</p>
<h2>Is population growth a problem?</h2>
<p>This contradiction is seen across Africa. </p>
<p>Family planning <a href="https://www.jstor.org/stable/1971615?seq=1#metadata_info_tab_contents">programs</a> have <a href="https://esa.un.org/PopPolicy/charting/graphs.aspx">nearly universal government support</a>. Yet the continent is still projected to account for <a href="https://esa.un.org/unpd/wpp/Publications/Files/WPP2017_KeyFindings.pdf">82 percent of the world’s population growth</a> between now and 2100.</p>
<p>Common wisdom sees rapid population growth as a problem for low-income countries. If economic growth doesn’t keep pace, governments struggle to adequately provide services like housing, health care and education. </p>
<p>But the relationship between population growth and economic development is <a href="https://www.tandfonline.com/doi/abs/10.1080/0032472031000149536?casa_token=FODrOCX_q84AAAAA:1jBuNOeCyomLUHRm8yIunY_HFi-xGrOcgM3VXhCfm5lSnKmmrrxNItcrGL03YLi8nDbV_OQHBxs">murkier</a> than international organizations like the UN have long thought. And it’s changing with the times.</p>
<p>With fertility rates in Western Europe <a href="https://www.theguardian.com/world/2015/aug/23/baby-crisis-europe-brink-depopulation-disaster">perilously low</a> – in Spain, two people die for every one person born – some developing countries believe that a huge workforce and consumer pool could give them a global advantage. </p>
<p><iframe id="Tdo5w" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/Tdo5w/1/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p><a href="https://www.theguardian.com/world/2018/aug/28/china-could-scrap-two-child-policy-ending-nearly-40-years-of-limits">China</a> and <a href="https://www.kyivpost.com/russia/the-economist-russia-to-raise-pension-ages-that-date-back-to-stalin.html">Russia</a> recently reversed long-standing population-control policies, citing economic reasons. </p>
<p>Ugandan President Yoweri Museveni also <a href="https://www.yowerikmuseveni.com/address-national-state-affairs">sees population growth</a> as a boon to Africa – and global markets.</p>
<p>Magufuli’s anti birth-control comments came in <a href="http://www.thecitizen.co.tz/News/Magufuli-advises-against-birth-control/1840340-4751990-4h8fqpz/index.html">this context</a>. Emboldened by <a href="https://www.hks.harvard.edu/announcements/new-2025-global-growth-projections-predict-chinas-further-slowdown">optimistic projections</a> of economic growth in East Africa, he says a booming population could actually benefit Tanzania. </p>
<p>Tanzania has US$10 million <a href="https://allafrica.com/stories/201806130591.html">earmarked</a> for family planning next year. Magufuli seems to be considering redirecting this money to pay for education, health care and other social programs with a more tangible socioeconomic impact. </p>
<h2>Choosing a demographic destiny</h2>
<p>Most demographers agree that African countries will eventually experience the same drop in fertility rates that <a href="https://www.jstor.org/stable/1972620?seq=1#page_scan_tab_contents">high-income Western democracies</a> in the 20th century.</p>
<p>So far, there is little evidence that government policies promoting <a href="https://www.jstor.org/stable/10.1086/657081?seq=1#metadata_info_tab_contents">women’s reproductive choice</a> and access to contraception will spur that process. </p>
<p>If Magufuli’s rejection of family planning becomes policy, it would be a major setback for Tanzanian <a href="https://books.google.com/books?hl=en&lr=&id=RX1-GvI-WKkC&oi=fnd&pg=PR7&dq=population+growth+development+women%27s+rights+environment&ots=SVwQXKiVgT&sig=4QjruUWcjNL9PKn1cCzuMUKFUhI#v=onepage&q=population%20growth%20development%20women's%20rights%20environment&f=false">women’s rights</a>.</p>
<p>But he is not alone in questioning long-accepted wisdom on population control.</p><img src="https://counter.theconversation.com/content/103513/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kristen Carey has received research funding from the U.S. Department of Defense in the form of a Boren Fellowship. </span></em></p>Tanzania was an early, ardent believer in family planning. Now it joins a growing number of developing nations that see potential advantage in having a huge and growing workforce.Kristen Carey, PhD Candidate in History, Boston UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/986842018-06-21T10:27:15Z2018-06-21T10:27:15ZCorporate CEOs’ political voice growing louder as they criticize Trump policies like separating migrant children<figure><img src="https://images.theconversation.com/files/224135/original/file-20180621-137741-1d0kkco.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Children wait at a private charity after being released by Customs and Border Protection.</span> <span class="attribution"><span class="source">AP Photo/Eric Gay</span></span></figcaption></figure><p>America’s CEOs have become increasingly active on political issues that they would have shunned in prior years.</p>
<p>The <a href="https://www.bloomberg.com/news/articles/2018-06-20/american-asks-u-s-not-to-put-detained-children-on-its-flights">latest example</a> came in response to the Trump administration’s “zero tolerance” border enforcement policy that led to the <a href="https://theconversation.com/breaking-up-families-america-looks-like-a-dickens-novel-98660">forced separation</a> of several thousand immigrant children from their <a href="https://theconversation.com/forced-migration-from-central-america-5-essential-reads-98600">detained parents</a>. United Continental CEO Oscar Munoz called the policy “in deep conflict with our company’s values.” </p>
<p>United and fellow airlines <a href="http://news.aa.com/news/news-details/2018/Statement-on-Recent-Reports-of-Separated-Families/default.aspx">American</a>, Southwest and <a href="https://twitter.com/FlyFrontier/status/1009488027985596416">Frontier</a> each indicated they didn’t want the government to use their planes to fly separated children. President Donald Trump hoped to quell the furor over the issue by signing an executive order <a href="https://www.nytimes.com/2018/06/20/us/politics/trump-immigration-children-executive-order.html">ending the separations</a>.</p>
<p>It’s certainly not the first time corporate CEOs took a stand against a Trump policy or his words. After the president’s <a href="https://www.nytimes.com/2017/08/15/us/politics/trump-press-conference-charlottesville.html">contentious response</a> to violent clashes in Charlottesville, Virginia, CEO resignations and <a href="http://fortune.com/2017/08/17/ceos-trump-charlottesville-criticized">denunciations</a> led to the <a href="https://www.washingtonpost.com/news/on-leadership/wp/2017/08/16/after-wave-of-ceo-departures-trump-ends-business-and-manufacturing-councils/">dissolution</a> of two White House advisory councils.</p>
<p>While Trump’s actions likely sparked this increase in political activism by corporate CEOs, its roots run deeper and will survive beyond the end of the current administration.</p>
<h2>From custom abiders to bullies</h2>
<p>When I first began studying the interactions between social movements and corporations in the 1990s, it was rare to see business take a public stand on social issues. Yet today we see organizations ranging from General Electric to the NCAA <a href="http://www.nbcnews.com/feature/nbc-out/major-corporations-join-fight-against-north-carolina-s-bathroom-bill-n605976">weighing in</a> on, for example, transgender rights, something hard to imagine even a decade ago.</p>
<p>Traditionally, corporations aimed to be scrupulously neutral on social issues. No one doubted that corporations exercised power, but it was over bread-and-butter economic issues like trade and taxes, not social issues. There seemed little to be gained by activism on potentially divisive issues, particularly for consumer brands. </p>
