California has stacked the deck against lower-income pregnant women. There is far more public concern, funding, attention, and opportunity for a poor woman to get an abortion than to get prenatal care.
In response to the Supreme Court overturning Roe, Governor Newsom and the Legislature (whose 2018 promises of universal, single-payer California healthcare remain unfulfilled) tripped over themselves to pass 13 different abortion laws this legislative year, a broad-based effort to maximize abortion accessibility to women throughout California and beyond. They intend to crown these efforts with Proposition 1, a statewide ballot initiative to enshrine a completely unbound right to abortion into the California Constitution, with no limits on abortion even after viability.
But what about women who want to keep their babies? On that score, Newsom and the Democrats have been silent, in spite of the growing public health crisis with the lack of prenatal care access.
I live near Fresno, California, a community with high levels of poverty and a large population receiving health coverage from Medi Cal, our state Medicaid program. Ever since abortion’s legalization, Medi Cal has always covered abortion, despite attempts by the California Legislature in the 70’s and 80’s to eliminate public abortion funding. The California Supreme Court blocked these efforts on the grounds that it was impermissible for California to “tip the scales” of the abortion decision by having Medi Cal cover prenatal care and childbirth, but not abortion.
But it’s now clear that California has actually “tipped the scales” in the opposite direction: to abortion, away from childbirth. Almost 25% of women in south Fresno get no prenatal care before they deliver their children. This has serious public health consequences, like increased infant and maternal mortality, low infant birth weight, and other pediatric and maternal health issues.
The central problem is straightforward: Medi Cal reimburses poorly for prenatal care services. As a result, private doctors’ offices, which used to be more willing to receive Medi Cal patients for OB care as a kind of public service, are starting to close their doors to such patients. More and more providers are determining that they cannot afford to shoulder the financial loss and state-imposed administrative burdens attendant to serving Medi Cal OB patients.
These financial dynamics underlie abortion providers’ strategic decisions to often not provide prenatal care. Prenatal visits are a financial loser for abortion clinics like Planned Parenthood, if the patient is on Medi Cal. These checkups eat up provider time, exam room space, and reimburse poorly.
In Fresno, Planned Parenthood has two locations: one in north Fresno near California State University, Fresno, and another in the Tower District neighborhood of south Fresno. The clinic near Fresno State is in a wealthier part of the city, with more college-aged patients on their parents’ private insurance plans. Planned Parenthood provides prenatal care at this clinic. They do not provide prenatal care in the Tower District, where essentially all of their patients are on Medi Cal. Clearly, these decisions are driven by nothing more than the almighty dollar.
If a Medi Cal beneficiary finds she is unexpectedly pregnant and in difficult circumstances, she has a few choices, but the scales are clearly tipped in one direction. She can try to become a patient at one of the few remaining private OB/GYN offices that are willing to take her insurance, where the patient volume is enormous and her wait time will be extensive before she can get an appointment. She can go to a Federally Qualified Health Clinic or other community clinic, where she will face similar challenges. In either path, she will have out-of-pocket payments of various sorts, lots of unnecessary visits (due to bizarre Medi Cal rules banning reimbursements for multiple same-day services), and unexpected costs.
Or she can go to Planned Parenthood to swiftly obtain an abortion. Abortion works well with Planned Parenthood’s structures of revenue and clinic flow, and they make so-called “medication,” pill abortions available at essentially all their locations. Their South Fresno clinic offers both pill abortions and surgical abortions. Out of all its services, abortion is far and away Planned Parenthood’s leading generator of revenue.
And California will bend over backwards to facilitate a lower-income woman getting that abortion. If she needs transportation for an out-of-town abortion, California will pay for it. Starting January 1, she will have no out-of-pocket costs: no copay, no deductible. And California is actively incentivizing more providers to perform abortions or to set up new clinics for her ease of access.
California is offering none of those supports to women who just want to have their baby. Clearly, in California, we are okay with tipping the scales, as long as they are tipped in one direction.