Throughout President Trump’s first year in office, social conservatives in the administration and Congress mounted an all-out assault on people’s ability to obtain comprehensive reproductive health care in the United States and abroad. Despite coming up short in many respects, policymakers did considerable harm while also signaling their intentions for further attacks in the years ahead.
Undermining Health Insurance Coverage
President Trump entered office last January with a bold promise: to repeal Obamacare. And for much of 2017, Congress—with vocal if mercurial backing from Trump—pursued dismantling the Affordable Care Act (ACA), which is largely credited with reducing the proportion of uninsured women of reproductive age by 41 percent in its first three years. Social conservatives not only targeted private coverage, but also sought to fundamentally disrupt Medicaid by eliminating the ACA’s option for states to expand eligibility and by imposing draconian caps on federal funding.
Although this ambitious plan collapsed, conservative policymakers did secure a partial victory in December, when Trump signed a sweeping tax reform bill. Among many other provisions, the legislation repealed the ACA’s requirement that individuals have comprehensive health insurance coverage or else pay a tax penalty—a provision designed to help stabilize the market and keep premiums down.
Furthermore, Trump is increasingly using his executive powers to undercut other critical advances for reproductive health coverage. In October, the administration overhauled federal regulations governing the ACA’s contraceptive coverage guarantee. Although temporarily blocked by two federal courts, if implemented, these regulations would allow any employer, college, or university to opt out of covering contraceptive care on religious or moral grounds.
Looking ahead, the administration may well continue to try to undermine the ACA and its health insurance marketplaces. Already, under Seema Verma’s leadership, the Centers for Medicare and Medicaid Services is encouraging states to apply for “waivers” of federal law in order to impose work requirements on Medicaid enrollees, and will continue to work with states to move Medicaid in a conservative direction, likely interfering with people’s ability to obtain reproductive health care.
Destabilizing the Family Planning Safety Net
On top of the threats posed by restructuring Medicaid, many safety-net family planning providers—particularly Planned Parenthood—have withstood relentless attacks. Congressional attempts to repeal the ACA and spending proposals for fiscal year 2018 from both the U.S. House of Representatives and the Trump administration would exclude Planned Parenthood from federally funded programs. Recent Guttmacher Institute analyses show that doing so would place unrealistic burdens on other safety-net family planning providers, significantly jeopardizing access to publicly funded contraceptive care.
The same policymakers have targeted the Title X national family planning program. In recent years, the House has routinely proposed eliminating Title X funding, though it has thus far been thwarted by the Senate. In May, Trump picked Teresa Manning—who has publicly doubted the efficacy of birth control and the government’s role in helping women obtain it—to head the Office of Population Affairs (OPA), which oversees Title X. Earlier this month, Manning abruptly left her post, now filled by Valerie Huber—a longtime advocate of abstinence-only sexual education programs who will also continue in her role as chief of staff to the assistant secretary of the Department of Health and Human Services. Meanwhile, OPA has yet to release a long-delayed funding announcement, which is widely expected to signal some of the ways in which the administration intends to realign and undermine the Title X program.
Limiting Abortion Access
Although Trump has stocked his administration with abortion foes, federal attempts to further restrict abortion access have had limited success. In October, the House passed a nationwide ban on abortion after 20 weeks post-fertilization, which the Senate may take up next. Moreover, all of Congress’ major proposals to repeal the ACA would have barred federal funds from supporting plans that cover abortion beyond very limited circumstances. These measures sought to build on existing restrictions barring Medicaid coverage of abortion by also limiting coverage in the private market.
In perhaps the biggest coup for abortion opponents, President Trump could remake the federal judiciary on a scale that has not been possible in decades. Last year, Trump nominated dozens of justices whose records reveal an alarming willingness to dismantle reproductive rights, including Neil Gorsuch’s successful nomination to the U.S. Supreme Court. Indeed, the extreme anti-abortion advocacy group Operation Rescue named Trump its 2017 Person of the Year.
In the years ahead, the most vulnerable women will likely be hit hardest by the federal government’s opposition to abortion. This started to play out in 2017, when administration officials tried mightily to force young immigrant women in federal custody to carry pregnancies to term against their wills. Although some obtained the abortions they sought under court order, others’ cases continue into 2018, and the administration is staunchly willing to take the issue all the way to the Supreme Court.
Bolstering Discredited Abstinence-Only Programs
Many in Congress and the administration are also now calling for dramatic funding increases for abstinence-only-until-marriage programs. These programs insist that refraining from sex outside of marriage is the only acceptable behavior for people of all ages, and adolescents in particular. Toward this end, these programs provide medically inaccurate and incomplete sexual health information and perpetuate stigma around sex, sexual health, and sexuality.
Back in 2010, the federal government drastically cut spending on these programs, heeding overwhelming scientific evidence that they are ineffective and potentially harmful. But in recent years, social conservatives in Congress have funneled more and more taxpayer dollars into abstinence-only programs. With President Trump in office, that push is now in overdrive. In 2017, the administration pulled more than $200 million for teen pregnancy prevention efforts, ending funding after just three years of what were expected to be five-year grants. The administration and many in Congress also started aggressively reshaping policy with new messaging, for instance rebranding abstinence-only programs as “sexual risk avoidance.”
Dismantling Support for Global Reproductive Health
Within days of President Trump’s inauguration, his administration took drastic steps to undercut U.S. support for global sexual and reproductive health and rights. First, it reinstated and expanded the global gag rule, which prevents foreign nongovernmental organizations that receive U.S. global health assistance from using private, non-U.S. funding to provide abortion services or information or to advocate for abortion policy reform. Next, based on a long-debunked allegation that the agency supports coercive abortion in China, it blocked funding for the United Nations Population Fund, which supports reproductive and maternal health programs in over 150 countries.
More recently, the administration proposed eliminating funding for international family planning and reproductive health assistance in its fiscal year 2018 budget, representing the first time that an administration has tried to wipe out these programs. For more than 50 years, the U.S. Agency for International Development has supported family planning and reproductive health programs in developing countries that markedly improve the well-being of women, families, and societies. Looking ahead, these programs—and their hard-fought gains—are endangered.
Only Year One
Underneath this multipronged—if not fully realized—offensive, the Trump administration has promoted ideology over science and public health. And political appointees are fostering toxic environments of secrecy, urging their agencies to act without transparency, and causing well-intentioned civil servants to self-censor out of fear. Still, the first year of Trump’s tenure revealed the considerable, systemic extent of the campaign against reproductive health and rights being waged by President Trump, his administration, and social conservatives in Congress. Policymakers and advocates seeking to defend people’s right and ability to obtain high-quality reproductive care the world over must remain vigilant.