<p>A watershed of the civil rights movement, for example, was the <a href="http://www.jstor.org/stable/2095077">1960 sit-in protest by students that began at a segregated lunch counter</a> in a Woolworth store in Greensboro, North Carolina, and spread across the South. Woolworth’s corporate policy had been to “abide by local custom” and keep black and white patrons separated. By supporting the status quo, Woolworth and others like it stood in the way of progress.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/139327/original/image-20160926-31842-15nz195.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/139327/original/image-20160926-31842-15nz195.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=469&fit=crop&dpr=1 600w, https://images.theconversation.com/files/139327/original/image-20160926-31842-15nz195.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=469&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/139327/original/image-20160926-31842-15nz195.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=469&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/139327/original/image-20160926-31842-15nz195.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=590&fit=crop&dpr=1 754w, https://images.theconversation.com/files/139327/original/image-20160926-31842-15nz195.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=590&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/139327/original/image-20160926-31842-15nz195.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=590&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">When the Greensboro Four launched their sit-in protest, companies tended to stay neutral on social issues.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:A%26T_four_statue_2000.jpg">Cewatkin via Wikimedia Commons</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>But negative publicity led to substantial lost business, and Woolworth eventually relented. In July, four months after the protest started – and after the students had gone home for the summer – the manager of the <a href="http://www.history.com/topics/black-history/the-greensboro-sit-in">Greensboro store</a> quietly integrated his lunch counter.</p>
<p>In general, companies were more worried about the costs of taking a more liberal stand on such issues, a point basketball legend and Nike pitchman Michael Jordan made succinctly in 1990. Asked to support Democrat Harvey Gantt’s campaign to replace segregationist incumbent Jesse Helms as a North Carolina senator, Jordan declined, reportedly saying “<a href="http://www.slate.com/articles/sports/sports_nut/2016/07/did_michael_jordan_really_say_republicans_buy_sneakers_too.html">Republicans buy sneakers, too</a>.”</p>
<p>And companies presumed that taking controversial positions would lead to boycotts by those on the other side. That’s what happened to Walt Disney in 1996 as a result of its early support for gay rights, such as <a href="https://en.wikipedia.org/wiki/Gay_Days_at_Walt_Disney_World">“Gay Day”</a> at its theme parks. Its stand prompted groups including America’s largest Protestant denomination, the Southern Baptists, to <a href="http://www.cnn.com/US/9706/18/baptists.disney/">launch a boycott</a>, calling Disney’s support for gay rights an “anti-Christian and anti-family direction.” The <a href="http://www.nbcnews.com/id/8318263/ns/us_news/t/southern-baptists-end--year-disney-boycott/">eight-year boycott</a>, however, was notably ineffective at changing Disney policy. It turns out that too few parents had the heart to deny their children Disney products to make a boycott effective. </p>
<p>Since then, some of the biggest U.S. companies have taken similar stands, in spite of the reaction from conservatives. For example, when the Arkansas legislature passed a bill in March 2015 that would have enabled LGBT discrimination on the grounds of “religious freedom,” <a href="http://www.reuters.com/article/us-walmart-arkansas-analysis-idUSKBN0MT13E20150402">the CEO of Walmart urged the governor to veto the bill</a>. </p>
<p>Not surprisingly, given Walmart’s status in the state and the corporate backlash that accompanied a similar law in Indiana, the <a href="http://www.usatoday.com/story/news/politics/2015/04/01/govt-and-business-leaders-object-to-ark-religion-bill/70757942/">governor obliged</a> and eventually signed a <a href="http://www.cnn.com/2015/03/31/politics/arkansas-religious-freedom-anti-lgbt-bill/">modified bill</a>. That didn’t sit well with former Louisiana Governor Bobby Jindal, however, who <a href="http://www.nytimes.com/2015/04/23/opinion/bobby-jindal-im-holding-firm-against-gay-marriage.html">argued in The New York Times</a> that companies in those states were joining “left-wing activists to bully elected officials into backing away from strong protections for religious liberty.” He warned companies against “bullying” Louisiana.</p>
<p>Why have corporations shifted from “abiding local custom” around segregation and other divisive social issues to “bullying elected officials” to support LGBT rights?</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/183830/original/file-20170829-6653-za65f9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/183830/original/file-20170829-6653-za65f9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/183830/original/file-20170829-6653-za65f9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/183830/original/file-20170829-6653-za65f9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/183830/original/file-20170829-6653-za65f9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/183830/original/file-20170829-6653-za65f9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/183830/original/file-20170829-6653-za65f9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Merck CEO Ken Frazier, seated next to Trump, was the first to resign from a manufacturing council after Charlottesville.</span>
<span class="attribution"><span class="source">AP Photo/Evan Vucci</span></span>
</figcaption>
</figure>
<h2>Changing environment</h2>
<p>In my view, there are two broad changes responsible for this increased corporate social activism.</p>
<p>First, <a href="https://www.amazon.com/Changing-Your-Company-Inside-Intrapreneurs/dp/1422185095/ref=asap_bc">social media and the web have changed the environment for business</a> by making it cheaper and easier for activists to join together to voice their opinions and by making corporate activities more transparent. </p>
<p>The rapid spread of the Occupy movement in the fall of 2011, from Zuccotti Park in New York to encampments across the country, <a href="http://www.huffingtonpost.com/2011/10/06/occupy-wall-street-social-media_n_999178.html">illustrates</a> how social media can enable groups with a compelling message to scale up quickly. Sometimes even online-only movements can be highly effective.</p>
<p>When the Susan G. Komen Foundation cut off funds to Planned Parenthood that were aimed at supporting breast cancer screenings for low-income women, a pop-up social movement arose: Facebook and Twitter exploded with <a href="http://www.nytimes.com/2012/02/03/us/komen-foundation-urged-to-restore-planned-parenthood-funds.html">millions of posts and tweets voicing opposition</a>. Within days the policy was walked back.</p>
<p><a href="http://blogs.hbr.org/2014/04/what-matters-about-mozilla-employees-led-the-coup/">Mozilla’s appointment of a new CEO</a> who had supported a California ballot proposal banning same-sex marriage also generated outrage online, both inside and outside the organization. He was gone within two weeks. </p>
<p>In each case, social media allowed like-minded “clicktivists” to draw attention to an issue and demonstrate their support for change, quickly and at very little cost. It’s never been cheaper to assemble a virtual protest group, and sometimes (as in the massive <a href="https://www.nytimes.com/2017/01/21/us/womens-march.html?mcubz=1&_r=0">Women’s March</a> that took place in cities around the world the day after Trump’s inauguration) online tools enable real-world protest. As such, activism is likely to be a constant for corporations in the future.</p>
<h2>Millennials don’t like puffery</h2>
<p>A second change is that millennials, as consumers and workers, <a href="http://ssir.org/articles/entry/the_new_face_of_corporate_activism">are highly attuned</a> to a company’s “social value proposition.” </p>
<p>Companies targeting the sensibilities of the young often tout their social missions. <a href="http://www.toms.com/improving-lives">Tom’s Shoes</a> and <a href="https://www.warbyparker.com/buy-a-pair-give-a-pair">Warby Parker</a> both have “buy a pair, give a pair” programs. Chipotle highlights its <a href="https://chipotle.com/food-with-integrity">sustainability efforts</a>. And Starbucks has promoted fair trade coffee, marriage equality and racial justice <a href="https://www.fastcompany.com/3046890/the-inside-story-of-starbuckss-race-together-campaign-no-foam">more or less successfully</a>. In each case, transparency about corporate practices serves as a check on puffery. </p>
