Threats On All Fronts

The Links Between the Lack of Abortion Access, Health Care and Workplace Equity

August 2022
Reproductive Rights

Every person should have the freedom to decide if, when and how to raise a family. But many people in the United States face limits on this freedom – especially women of color, women with disabilities or with low incomes, transgender and nonbinary people, and those who are multiply marginalized. Tens of millions have long experienced layers of obstacles, including barriers to accessing abortion care, inadequate maternal health care, barriers to health insurance coverage and a lack of supports needed to manage both work and care needs. Now, this dire situation has been worsened by the Supreme Court’s ruling in Dobbs v. Jackson Women’s Health Organization, which overturned Roe v. Wade despite the fact that women and families have relied on the legal right to abortion for 50 years. As states across the country move rapidly to ban or severely restrict abortion, people are being forced to go to extreme lengths to access reproductive health care, and in some cases being forced into pregnancy and parenthood, despite the devastating impacts this has on individuals, families and communities.

The systemic failure to enact policies that protect abortion access, promote high-quality health care, and advance economic justice leave pregnant and parenting people caught in an impossible bind, with their health and economic security threatened at nearly every turn. This new National Partnership for Women & Families analysis of state policies reveals that:

  • The states that have banned or are likely to ban abortion are also those that have done little to support the health and economic security of pregnant and birthing people and their families.
  • Every state that has failed to adopt Medicaid expansion is also either somewhat or very restrictive on abortion.
  • The states that have banned or are likely to ban abortion are also likely to fail women on a range of key work and care policies, leaving a disproportionate number of Black and Native women, women with disabilities, women veterans, and women who are economically insecure to face compounding threats on all fronts.
  • Of the 30 states that rate poorly on key work and care policies, 24 lack abortion protections and six others have some mix of restrictions and protections. In terms of health coverage, 18 of those states have adopted Medicaid expansion and 10 states have fully implemented 12-month postpartum coverage.
  • Of the 21 states, including the District of Columbia, that are supportive or expansive with respect to key work and care policies, only one state has restrictive abortion access. Conversely, of those 21 states, 12 are protective of abortion access, and eight states have some restrictions and protections. All of these states have adopted Medicaid expansion, and 17 states have taken some steps to implement 12-month postpartum coverage.

This issue brief is a call to action, and a demand for the full range of policies that lift women and families up instead of deepening their struggles.

Abortion bans undermine the health and economic security of individuals and families

Everyone should be able to access high-quality health care – including abortion care – no matter who they are, where they live, or what their economic status. But the Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization, which overturned Roe v. Wade, has fundamentally altered the landscape of care in the United States by denying millions of people the right to abortion. Following this decision, several states have significantly restricted or banned abortion, with many more poised to follow suit.; Even prior to Dobbs, abortion has long been difficult to access – especially for people of color, LGBTQ people, young people, immigrants, people with low incomes, and people with disabilities. Then, and even more so now, getting care involves navigating multiple barriers, such as needing to travel long distances, take multiple days off from work and/or caregiving responsibilities, make multiple medically unnecessary visits to a provider, and having to pay out of pocket for abortion care. This can add up to hundreds or even thousands of dollars in expenses. These barriers are further compounded by lost wages due to a lack of paid leave or sick days, the cost of accommodations and child care, and a lack of personal transportation, all of which potentially cause delays in accessing care or being forced to carry a pregnancy to term. Delays in care make abortion more difficult to access and drive up the cost even further, putting abortion care entirely out of reach for many.

People of color have long been disproportionately harmed by abortion restrictions and are also more likely to be negatively impacted by the overturning of Roe, as they face several inequities and structural barriers that undermine their ability to access care.; and see text box Among women of reproductive age, more than half of Black women and Indigenous women live in states that have banned or are likely to ban abortion, as do millions of Latina, Asian, Pacific Islander and multiracial women.

