What Could Happen to Reproductive Health Care Under Single Payer?

Under a single-payer health care system, the government would be the sole payer and decider of health services and coverage in the United States. Section 107 of Senator Bernie Sanders’ legislation confirms that fact by banning private insurance from covering any of the services covered by the government plan—making the government-run plan the only coverage option.

The Sanders legislation includes coverage for the full range of reproductive services, including abortion and related health care services. However, the bill as proposed could be substantially amended on the road to passage. And for decades, every health program that relies on federal dollars has included limitations on abortion services. This is known as the Hyde Amendment which has been in effect since 1976.¹  Medicaid, veteran’s health care, and TRICARE all ban coverage for abortion care except in the cases of rape, incest, or to save the life of the woman. So does the Federal Employee Health Benefits Program which covers all federal employees, the Indian Health Service Program, the Bureau of Prisons, the Children’s Health Insurance Program, and even the current Medicare program.

But let’s say that a single-payer law was able to overcome more than 40 years of federal abortion restrictions and allow women to access the full range of reproductive care. What could happen to abortion access and access to other reproductive services when a future government is controlled by Republicans in a world where all health insurance is provided by the state? As we’ve seen under the Trump Administration and Republican presidents before him, when Republicans run the government, reproductive health care is constantly under attack. For years, Republican leaders in government have worked to limit access to abortion, reproductive health services, and sexual health services. Most recently, the GOP forced Planned Parenthood clinics to stop providing contraception and services to low-income patients in an attempt to force them to close. What is to stop the next Republican administration from changing the benefit package under a new single-payer plan to severely limit access to certain types of health care of which they disapprove?

As noted, single payer covers reproductive health and it does so in three ways. First, Section 201 requires the Secretary of Health and Human Services (HHS) to pay providers for medically-necessary treatment for reproductive and maternity care. There is no mention of a minimum or maximum that providers should be paid for those services. Second, Section 401 gives the Secretary the authority to develop policies to carry out the benefits package. While the benefit package includes reproductive health services, it does not specify which specific services. Finally, Section 701 states that an existing ban on the use of federal funds for reproductive health services does not apply to the Medicare for All Trust Fund.  

But what are the implications for reproductive health with a GOP-run government?

1. Specific services could be excluded. In Section 401, the HHS Secretary has full authority to decide which benefits will be covered in a person’s government insurance plan. It would be easy for an incoming Republican Secretary to alter the benefits package through the rule-making process and cut off coverage for things like abortion services or certain types of contraception. This isn’t hypothetical: Republican-controlled states have already tried to outlaw abortion as early as six weeks into pregnancy and even ban birth control methods like the IUD and emergency contraception. The Trump administration has already given many employers permission to pick and choose which birth control methods its employees can use. And more than half of the states have enacted limits on insurance coverage for abortion. Single payer would empower Republicans to impose these restrictions on every woman in America.
2. Reimbursement levels for reproductive health care could be slashed. While the bill specifically exempts the Medicare for All Trust from current bans on the use of federal funds for reproductive health, that doesn’t stop a Republican Secretary from being able to lower the reimbursement providers are paid for administering these services to $0. Without fair compensation for services, many providers would be forced to stop providing that care. This could reduce access to reproductive health services severely. Zeroing out or dramatically reducing these payments would technically allow the Secretary to cover all the services, while significantly restricting access and setting women back, as two-thirds are currently paying nothing out of pocket for contraception.
3. Accessing specific reproductive health services could face even more hurdles. A Republican Secretary could change the definition of what a “medically necessary” procedure is. For example, the Secretary could say that abortion is only appropriate for the maintenance of health before the sixth week of pregnancy, as certain states have tried. This would allow abortion to be a covered service but would impose strict rules on when those services can actually be used. Similar limitations could be crafted to impede access to certain forms of birth control, particularly long-acting reversible contraception (e.g. IUDs), which are currently the most effective options on the market or to restrict access to emergency contraception including for victims of sexual assault.

People evaluating single payer cannot just think of what it would mean under a friendly Democratic administration. As currently written, the bill provides extraordinary power to the party running the government and could lead to potentially disastrous consequences for reproductive health services under a GOP administration.

Private insurance companies have quietly eschewed the culture wars roiling Washington and state capitols across the country by providing services that governments are afraid to touch: reproductive and abortion services, end-of-life care, and myriad other sensitive and personal health care matters. Under single payer, access to these kinds of services would be under the purview of Congress and subject to the whim of presidential executive orders. And without the ability for private insurance to step in to fill the gap, women’s health care would be in even greater jeopardy than under our current system.