<p>Social mission is even more important when it comes to recruiting. At business school recruiting events, it is almost obligatory that <a href="http://ssir.org/articles/entry/the_new_face_of_corporate_activism">companies describe</a> their LEED-certified workplaces, LGBT-friendly human resource practices and community outreach efforts. </p>
<p>Moreover, our employer signals something about our identity. Value alignment is part of why people stay at their job, and among many millennials, socially progressive values – particularly around LGBT issues – are almost a given.</p>
<p>In this situation, corporate activism may be the sensible course of action, at least when it comes to LGBT issues. According to the <a href="http://www.pewforum.org/2016/05/12/changing-attitudes-on-gay-marriage/">Pew Research Center</a>, for example, support for same-sex marriage has doubled from 31 percent in 2004 to 62 percent in 2017, and there is little reason to expect a reversal. </p>
<h2>Red and blue companies?</h2>
<p>While prominent companies like Starbucks and Target have taken stances associated with liberal causes, some businesses have gone the other direction. </p>
<p><a href="http://www.latimes.com/business/la-fi-mo-chick-fil-a-gay-20120718-story.html">Chick-fil-A aimed to implement</a> “biblical values” and supported anti-gay groups in the 2000s. Those groups returned the favor by encouraging like-minded people to dine there on “<a href="https://www.theguardian.com/lifeandstyle/us-news-blog/2012/aug/01/chick-fil-a-appreciation-day">Chick-fil-A appreciation day</a>.”</p>
<p>Hobby Lobby <a href="http://www.usnews.com/news/articles/2015/07/10/after-hobby-lobby-ruling-hhs-announces-birth-control-workaround">famously sought to abstain</a> from providing funding for birth control for employees on religious grounds. Koch Industries, overseen by the famous Koch brothers, <a href="http://www.dailykos.com/story/2014/4/1/1288957/-Sign-the-pledge-Don-t-buy-these-Koch-products">has long been a lightning rod</a> for boycotts due to the right-wing proclivities of its dominant owners. And small businesses across the country are not always shy in advertising their conservative political orientations. </p>
<p>As <a href="http://press.princeton.edu/titles/9030.html">states have seemingly divided</a> into red (for conservative) and blue (for liberal), might we expect the same thing from corporations, as consumers and employees drift toward the brands that best represent their views – red companies and blue companies? </p>
<p><a href="https://www.opensecrets.org/orgs/list.php">It is already easy to look up</a> political contributions by companies and their employees. For example, Bloomberg, Alphabet and the Pritzker Group lean Democratic; Oracle, Chevron and AT&T tend Republican. </p>
<p>In the current electoral climate, it is not hard to imagine this continuing. </p>
<p><em>This is an updated version of an <a href="https://theconversation.com/when-did-che-guevara-become-ceo-the-roots-of-the-new-corporate-activism-64203">article originally published</a> on Sept. 27, 2016.</em></p><img src="https://counter.theconversation.com/content/98684/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jerry Davis does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>United’s CEO called the Trump policy ‘in deep conflict’ with his company’s values, the latest example of a corporate leader speaking out on a political issue, something almost unheard of a few decades ago.Jerry Davis, Professor of Management and Sociology, Ross School of Business, University of MichiganLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/803082017-07-19T06:40:40Z2017-07-19T06:40:40ZRepublicans fail on health care. Here’s why the rest of Trump’s agenda won’t be ‘so easy,’ either<figure><img src="https://images.theconversation.com/files/178724/original/file-20170718-24356-pnpncr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Sen. Rand Paul speaks at a news conference on Capitol Hill.</span> <span class="attribution"><span class="source">AP Photo/Andrew Harnik</span></span></figcaption></figure><p>Passing legislation is always a difficult, messy task. America’s highly polarized political environment, with party activists demanding ideological purity on both sides of the aisle, makes that task even harder.</p>
<p>The announcement by Senators Mike Lee and Jerry Moran that they would oppose bringing the Better Care Reconciliation Act to the Senate floor has <a href="https://www.nytimes.com/2017/07/17/us/politics/health-care-overhaul-collapses-as-two-republican-senators-defect.html?_r=0">derailed Republican attempts</a> to replace the Affordable Care Act. </p>
<p>During his campaign, <a href="https://www.realclearpolitics.com/video/2016/10/25/trump_repealing_obamacare_is_going_to_be_so_easy.html">Donald Trump claimed</a> that passing health care reform would be “so easy.” So why were Republicans unable to pass a health care law despite controlling both the White House and Congress?</p>
<p>It turns out that the relationship between Congress and the president is more complicated than Trump thought. Most citizens and <a href="https://www.amazon.com/Ideology-Congress-Keith-T-Poole/dp/1412806089">political scientists</a> assumed that conservative Republicans <a href="http://press.uchicago.edu/ucp/books/book/chicago/P/bo3616471.html">would prefer any health care law</a> that Trump supported over the Obamacare status quo.</p>
<p>However, my <a href="http://www.tandfonline.com/doi/abs/10.1080/07343469.2015.1122671">research</a> shows that this assumption is too simplistic. As Trump now knows, ideological extremists may also vote against bills proposed by their party’s president. The recent struggle to pass a Republican health care law is a prominent example of this phenomenon.</p>
<h2>Trump’s two-sided task</h2>
<p>President Trump, House Speaker Paul Ryan and Senate Majority Leader Mitch McConnell are waging a legislative battle on two fronts with no compromise in sight. Both moderate Republicans and extremely conservative Republicans oppose the current health care bill for <a href="https://www.nytimes.com/interactive/2017/07/13/us/senate-health-care-bill-changes.html">completely separate reasons</a>.</p>
<p>Moderate Republicans are concerned about how Medicaid cuts and changes to Obamacare regulations, like guaranteed essential health benefits and protections for people with preexisting conditions, will affect their constituents. On the other hand, extremely conservative Republicans want to both remove those Obamacare regulations and repeal all Obamacare taxes. This puts Republicans leaders in a bind. Anything they do to please moderates will tend to alienate the extreme conservatives, and vice versa.</p>
<p>The House passed the American Health Care Act thanks to support from extremely conservative members who switched their votes to <a href="https://www.nytimes.com/2017/04/26/us/politics/affordable-care-act-health-republicans.html">support the bill</a>. This may explain why Majority Leader McConnell’s strategy seemed more focused on winning conservative support than moderate support. The major change to the most recent version of the health care bill was the Cruz Amendment, which would allow insurance companies to offer low-cost plans that provide coverage that is much less than the <a href="http://thehill.com/policy/healthcare/341828-new-gop-healthcare-bill-includes-version-of-cruz-amendment">standards set by Obamacare</a>. Yet this bill did not provide <a href="http://www.nbcnews.com/politics/congress/major-health-care-changes-senate-gop-bill-n782691">funding for Planned Parenthood or protect Medicaid</a>, two provisions that a number of moderate Republicans like Susan Collins, Shelley Moore Capito, Rob Portman and Lisa Murkowski wanted to see included.</p>
<p>The president’s strategy seemed to focus on conservatives as well. The list of senators invited to the White House on July 17 to solidify support for the bill included a number of conservative senators and <a href="http://www.politico.com/story/2017/07/17/trump-obamacare-repeal-senators-outreach-240636">almost no moderates</a>. </p>