The impact of abortion bans is significant: Women who seek but are denied abortion care are more likely to experience chronic pain and poor health, and are more likely to report life-threatening pregnancy complications like eclampsia and postpartum hemorrhage compared to those who received wanted abortions. They are also more likely to experience an increase in household poverty and more likely to report persistent challenges to having the money needed to cover basic living expenses like food and housing. Clearly, abortion access is essential to the health and economic security of individuals and their families.

Key health and economic policies that intersect with abortion access

Abortion access goes hand in hand with policies like Medicaid coverage, including in the postpartum period, and economic policies that support the ability to both work and care for oneself and one’s family, including paid family and medical leave, paid sick days, fair pay, raising the minimum wage, pregnancy accommodations, and fair scheduling. Each of these policies is necessary to provide the foundation for women and their families to thrive. At the same time, no single one of these policies is a silver bullet. Instead, they are mutually reinforcing, and we need a comprehensive strategy to improve women’s health, labor force participation and economic security. Importantly, none of these policies are substitutes for legally protected access to abortion – but losing the right to abortion and simultaneously not having these additional policy supports compounds harms. Most of all, the intersections of these policies – or lack thereof – reveal how fundamentally, these are issues of dignity and equality for people of all genders.

The role of Medicaid expansion and postpartum Medicaid coverage in improving health outcomes

Bans on abortion care are egregious enough on their own, but they are especially problematic in a context where access to health care overall is inadequate. Medicaid expansion plays an essential role in addressing disparities in health care coverage and access to care: state expansion of Medicaid has enabled health coverage for more than 12 million Americans, particularly benefitting people of color. However, 12 states have yet to adopt Medicaid expansion under the Affordable Care Act, limiting Medicaid eligibility for many low-income adults who do not satisfy the income requirements.,%22sort%22:%22asc%22%7D; States in the South, which have a sizable population of people of color, make up the majority of states that have not expanded Medicaid. Black Americans in particular are more likely to be uninsured in non-expansion states in the South, and Black women are especially likely to be in the coverage gap income group.

In the 12 non-expansion states, 2.2 million adults are left uninsured and 800,000 of them are women of reproductive age, with two-thirds being women of color.; Accessing health care may be challenging for those who fall in the coverage gap, and uninsured people are less likely to obtain preventive care and needed health services.; This is particularly true for Black women.; Where health services are available, some may be required to pay unaffordable out-of-pocket costs; and some may even delay care due to fear of financial burden.,until%20they%20are%20in%20crisis. These barriers to health care often result in worse health outcomes.

In addition to expanding Medicaid overall, it is also essential that states explicitly extend Medicaid postpartum coverage. Access to postpartum coverage is critical for the wellbeing of parents and infants; Medicaid plays a critical role in ensuring this access. More than 40 percent of all births in the U.S. are financed through Medicaid, yet postpartum coverage through Medicaid has historically been limited to just 60 days. However, 60-day postpartum coverage is insufficient, as the majority of Medicaid-insured women experience a gap in insurance six months after birth. Black and Hispanic women are disproportionately affected by insufficient postpartum coverage through Medicaid as Medicaid supports 65 percent and 59 percent of all births in these populations, respectively. Thirty-four states and the District of Columbia have or are in the process of extending postpartum Medicaid coverage for 12 months following birth.; This still leaves many Medicaid enrollees uninsured beyond 60 days postpartum. Since 33 percent of pregnancy-related deaths occur in the postpartum period (defined as one week to one year following birth), any coverage gap during that critical time puts childbearing people’s health at risk.,week%20to%201%20year%20postpartum; Black women are especially vulnerable as they are 3.5 times more likely to have a late maternal death as compared to white women. With the lack of adequate postpartum coverage, coupled with the continued inaccessibility to abortion care in states, the health and wellbeing of many are at risk.

