Across all of the major House and Senate Republican proposals in 2017 to repeal and replace major portions of the Affordable Care Act (ACA), one thing that has been consistent is their inclusion of language barring federal money from being used to support private insurance plans that covers abortion. The latest proposal, from Sens. Lindsey Graham (R-SC), Bill Cassidy (R-LA), Dean Heller (R-NV) and Ron Johnson (R-WI), continues that trend.

The Graham-Cassidy proposal has abortion coverage provisions in common with the American Health Care Act (AHCA), which passed the House in May, and the Better Care Reconciliation Act (BCRA), which was rejected on the Senate floor in July. (See my post from March 21 for a description of the abortion coverage restrictions in AHCA and a fuller discussion of this topic, including the history behind these restrictions, current limitations on abortion coverage in private insurance and why abortion coverage restrictions matter.)

Like its predecessors, Graham-Cassidy would phase out the ACA’s subsidies to help low- and middle-income individuals purchase health plans on their own, as well as ACA subsidies to help small employers purchase health plans for their employees. During the two years (2018 and 2019) that those subsidies would still exist, the legislation would bar them from going to any plan that includes coverage for abortion, beyond those rare cases when the woman’s life is endangered or the pregnancy is the result of rape or incest. Unlike AHCA, the Graham-Cassidy proposal does not make any pretense of allowing for the purchase of abortion “riders.”

Problematic Provisions

As several media reports have highlighted, the timing of this proposal is especially problematic, because the deadline for insurers to participate in the ACA’s marketplaces in 2018 is on September 27. Plans that include abortion coverage could end up ineligible for purchase in 2018 by anyone receiving a premium assistance subsidy. That would include all plans in California and New York, which require abortion coverage in marketplace plans. That problem would eventually extend to Oregon, which has enacted an abortion coverage requirement that goes into effect in 2019.

The Graham-Cassidy proposal also includes a provision (seen earlier in BCRA) that would allow people to use money in Health Savings Accounts (HSAs) to pay premiums for certain high-deductible health plans—but not if the plan includes coverage of abortion (except in the same limited cases). That would be the first abortion-related restriction applied to HSAs, which allow individuals to set aside money in a tax-sheltered account dedicated to medical expenses and which are in great favor among conservative lawmakers.

The most distinctive feature of the Graham-Cassidy proposal is its massive block grant to the states—well over a trillion dollars over seven years—that would, starting in 2020, replace the ACA’s premium and cost sharing subsidies and its Medicaid expansion. States could use the block grant in numerous ways, including direct payments to health insurers or health care providers, funding for high-risk pools, and subsidies to help people pay premiums and cost sharing. This block grant provision is routed through an existing federal statute that bars federal funding for abortion care or for insurance coverage that includes abortion (again, except in cases of life endangerment, rape or incest). It is unclear exactly how that provision would be applied in all of the different scenarios possible under this block grant. For example, would an insurance company or health care provider receiving block grant dollars be barred from providing abortion coverage or care throughout its business? Regardless, the intention seems clear: to eliminate abortion coverage and care in as many arenas as possible.

Broader Restrictions On Reproductive Health

Finally, it should be made clear that the abortion coverage restrictions in Graham-Cassidy are part of a broader collection of provisions that would undermine access to reproductive health services. The legislation would also exclude Planned Parenthood health centers nationwide from being reimbursed for family planning and other services provided to Medicaid enrollees. The block grant provision would allow states to eliminate key ACA protections for some insurance plans, including requirements to cover maternity care, contraceptive methods and services, and other preventive care. And, although official projections are not yet available from the Congressional Budget Office, the legislation would likely lead to the loss of comprehensive insurance coverage—including coverage for reproductive health care—for many millions of people in the United States.