<h2>Moving down the agenda</h2>
<p>After the original bill’s failure, both Trump and McConnell wanted the Senate to vote on a bill to completely repeal the Affordable Care Act <a href="http://abcnews.go.com/Politics/mcconnell-calls-obamacare-repeal-vote-replacement-plan-fails/story?id=48690900">after a two-year delay</a>. This gambit was essentially Republican leadership playing chicken in two ways.</p>
<p>First, leadership dared rank-and-file Republicans to vote against a repeal bill because most Republicans campaigned on the premise that the ACA should be repealed. However, doing so could potentially create chaos in the health care market.</p>
<p>Second, if Congress failed to pass a replacement health care bill within the next two years, chaos would ensue. Congress often gives itself such incentives in order to <a href="https://www.polisci.washington.edu/research/publications/congress-and-politics-problem-solving">promote compromise</a>. The major problem with this tactic is that Republican leadership would still have to find a way to placate both moderates and extreme conservatives, and potentially Democrats as well. While legislative compromise used to be a regular occurrence, it is becoming rarer in recent times due to increased polarization. Legislative productivity is near an <a href="https://www.washingtonpost.com/news/the-fix/wp/2014/04/10/president-obama-said-the-113th-congress-is-the-least-productive-ever-is-he-right/?utm_term=.11d0739d6811">all-time low</a>.</p>
<p>The August 2011 budget deal is the last major example of Congress creating a potentially negative situation in order to incentivize cooperation. The bill created the “sequester,” which threatened to cut government spending across the board beginning in 2013 if Congress was unable to come to <a href="http://money.cnn.com/2011/08/01/news/economy/debt_ceiling_breakdown_of_deal/index.htm">an agreement by that date</a>. The idea was that neither Democrats nor Republicans wanted that to happen, so they would be forced to make a deal. While the sequester was intended to bridge differences between the two parties, a repeal and delay plan would be intended to bring Republican moderates and extreme conservatives to the bargaining table.</p>
<p>The trouble is that the sequester gambit failed miserably. While Congress made some small deals on both military and social spending, the 2011 sequestration agreement is still largely in effect. It <a href="https://www.theatlantic.com/politics/archive/2017/03/donald-trump-meet-sequestration/519798/">looms over budget policy today</a>. Democrats and Republicans still refuse to compromise on most budgetary issues. Republicans run the risk of the same thing occurring with health care policy if they decide to fully repeal the Affordable Care Act without a replacement in place.</p>
<p>In order to repeal and replace Obamacare, Republicans needed to strike a deal that pleased both moderates and conservatives. It seems unlikely that such a deal exists. </p>
<p>The big question moving forward is whether such a deal is possible on taxes, infrastructure, the border wall and other major parts of President Trump’s legislative agenda. In my opinion, tax reform is the item that is most likely to become law. But Republicans’ failure on health care could foreshadow an inability to bridge the moderate-conservative divide on other major issues as well.</p><img src="https://counter.theconversation.com/content/80308/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Patrick T. Hickey does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>It turns out a unified government isn’t enough to get bills passed.Patrick T. Hickey, Assistant Professor of Political Science, West Virginia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/716722017-02-02T02:57:50Z2017-02-02T02:57:50ZHow Planned Parenthood has helped millions of women, including me<figure><img src="https://images.theconversation.com/files/155267/original/image-20170201-22544-qlwipn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A woman shows her support for Planned Parenthood at the Women's March in New York City on Jan. 21. </span> <span class="attribution"><span class="license">Author provided</span></span></figcaption></figure><p>Planned Parenthood has allowed <a href="https://www.plannedparenthood.org/">generations</a> of low-income women to survive childbirth, to combat sexually transmitted infections (STIs) and to plan their pregnancies. However, the fact that women live healthier and longer lives is not Planned Parenthood’s ultimate superpower. No, that is reserved for the legions of low-income women, including me, who now have been given the opportunity to dramatically move up the economic ladder and prosper.</p>
<p>For millions of women, Planned Parenthood is at once a symbol of and a means to women’s empowerment. Since the organization helped topple cultural norms that held back women, it’s no surprise that men, many of whom feel excluded from this process, grasp familiar though outdated standards to justify defunding it.</p>
<p>Recently, Republican congressional leadership has tied the <a href="http://time.com/4626516/planned-parenthood-defund-republicans/">defunding of Planned Parenthood</a> (along with the repeal of the Affordable Care Act) to the upcoming budget reconciliation bill, which needs only a <a href="http://www.cbpp.org/research/federal-budget/introduction-to-budget-reconciliation">simple majority</a> of senators to pass. It is hard to say what will happen next. Although all sides acknowledge the odds favor Republican efforts, they also acknowledge that Planned Parenthood will not go down without a fight. </p>
<p>As a public health researcher with expertise in the social factors that influence disease transmission, especially sexually transmitted infections, I think it’s important to look at the history and the facts about Planned Parenthood. Many lies have been told about it, and it’s important to know the truth. </p>
<h2>More than 100 years of promoting reproductive health</h2>
<p>In 2016, Planned Parenthood celebrated its 100th year of existence. In 1916, <a href="https://100years.plannedparenthood.org/#e1916-1936/1">Margaret Sanger opened</a> the first Planned Parenthood, a birth control clinic, in Brownsville, Brooklyn to address the hardships that childbirth and self-induced abortions brought to low-income women. She and her colleagues were promptly arrested. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/155268/original/image-20170201-22554-f0j7c3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/155268/original/image-20170201-22554-f0j7c3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=497&fit=crop&dpr=1 600w, https://images.theconversation.com/files/155268/original/image-20170201-22554-f0j7c3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=497&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/155268/original/image-20170201-22554-f0j7c3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=497&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/155268/original/image-20170201-22554-f0j7c3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=624&fit=crop&dpr=1 754w, https://images.theconversation.com/files/155268/original/image-20170201-22554-f0j7c3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=624&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/155268/original/image-20170201-22554-f0j7c3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=624&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A man shares his views about reproductive rights at the Women’s March.</span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>So began the many legal and political battles Planned Parenthood has waged over the control of women’s fertility. Yet it was men who had the strongest impact on the social acceptance of birth control at that time. World War I saw the largest global mobilization and deployment of populations in history. Since the populations were almost exclusively young men, this led, not surprisingly, to a <a href="https://global.oup.com/academic/product/no-magic-bullet-9780195042375?cc=us&lang=en&">massive increase in STIs</a>, then called venereal disease. Suddenly, “birth control” seemed like a really good idea.</p>