Paid leave policies enable caregivers not to have to choose between their work and their families

Bans on abortion will also exacerbate the many economic hardships that people – particularly people of color, those with disabilities and those with low incomes – already face in trying to care for their health and their loved ones and to make ends meet. People will need to take time away from work to address their own health needs or to care for loved ones. Yet nearly one in four workers does not have a single paid sick day, and nearly eight in ten do not have paid family leave, with workers of color and those in low-paid jobs the least likely to have access or to have economic resources to fall back on if they lose a job or take unpaid leave. Even before Dobbs, lack of paid leave and paid sick days exacerbated the maternal health crisis, disparities in abortion access and health inequities more broadly. Now, the lack of paid sick leave means that many of those forced to travel out of state for abortion care will face not only the time and expense of travel, but the risk of losing a paycheck or job simply to seek health care. At the same time, many of those forced to continue a pregnancy to term will do so without paid sick leave for prenatal care or paid medical leave to recover from birth – exacerbating our maternal health crisis – and their co-parents or other loved ones will not have paid family leave to support their health and recovery.

When combined with access to comprehensive health care, including abortion care, paid sick days and paid family and medical leave help enable people to have the resources and autonomy to decide whether and in what circumstances they want to become parents. Paid sick days laws, which have been enacted in 14 states and 24 cities and counties – are proven to reduce the spread of illness, including flu and COVID-19, and to support preventive health care including cancer screenings and annual physicals for adults and well-child checkups and dental care for children. New and expecting parents need paid family leave for pregnancy-related conditions, childbirth recovery, supporting a partner through pregnancy and childbirth recovery, and bonding with a foster or adopted child. Twelve states, including D.C., have enacted paid family leave programs that include gender-neutral leave. These programs have been shown to improve infant, child and parental health; to reduce racial disparities in the duration of leave taken between white women and women of color, as well as in rates of initiation of breastfeeding. They also improve economic outcomes for workers and families, for example through reduced rates of food insecurity in the year following a birth – especially for households with very low food security, which are disproportionately likely to be Black or Latinx – as well as improve wages and labor force attachment for mothers. Recognizing that people continue to need to care for themselves and their children and other loved ones throughout life – in fact, three-quarters of people who take family or medical leave each year do so for reasons other than welcoming a new child – these state programs are comprehensive, providing leave to care for ill, injured or disabled family members and for people’s own serious health conditions, not only during and immediately after birth. Access to paid family and medical leave and paid sick leave helps ensure caregivers can provide the care they and their families need and remain in the labor force.

The importance of fair pay and raising the minimum wage to protecting against household poverty

The Turnaway Study found that people who were denied an abortion were significantly more likely to fall into poverty. Women, especially women of color, make up a disproportionate share of workers at or near the minimum wage, as well as tipped and disabled workers paid subminimum wages, and also tend to be in lower-paid jobs due to historical and present-day systemic discrimination in pay and exploitation of workers./wp-content/uploads/2023/02/npwf-statement-for-the-record-minimum-wage-3-3-21.pdf Low and unfair wages undermine people’s ability to to parent their children safely and sustainably, to make a better life for themselves and their families and to care for and make decisions about their own health and reproductive lives – challenges that will only be worsened by additional restrictions on abortion care.

The economic hardships caused by abortion restrictions will disproportionately fall on women with low incomes and women of color, who already face the greatest harms from wages that are both too low and inequitable. In 2020, Asian American, Native Hawaiian and Pacific Islander women were paid 75 cents; Black women 58 cents; Native American women 50 cents and Latina women just 49 cents for every dollar paid to white, non-Hispanic men – wage gaps that add up to tens of thousands in lost income each year, and as much as $1.2 million over a lifetime. These trends result from factors ranging from pervasive stereotypes and social norms about gender and work, to a lack of workplace support for family caregiving, to gender and racial discrimination, to the devaluation of work when it is primarily done by women – and the effects are both starker and qualitatively different for women of color.

On the other hand, policies that address low and unfair wages, especially when aligned with work-family policies and accessible, affordable health care including abortion care, help financial stability for women of color and all workers, and advance racial equity. If the minimum wage were raised to $15, nearly 19 million women would benefit, including 3.4 million Black women and 4 million Latinas, helping to narrow the persistent gender wage gap. Fair pay policies, including pay transparency and salary history bans, also help close gaps and raise wages for women.