<p>In fact, even today the <a href="https://www.plannedparenthood.org/files/4013/9611/7243/Planned_Parenthood_Services.pdf">largest percentage</a> (41 percent) of Planned Parenthood’s budget is spent on testing and treating STIs, followed by <a href="https://www.plannedparenthood.org/files/7214/6833/9709/20160711_FS_PPNumbers_d1.pdf">contraceptive services</a> (31 percent) for both women and men. The number of men who receive services such as testing for STIs and checkups for reproductive or sexual health issues from Planned Parenthood has grown steadily and has <a href="https://www.plannedparenthood.org/files/7214/6833/9709/20160711_FS_PPNumbers_d1.pdf">increased by almost 100 percent</a> over the past decade. </p>
<p>All of these statistics are buried in data-filled documents that are hard to find and daunting to review. But here are some <a href="https://issuu.com/actionfund/docs/2014-2015_annual_report_final_20mb">numbers readily available</a>: In 2014 (the most recent year for which complete data are available) Planned Parenthood operated with a budget of US$1.3 billion, more than 40 percent of which came from the federal government (mostly in the form of Medicaid reimbursements). It provided almost 10 million clinical services to about two and a half million patients, the majority of whom were low-income. </p>
<p>Men have lobbied for the inclusion of men in maternal and child health (MCH) programs. Beginning in 1975, Alan Rosenfield, the former dean of the Mailman School of Public Health at Columbia University, established a series of sexual health clinics in Upper Manhattan, including one of the first “Young Men’s Health” clinics. </p>
<p>However, it was his groundbreaking and oft-cited piece in The Lancet, <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(85)90188-6/abstract">“Maternal mortality: a neglected tragedy</a>,” that provided <a href="http://www.sciencedirect.com/science/article/pii/S0140673685901886">influential public support</a> for Planned Parenthood missions to prevent women dying from pregnancy-related complications and the need for family planning.</p>
<p>It is perhaps no surprise that all of this attention on women’s sexual rights, combined with the widespread uptake of oral contraceptives – the “pill,” the first entirely female-controlled method of pregnancy prevention – found Planned Parenthood once again at the center of a firestorm, of which I was blissfully unaware on my first visit to Planned Parenthood.</p>
<h2>A personal story</h2>
<p>When I was 14 years old, my mother dropped me off at the local Planned Parenthood and told me she’d be back in an hour. Up until that day, she had been the only person willing to answer the myriad questions about sex posed by her breathless and curious all-girl 4-H club, of which I was a member. (I doubt they would have approved her choice of troop leader topics.) </p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/155009/original/image-20170131-3269-1o9xq3g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/155009/original/image-20170131-3269-1o9xq3g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=904&fit=crop&dpr=1 600w, https://images.theconversation.com/files/155009/original/image-20170131-3269-1o9xq3g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=904&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/155009/original/image-20170131-3269-1o9xq3g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=904&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/155009/original/image-20170131-3269-1o9xq3g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1136&fit=crop&dpr=1 754w, https://images.theconversation.com/files/155009/original/image-20170131-3269-1o9xq3g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1136&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/155009/original/image-20170131-3269-1o9xq3g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1136&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The author as a teenager.</span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>At the time, filmstrips of Roman gods and goddesses with strategically draped fig leaves passed for sex education at our school. Now, my mother had reached her limit. Despite my delusions of sophistication (I was the recent owner of two-inch heeled, cork-bottomed white clogs), the idea that I would actually have sex with someone – with a man! – was the farthest thing from my mind. </p>
<p>As I headed toward the entrance, head down and slump-shouldered, to attend a real sex education class, I searched for the words and the nerve to announce myself to the receptionist. I didn’t even have to open my mouth. I was whisked away to a room filled with eight other girls. None of us made eye contact, but my eyes were certainly opened that day. </p>
<p>Did I mention that my mother had me when she was 19 years old?</p>
<p>My mother, who was the first in her family to go to college, did not graduate. I have a Ph.D. I was given the privilege to determine the course and timing of my reproductive life. Though not without bumps, reproductive freedom allowed me to pursue academic and professional dreams. This was an opportunity not afforded to my mother, though one she made darn sure that both my sister and I would have. </p>
<h2>Educational gains: A connection?</h2>
<p>Over the last decade in the U.S., the number of women attending college has greatly eclipsed the number of men attending. This is true across communities: Among Latinos there is a 13 percent point gap in college enrollment between women and men, among African-Americans a 12 percent gap and among whites a <a href="http://www.pewresearch.org/fact-tank/2014/03/06/womens-college-enrollment-gains-leave-men-behind/">10 percent gap</a>. </p>
<p>The result is economic independence for women, but at social cost. Highly educated women are being urged to <a href="http://www.theatlantic.com/magazine/archive/2011/11/all-the-single-ladies/308654/">date and marry “down,”</a> given the dearth of equally educated men. This bucks the traditional norm in which the man is the primary breadwinner and the woman is the stay-at-home mom, a philosophy to which research shows both men and women <a href="http://www.sciencedirect.com/science/article/pii/S0749597814000685">continue to subscribe</a>. </p>
<p>This cataclysmic shift of women’s economic independence, along with rapidly changing demographics in the U.S., has given rise to nostalgia for the “old days” as well as calls to challenge the morality of sexual harassment and discrimination implicitly associated with the old days. Fueling these divergent attitudes is a sense of real frustration on both sides and, perhaps more importantly, an inability to communicate and find common ground. </p>
<p>But there may be ways to take emotion out of the equation, especially for Planned Parenthood. Throughout the history of the organization, men have played an outsized role in support of the Planned Parenthood mission and now make up a larger percentage of patients than ever before.</p>
<p>As the name implies, Planned Parenthood is not only a woman’s organization, it is also a man’s organization that increasing numbers of men are beginning to recognize. Like parenthood itself, the success of the organization will require the actions and support of both women and men. It’s time that men know that they, too, benefit directly from Planned Parenthood.</p><img src="https://counter.theconversation.com/content/71672/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Maureen Miller does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The defunding of Planned Parenthood is a goal of many in the new administration. Here’s a look at the facts about the group, including the number of people it serves and the services it provides.Maureen Miller, Adjunct Associate Professor of Epidemiology, Columbia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/716112017-01-20T21:12:32Z2017-01-20T21:12:32ZPrice, author of long proposal to replace Obamacare, short on specifics in hearing<figure><img src="https://images.theconversation.com/files/153669/original/image-20170120-5251-1b9fav.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Rep. Tom Price (R-GA) in confirmation hearing.</span> <span class="attribution"><span class="source">Carolyn Kaster/AP</span></span></figcaption></figure><p>It is hardly unusual for Cabinet nominees to leave more questions than answers after their confirmation hearings. Yet for the millions whose lives hang in the balance depending on the future of the Affordable Care Act, Rep. Tom Price’s (R-Ga.) answers were surprisingly vague on Jan. 18 – especially coming from a man who has authored a detailed, <a href="http://tomprice.house.gov/sites/tomprice.house.gov/files/HR%202300%20Empowering%20Patients%20First%20Act%202015.pdf">242-page replacement</a> for the ACA, more commonly called Obamacare. </p>