Workplace accommodations and fair scheduling are necessary during pregnancy and beyond

The ability of many pregnant people to manage their health and caregiving needs on the job was already limited, even before the Dobbs decision. Each year an estimated quarter of a million pregnant workers are denied reasonable pregnancy-related workplace accommodations, like having a bottle of water on hand or sitting instead of standing, and many more do not ask for the accommodations they need. Women report pregnancy discrimination across races and ethnicities, but Latinas, Black women and immigrant women are more likely to hold certain inflexible and physically demanding jobs that can present specific challenges for pregnant workers; and Black women file nearly three in 10 charges of pregnancy discrimination (28.6 percent), despite making up only 14 percent of women in the workforce aged 16 to 54. Denied accommodations, pregnant workers may have to risk their health or the health of their pregnancies to continue working, or risk losing a job and critical income, health insurance and other crucial workplace supports.

In addition, an estimated one in six workers has an unstable schedule at work. Many of these workers receive their schedules just days or hours before they are expected to work and are unable to request changes without fear of retaliation. This makes it much more difficult to plan health care appointments, arrange child care and even get enough sleep.;; Workers of color, particularly women, are more likely to experience schedule instability, not only because they disproportionately make up low-wage workers that tend to have unpredictable scheduling practices, but also due to discrimination in the workplace. The result is uncertainty, lost pay and a lack of control for people who are trying to provide for themselves and their families.

Some states and localities have enacted fair scheduling protections that guarantee workers more control over their work hours, and laws to ensure a right to reasonable accommodations while pregnant. Together with the other policies described in this brief, these policies help ensure people and their families truly have the dignity, security and autonomy to make decisions about their health and their reproductive lives, and to care for themselves and their loved ones whether or not they choose to have or raise a child.

Deep dive: State policies overlap in their support – or lack thereof – for pregnant and parenting people

There is significant overlap between states that ban or restrict abortion access, those that offer inadequate health care coverage and those that do not provide sufficient public policies guaranteeing workplace supports for expecting and new parents.State abortion policies are taken from the Guttmacher Institute’s detailed tracking and analysis of a wide range of bans, restrictions, and protective/supportive policies, available here. Health care policy metrics include Medicaid expansion and 12-month postpartum Medicaid coverage. Work-family policies include paid family and medical leave, paid sick days, equal pay, fair scheduling, pregnancy nondiscrimination, and minimum wage above the federal law. Analysis and maps reflect state policies as of July 18, 2022. In these states, the health and economic security of women of reproductive age is significantly harmed by the interplay between all of these policies.

States that are most restrictive on health care access, including abortion care, also tend to lack support for working families.

  • Mississippi does not have a single workplace protection for expecting and new parents that goes beyond what federal law provides. In addition, Mississippi has restrictive abortion access and has not adopted Medicaid expansion or 12-month post-partum coverage. This is especially harmful as Mississippi has a large population of women of color.
  • The six states with the most restrictive abortion access all rate poorly on policies that support working families.
  • Of the 12 states that rate the lowest on key work-family policies, three have the most restrictive abortion access, seven have restrictive abortion access, and two have some restrictions and some protections. In terms of health care coverage, only half of these 12 states have adopted Medicaid expansion, and only Florida has fully implemented 12-month postpartum coverage, with one state pending, three states planning to implement, two states with limited coverage and four states with no action.
  • Of the 17 states that have minimal workplace protections for expecting and new parents, 13 have restrictive abortion access, and four have a mix of restrictions and some protections. In terms of health care coverage, 12 states have adopted Medicaid expansion, and nine states have fully implemented 12-month postpartum coverage, with two states pending, one state planning to implement, one state with limited coverage and four states with no action.

Overall, states that are doing the most to support expecting and new working parents are the least likely to restrict access to abortion and healthcare.