<p>Price <a href="https://www.nytimes.com/2017/01/18/us/politics/confirmation-hearing-cabinet.html">appeared</a> before the Senate Committee on Health, Education, Labor, and Pensions (HELP) for confirmation as secretary of health and human services, which oversees and administers Obamacare.</p>
<p>His hearing came only a day after the nonpartisan Congressional Budget Office <a href="https://www.cbo.gov/sites/default/files/115th-congress-2017-2018/reports/52371-coverageandpremiums.pdf">released a report</a> on the economic impact of a repeal of the ACA. Price has consistently voted for repeal. </p>
<p>The CBO projected that in the first year of health plans following an ACA repeal, 18 million would become uninsured, with that number growing to 32 million becoming uninsured in 2026. It also forecast those who do not become uninsured will face higher premiums. </p>
<p>With Republicans so far failing to coalesce around a single replacement plan, the report provided added support for those claiming that a repeal would be unwise if not reckless. Price also voted with the House Republicans to move forward with the repeal, without a viable alternative to preserve the health care gains that were made under the act. </p>
<p>Thus, Price’s answers mattered to millions. As a health policy scholar, I think it is important to analyze what he said and what he didn’t say. I’ll also offer some questions for his second hearing, which is scheduled for Jan. 24 before the Senate Finance Committee</p>
<p>While he is most likely a shoo-in, it is vital nonetheless to understand his answers so we can gain insight into the direction the vast Department of Health and Human Services (HHS) is heading.</p>
<h2>‘Greater choices and options’</h2>
<p>When pushed on policy specifics, Price often punted by saying Congress would provide the policy details that he, as secretary of HHS, would administer. This is despite the significant policy impact he would have with respect to the nation’s health care delivery. </p>
<p>He did not commit to protecting those with preexisting conditions. He did not list the essential health benefits to be covered. Instead, he said, “I think it’s absolutely imperative that we have a system in place that works for patients.” He reiterated an interest in moving toward “greater choices and options for them to gain the kind of coverage they want for themselves and their families.” </p>
<p>While such goals are optimal, to be sure, Price rarely offered anything more concrete. He also did not explain how that lined up with his 242-page plan, which called for repeal of the ACA and a new plan based on tax credits and savings plans. </p>
<p>No one challenged him on the fact that millions of consumers believe the ACA is a <a href="http://thehill.com/policy/healthcare/314759-tom-prices-confirmation-hearing-live-coverage">“system in place that works for patients.”</a> And, of course, he wasn’t going to acknowledge that.</p>
<h2>Is health care a right? He didn’t say</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/153678/original/image-20170120-30764-uoj2xg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/153678/original/image-20170120-30764-uoj2xg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=382&fit=crop&dpr=1 600w, https://images.theconversation.com/files/153678/original/image-20170120-30764-uoj2xg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=382&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/153678/original/image-20170120-30764-uoj2xg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=382&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/153678/original/image-20170120-30764-uoj2xg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=480&fit=crop&dpr=1 754w, https://images.theconversation.com/files/153678/original/image-20170120-30764-uoj2xg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=480&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/153678/original/image-20170120-30764-uoj2xg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=480&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Sen. Bernie Sanders (I-Vt.) questioning Rep. Tom Price (R-Ga.).</span>
<span class="attribution"><span class="source">Carolyn Kaster/AP</span></span>
</figcaption>
</figure>
<p>While many issues divide the parties, health care is perhaps unique in the extent to which it is so deeply human and, in all too many cases, life or death. As such, <a href="https://www.nytimes.com/video/us/politics/100000004878423/bernie-sanders-gets-tough-on-tom-price.html">Sen. Bernie Sanders (I-VT)</a> raised the question that dominated the Democratic Party primary: Is health care a right? </p>
<p><a href="https://www.nytimes.com/video/us/politics/100000004878423/bernie-sanders-gets-tough-on-tom-price.html">Price avoided the yes-or-no question</a>, instead saying that he looked forward to working with Congress to ensure “access” to care. He also answered by saying that the United States is a “compassionate society,” at which point Sanders interrupted and said “no, we are not…”</p>
<h2>Planned Parenthood questions</h2>
<p><a href="http://www.politico.com/story/2017/01/tom-price-hhs-confirmation-hearing-233755">Sen. Patty Murray (D-WA)</a> was the main one to press Price on the matters of access to contraception and other women’s health services. Price has championed the defunding of Planned Parenthood, despite the fact that no federal funds can be used for abortion services anywhere. Many want to defund Planned Parenthood because it offers abortion services at some centers.</p>
<p>Indeed, the <a href="https://www.guttmacher.org/gpr/2017/01/understanding-planned-parenthoods-critical-role-nations-family-planning-safety-net">Guttmacher Institute reported recently</a> that in 332 of the 491 counties in which Planned Parenthood clinics are located, Planned Parenthood served at least half of the women receiving contraception from safety-net health centers.</p>
<p>Despite empirical evidence to support that Planned Parenthood expands the availability of contraception, Price would not in the hearing commit to maintaining coverage of all FDA-approved contraceptive methods.</p>
<h2>Questions for second hearing</h2>
<p>Price acknowledged that these are important issues, which one might expect from a nominee of the federal department charged with overseeing them. Yet his answers were vague at best. He proclaimed a commitment to access to the care that people want, though he often conflated access and affordable care that people ultimately can receive. He articulated goals and interests, but he declined to define them and how he would achieve them. </p>
<p>Indeed, many Democrats on the HELP committee worked to point out that the Republican Party’s proposals are a far cry from Mr. Trump’s recent claim to support “insurance for everybody,” a proposal from which Trump staffers Kellyanne Conway and Sean Spicer both quickly backed away. </p>
<p>Some spotlight was notably occupied by <a href="https://www.nytimes.com/2017/01/18/opinion/tom-prices-dubious-trades-in-health-care-stocks.html?_r=0">reports of his trading in stocks</a> of companies that were the subject of legislation that he introduced in Congress. </p>
<p>Price traded <a href="http://www.politico.com/tipsheets/politico-pulse/2016/12/wsj-tom-price-traded-300k-in-health-stocks-since-2012-218012">US$300,000 in health stocks since 2012</a>, which Sen. Al Franken (D-MN) and others pointed to. Price dismissed this point on the grounds that he worked through a broker and was unaware of the fact.</p>
<p>Given the Republican majority in Congress, the prospects for confirmation of Mr. Trump’s nominees are quite good. </p>
<p>However, though Sen. Susan Collins (R-ME) voted with the Republican majority in its first step toward the repeal of the ACA, she <a href="https://www.washingtonpost.com/powerpost/planned-parenthood-could-be-first-casualty-of-obamacare-repeal-efforts/2017/01/17/737cbfb0-da73-11e6-9f9f-5cdb4b7f8dd7_story.html?utm_term=.30abc485bdb7">expressed dismay</a> over the the Republicans’ tying the act’s repeal to defunding of Planned Parenthood.</p>