  • The five states with the most expansive workplace protections in place for expecting and new parents – California, Massachusetts, New Jersey, New York and Oregon – have all adopted Medicaid expansion and have implemented or are planning to implement 12-month postpartum coverage. In terms of abortion access, Oregon has the most protective abortion access; California, New Jersey and New York have protective abortion access; and Massachusetts has some restrictions and some protections.
  • Of the 16 states that have some supportive policies for expecting and new parents, eight states have protective abortion access, seven states have some restrictions/protections, and only Nebraska has restrictive abortion access. All 16 states have adopted Medicaid expansion, and four states have fully implemented 12-month postpartum coverage, with two pending, five planning to implement, and only three states with no action.

Our state-by-state analysis found that the states that have restricted abortion are also those that have done little to support people’s access to health care or their ability to care and provide for their families. There are vitally important opportunities for the federal government and states to enact legislation that closes these gaps and that better protect the health, economic security and well-being of women and families.

Federal Policy Recommendations

At the federal level, we urge swift adoption of:

  • Women’s Health Protection Act (WHPA) would protect the right of health care providers to provide abortion care, and a right for their patients to receive that care, free from medically unnecessary restrictions that single out abortion and impede access.
  • Equal Access to Abortion Coverage in Health Insurance (EACH) Act would restore abortion coverage to people who receive health care or insurance through the federal government, and would prohibit political interference with health insurance companies that decide to offer coverage for abortion care.
  • Family and Medical Insurance Leave (FAMILY) Act would create a national paid leave insurance program to allow workers to earn a portion of their pay while they take a limited amount of time away from their jobs to care for a newborn or newly adopted child or newly placed foster child; care for a family member with a serious health condition; address their own serious health condition; or manage certain military caregiving responsibilities.
  • Healthy Families Act, would establish a national paid sick days standard, allowing workers to earn up to seven paid, job-protected sick days each year to use to recover from their own illnesses, access preventive care, provide care to a sick family member, or attend school meetings related to a child’s health condition or disability.
  • Pregnant Workers Fairness Act (PWFA) would help ensure pregnant women have equal access to reasonable workplace accommodations and promote the health and economic security of pregnant women and their families.
  • Paycheck Fairness Act would make it harder for employers to engage in sex-based wage discrimination, prohibit employers from forbidding their workers from discussing wages and institute data collection that will help inform future enforcement efforts.
  • Schedules that Work Act would provide employees with the right to request changes to their work schedules related to the number of hours they are required to work or be on call, the location of the work, the amount of notification about work schedule assignments and fluctuations in work hours.
  • Raise the Wage Act would increase the federal minimum wage and eliminate subminimum wages for tipped, youth and disabled workers.

State Policy Recommendations

At the state level, we urge state legislators to:

  • Repeal laws that restrict or ban access to abortion care and enact robust protections that ensure meaningful access, including requiring insurance coverage for abortion care and using state funds to provide abortion care for Medicaid enrollees.
  • Expand Medicaid coverage, which would extend coverage eligibility to adults who would not have otherwise qualified in the past due to income restrictions.
  • Extend postpartum Medicaid to 12 months, which would extend coverage for those who lose insurance during the critical period after giving birth.
  • Enact paid sick days protections and paid family and medical leave programs to ensure workers can take time to care for their health and families without losing income.
  • Address pay inequities by strengthening and better enforcing fair pay laws, and raise incomes by increasing the state minimum wage to at least $15 per hour with annual adjustments for inflation, and eliminating subminimum wages.
  • Enact laws guaranteeing pregnant workers a right to reasonable accommodations, and fair and predictable work schedules for all workers.

This brief is a product of the National Partnership for Women & Families, with significant contributions from Khadija Amin, Vanisha Kudumuri, James Campbell, Jaclyn Dean, Katherine Gallagher Robbins, Shaina Goodman, Sharita Gruberg, Jessica Mason, Jake McDonald, Vasu Reddy and Gail Zuagar.

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