<p>Given Price’s rather extreme views on this subject, her vote may be one for which to look out, though his ultimate confirmation is likely.</p>
<p>He is scheduled to appear before the Senate Finance Committee Jan. 24. Here are some questions I’d suggest that the senators ask:</p>
<ul>
<li><p>What does Price view as his role as HHS secretary with respect to Planned Parenthood and other Republicans’ efforts to defund?</p></li>
<li><p>As Price cosponsored the National Right to Life Act, which defined 14th Amendment protections as applying at the moment of fertilization, does he want to end the availability of emergency contraception? </p></li>
<li><p>One area in which the American medical system is strained is its dearth of general practitioners. Are there any things that you might seek to do to address this limited access to primary care?</p></li>
<li><p>What would Price do to ensure more vigorous enforcement of parity for mental health conditions, including addiction?</p></li>
</ul>
<p>There’s a lot on the line.</p><img src="https://counter.theconversation.com/content/71611/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Miranda Yaver does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Rep. Tom Price (R-Ga.) has written a proposal to repeal Obamacare, a program under the Department of Health and Human Services, which he would head. Here are things to consider for his next hearing.Miranda Yaver, Lecturer in Political Science, Yale UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/575462016-04-27T10:07:15Z2016-04-27T10:07:15ZHow limiting women’s access to birth control and abortions hurts the economy<p>Reproductive health isn’t <a href="https://www.guttmacher.org/united-states/abortion/demographics">just about abortions</a>, despite all the attention they get. It’s also about access to family planning services, contraception, sex education and much else.</p>
<p>Such access lets women control the timing and size of their families so they have children when they are financially secure and emotionally ready and can finish their education and advance in the workplace. After all, <a href="http://www.nwlc.org/sites/default/files/pdfs/reproductive_health_is_part_of_the_economic_health_of_women_5.29.15pdf.pdf">having children is expensive</a>, costing US$9,000 to $25,000 a year. </p>
<p>And that’s why providing women with a full range of reproductive health options is good for the economy at the same time as being essential to the financial security of women and their families. Doing the opposite threatens not only the physical health of women but their economic well-being too.</p>
<p>The Supreme Court <a href="https://www.oyez.org/cases/1991/91-744">acknowledged</a> as much in 1992, stating in Planned Parenthood of Southeastern Pennsylvania v. Casey:</p>
<blockquote>
<p>The ability of women to participate equally in the economic and social life of the nation has been facilitated by their ability to control their reproductive lives.</p>
</blockquote>
<p>However, it seems that state and federal legislators, certain politicians running for president as well as some conservative Supreme Court justices have forgotten the meaning of this sweeping language.</p>
<p>As a consequence, the right to control their reproductive health has become <a href="http://thinkprogress.org/health/2013/05/08/1979831/women-struggle-afford-abortion/">increasingly illusory</a> for many women, particularly the poor.</p>
<h2>The economics of contraception</h2>
<p>With some conservative politicians dead set on limiting access to abortion, you’d assume that they would be for policies that help women avoid unintended pregnancies. But <a href="http://www.motherjones.com/politics/2012/02/republican-war-birth-control-contraception'">conservative attacks on birth control</a> are escalating, even though <a href="http://www.cdc.gov/nchs/data/nhsr/nhsr062.pdf">99 percent of sexually active women</a> have used <a href="https://www.guttmacher.org/fact-sheet/contraceptive-use-united-states">some form such as an intrauterine device (IUD), patch or pill</a> at least once. </p>
<p>In addition to its widely recognized health and autonomy benefits for women, contraception <a href="http://www.theatlantic.com/health/archive/2014/07/the-broader-benefits-of-contraception/373856">directly boosts the economy</a>. In fact, research shows access to the pill <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3684076/">is responsible</a> for a third of women’s wage gains since the 1960s. </p>
<p>And this benefit extends to their kids. Children born to mothers with access to family planning <a href="http://www.nber.org/papers/w19493.pdf">benefit from a 20 to 30 percent increase</a> in their own incomes over their lifetimes, as well as boosting college completion rates. </p>
<p>Not surprisingly, in a survey, <a href="http://www.ncbi.nlm.nih.gov/pubmed/23021011">77 percent of women</a> who used birth control reported that it allowed them to better care for themselves and their families, while large majorities also reported that birth control allowed them to support themselves financially (71 percent), stay in school (64 percent) and help them get and keep a job (64 percent). </p>
<p>Still, there is a class divide in contraception access, as evidenced by disparities in the 2011 rate of unintended pregnancies. While the <a href="http://www.nejm.org/doi/full/10.1056/NEJMsa1506575">overall rate</a> fell to 45 percent (from 51 percent in 2008), the figure for women living at or below the poverty line was <a href="https://www.guttmacher.org/sites/default/files/pdfs/pubs/FB-Unintended-Pregnancy-US.pdf">five times that of women</a> at the highest income level (although also decreasing).</p>
<p>One reason for this disparity is the <a href="http://www.thenation.com/article/why-does-best-birth-control-cost-entire-months-wages/">cost of birth control</a>, particularly for the most effective, long-lasting forms. For instance, it typically costs over $1,000 for an IUD and the procedure to insert it, amounting to <a href="http://www.jahonline.org/article/S1054-139X(13)00054-2/pdf">one month’s full-time pay</a> for a minimum wage worker. </p>
<p>These costs are significant, given that the <a href="https://www.guttmacher.org/sites/default/files/pdfs/pubs/fulfill.pdf">average American woman wants</a> two children and will thus need contraception for at least three decades of her life. Unfortunately, <a href="http://rooseveltinstitute.org/wp-content/uploads/2015/11/Breaking-the-Cycle-of-Poverty-Expanding-Access-to-Family-Planning.pdf">publicly funded family planning</a> meets only 54 percent of the need, and these funding streams are under constant attack by conservatives.</p>
<p>Not surprisingly, <a href="http://www.scotusblog.com/2015/12/symposium-womens-compelling-need-for-contraception-met-by-insurers-not-objecting-employers/">health insurance makes a difference</a>, and women with coverage are much more likely to use contraceptive care. The <a href="http://nwlc.org/resources/zubik-v-burwell-non-profit-objecting-employers-should-not-be-allowed-to-make-it-harder-for-women-to-access-critical-birth-control-coverage/">Affordable Care Act is responsible</a> for part of the drop in unintended pregnancies – it expanded contraception coverage to around 55 million women with private insurance coverage. </p>
<p>Yet this coverage is also at risk for millions of employees and their dependents who work for employers claiming a religious objection. In Burwell v. Hobby Lobby, the <a href="http://www.supremecourt.gov/opinions/13pdf/13-354_olp1.pdf">Supreme Court concluded</a> that a for-profit company cannot only profess religious beliefs but also impose those beliefs on their employees by denying them certain forms of contraception. The <a href="http://kff.org/womens-health-policy/issue-brief/round-2-on-the-legal-challenges-to-contraceptive-coverage-are-nonprofits-substantially-burdened-by-the-accommodation/">Obama administration has issued regulations</a> allowing religious employers to opt out of offering contraceptive coverage. Affected employees are then covered directly by their insurers.</p>
<p>This is not enough for some. In March, the Supreme Court heard oral arguments in the case of <a href="http://www.scotusblog.com/case-files/cases/zubik-v-burwell">Zubik v. Burwell</a>, in which several religious <a href="http://kff.org/womens-health-policy/issue-brief/contraceptive-coverage-at-the-supreme-court-zubik-v-burwell-does-the-law-accommodate-or-burden-nonprofits-religious-beliefs/">nonprofits assert</a> that even the act of seeking an accommodation from the law burdens their religious consciences. </p>
<p>These religious groups argue in part that women can get their birth control from other sources, such as federally funded family planning centers. Yet at the same time, <a href="http://time.com/4264955/contraceptive-coverage/">conservatives are on a mission to slash that funding</a>, particularly for Planned Parenthood, which provides sexual and reproductive health care to almost five million people a year.</p>
<p>This makes no economic sense. Publicly funded family planning programs <a href="https://www.guttmacher.org/news-release/2015/publicly-funded-family-planning-yields-numerous-positive-health-outcomes-while">help women avoid about two million unintended pregnancies</a> a year and save the government billions of dollars in health care costs. The net savings to government are $13.6 billion. For every $1 invested in these services, the government saves $7.09.</p>
<h2>Sex education and the economic ladder</h2>
<p>Another key to reproductive health – and one that isn’t discussed enough – is sexual education for teenagers. </p>
<p>For years, the public has spent over $2 billion on abstinence-only programs, which not only <a href="http://www.jahonline.org/article/S1054-139X(05)00467-2/fulltext?mobileUi=0">fail to reduce teen birth rates</a> but also reinforce gender stereotypes and are rife with misinformation. Low-income minority teens <a href="http://scholarship.law.berkeley.edu/cgi/viewcontent.cgi?article=1084&context=bjalp">are particularly subject</a> to these programs.</p>
<p>Teens without knowledge about their sexual health <a href="http://www.advocatesforyouth.org/publications/publications-a-z/597-abstinence-only-until-marriage-programs-ineffective-unethical-and-poor-public-health">are more likely</a> to get pregnant and less likely to work, spiraling them to the bottom of the economic ladder. </p>
<p>President Obama’s <a href="http://www.siecus.org/index.cfm?fuseaction=Feature.showFeature&FeatureID=2438">proposed 2017 budget would eliminate federal funding</a> for abstinence-only sex education and instead fund only comprehensive sexual education, which is age-appropriate and medically accurate. However, <a href="http://www.motherjones.com/mojo/2016/02/state-of-teen-sex-america-chart-abstinence">Congress has rejected</a> the president’s prior proposed cuts and the same result is likely for 2017. </p>
<h2>Access to abortion</h2>
<p>Then there’s the issue of abortion. Let’s start with the cost.</p>
<p><a href="http://www.nwlc.org/sites/default/files/pdfs/reproductive_health_is_part_of_the_economic_health_of_women_5.29.15pdf.pdf">Half of women who obtain an abortion</a> pay more than one-third of their monthly income for the procedure.</p>
<p>Costs rise significantly the longer a woman must wait, either because state law requires it or she needs to save up the money – or both. Studies show that women <a href="http://www.nytimes.com/2013/06/16/magazine/study-women-denied-abortions.html?_r=0">who cannot access abortion</a> are <a href="http://rhtp.org/abortion/documents/TwoSidesSameCoinReport.pdf">three times more likely</a> to fall into poverty than women who obtained abortions.</p>
<p>In addition to the financial burden, <a href="https://www.guttmacher.org/state-policy/explore/overview-abortion-laws">many states are enacting laws</a> designed to limit abortion access. These laws hit low-income women particularly hard. From 2011 to 2015, <a href="https://www.guttmacher.org/article/2016/01/2015-year-end-state-policy-roundup">31 states have enacted</a> 288 such laws, including waiting periods and mandatory counseling sessions. </p>
<p>Moreover, <a href="https://www.guttmacher.org/sites/default/files/pdfs/spibs/spib_TRAP.pdf">24 states have enacted so-called TRAP laws</a> (targeted regulation of abortion providers), which medical experts say go far beyond what is needed for patient safety and impose needless requirements on doctors and abortion facilities, <a href="http://www.acog.org/About-ACOG/News-Room/News-Releases/2013/ACOG-and-AMA-File-Amicus-Brief">such as requiring facilities</a> to have the same hallway dimensions as a hospital. </p>
<p>In March, the Supreme Court heard arguments in a case <a href="http://www.scotusblog.com/case-files/cases/whole-womans-health-v-cole/">challenging a Texas TRAP law</a>, <a href="http://www.reproductiverights.org/case/whole-womans-health-v-hellerstedt">Whole Women’s Health v. Hellerstedt</a>. If the court upholds the law, the entire state of Texas will be left with only 10 abortion providers.</p>
<p>A <a href="http://www.scotusblog.com/wp-content/uploads/2015/09/14-50928-CV0.pdf">lower federal appeals court stated</a> in the Texas case that travel distances of more than 150 miles one way are not an “undue burden” and are thus constitutional. This, I would argue, shows a <a href="http://papers.ssrn.com/sol3/papers.cfm?abstract_id=2446644">complete lack of understanding</a> regarding the difficulties that poverty – especially rural poverty – imposes. Traveling long distances adds additional costs to an already expensive medical procedure. </p>
<p>The court’s decision is expected in June. <a href="http://www.slate.com/articles/news_and_politics/supreme_court_dispatches/2016/03/in_oral_arguments_for_the_texas_abortion_case_the_three_female_justices.html">Observers fear</a> that the court could split 4-4, which would leave the Texas law intact. </p>
<h2>The Hyde Amendment</h2>
<p>Another way in which U.S. policy on abortions <a href="https://www.americanprogress.org/issues/women/news/2013/05/10/62875/how-the-hyde-amendment-discriminates-against-poor-women-and-women-of-color">exacerbates economic inequality, especially for women of color</a>, is through the ban on federal funding – which some aspiring politicians <a href="http://www.motherjones.com/mojo/2016/02/donald-trump-really-doesnt-understand-how-federal-funding-works-planned-parenthood-0">seem to have forgotten</a> is still in place.</p>
<p>It has been so since the <a href="http://billmoyers.com/content/five-facts-you-should-know-about-the-hyde-amendment/">1976 enactment of the Hyde Amendment</a>, which prevents federal Medicaid funds from being used for abortions except in cases of rape, incest or when the life of the mother is at risk. The Affordable Care Act does many wonderful things for women’s health, but it also <a href="http://kff.org/womens-health-policy/issue-brief/coverage-for-abortion-services-in-medicaid-marketplace-plans-and-private-plans/">extends the Hyde Amendment</a> through its expansion of Medicaid, and it allows states to ban abortion coverage in their private exchanges. </p>
<p>Denying poor women coverage under Medicaid contributes to the unintended birth rates that are <a href="https://www.guttmacher.org/fact-sheet/unintended-pregnancy-united-states">seven times higher</a> for poor women than high-income women. </p>
<h2>Economic and reproductive health</h2>
<p>Politicians cannot promise to grow the economy and simultaneously limit access to abortion, birth control and sexual education. Our nation’s economic health and women’s reproductive health are linked.</p>
<p>And as Hillary Clinton <a href="http://www.politifact.com/truth-o-meter/statements/2016/apr/15/hillary-clinton/hillary-clinton-says-democratic-debate-moderators-/">correctly noted</a> recently, it’s an issue that deserves more attention in the presidential campaign – and hasn’t received enough.</p><img src="https://counter.theconversation.com/content/57546/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michele Gilman is affiliated with the ACLU of Maryland and the Women's Law Center of Maryland.</span></em></p>Providing women with a range of reproductive health options – from abortions to IUDs – is not only essential for their financial security but good for the economy as well.Michele Gilman, Venable Professor of Law, University of BaltimoreLicensed as Creative Commons – attribution, no derivatives.