Abortion Hotlines Feel the Crunch
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"It's a sad calculus ... It helps if they are farther along in pregnancy rather than earlier. Or if they are living with their batterer, and he would know if they'd pawn anything. Or, if they are homeless ... like we got this call last week from a woman whose house burned down and her three children were taken away. We were able to get some money for her."
Laura, the case manager at the hotline of the National Abortion Federation, is explaining to me the triage that occurs in the effort to help desperate women raise money for abortions they can't afford. Most of the hotline's approximately 100 callers per day are simply looking for a referral to an abortion provider in their area. But a sizable minority seek the hotline's assistance in raising money from the various nonprofit abortion funds around the country and from NAF's own small discretionary fund.
Because there is not enough money to go around, being poor is not enough. "You have to have 'extenuating circumstances'" Laura says. Not surprisingly, rape is one such extenuating circumstance which the various abortion funds respond to. In fact, if state governments were obeying the law, the hotline would have to raise far less money for rape victims. The Hyde Amendment, a measure passed in Congress shortly after Roe v. Wade , forbids the use of Medicaid funds to pay for abortions but makes exceptions for rape, incest and threats to the life of the mother. Many of those rape survivors who asking the hotline for help are on Medicaid.
The problem however is that numerous state Medicaid programs simply refuse to enforce this provision. Fighting with anti-abortion state bureaucrats often drags on indefinitely and pushes women later into pregnancy â€” making the procedure even more expensive and a provider more difficult to find. Therefore last year nearly 28 percent of the $136,000 that the hotline helped raise went to those who are theoretically eligible for state funding.
But even those sufficiently high on the "extenuating circumstances" spectrum to qualify for financial aid often don't get enough to pay for their abortion. First trimester abortions costs range from about $300 to $500. Second trimester ones can cost over $2,000. As I sit and listen to Laura work the phones nonstop, I realize that much of what she does is a quite unique, and certainly challenging, form of financial counseling. Her task is to instruct her often indigent callers in the delicate art of fundraising.
"Could you ask your friends for $40? If they say 'no,' maybe ask for 20 or even 10?" I hear her ask in her calm voice. Later she tells me that this woman has been evicted from her house for lack of rent, and is crashing with her three children at a friend's. To another caller, I hear her say, "Well, do you have anything you might pawn? Some jewelry? A TV set?" And to another, "Is it possible you could postpone your car payment until after the abortion?"
Laura's case management is strikingly labor intensive. She averages about 15 phone calls per case -- with the client herself, with the various abortion funds, with the clinic that is the potential site of the abortion -- whether in the end the woman successfully obtains sufficient funds for an abortion or not.
After blocking the callers' names and other identifying information, Laura shows me some of the intake forms of the past month. The meticulously kept log of each call made or received hints at lives lived at the edge. For example, in response to the item on the form that asks about possible funds to be raised from the "man involved with pregnancy," I see the stark one-word response, "Crackhead,â€ recorded verbatim by a hotline staffer while talking to the patient. "No idea where he is," reads another response, and a third, "Has nothing." The hotline staff assures me, however, that there are numerous instances of "good guys" -- fathers and husbands and boyfriends -- who actively participate in the search for funding.
In response to the question about "items to pawn," one formâ€™s entry reads, "No TV." Another simply says, "House robbed, nothing left." There are numerous references to domestic violence, and an over-representation of pregnancies resulting from rapes. (Nationally, about 1 percent of all abortions occur because of rape).
Sometimes the grim realities of the callers' lives means that even seeming victories can include defeats. Consider, for example, the case of a woman from a Southern state, a mother of five, who lives in a mobile home. Believing herself to be 15 to 16 weeks pregnant, she obtained a tentative appointment at a clinic, which informed her the cost would be $450. Through a combination of Laura's calls to various funds and the patient's own fundraising -- I see a notation about "yard sale" in the file -- they were able to cobble together the necessary money. Reading this, I can visualize Laura and Rachel, the hotlineâ€™s director, pumping their fists in the air and going "Yesss!" as they once again have been able to help.
But there in the chart, I see a subsequent entry: "Patient called to leave message -- said she lost her ride to clinic." By the time the woman did make it to the clinic, according to Laura's crisp notes, "Pt sono'ed [had an ultrasound] at 18 weeks [gestation age], and clinic raised cost by $440. Pt decided to continue pregnancy since she didn't have sufficient funds to have abortion."
Talking to Laura and Rachel about this case, they confirm that this is not an uncommon thing. Many of the women who call her do not have cars and are dependent on sometimes unreliable friends and relatives to get them to their appointments. The problem of "sono'ing over," as the hotline staff puts it, is a serious one. Either the patient's pregnancy has advanced past to the point where the providing facility no longer performs abortions, or -- as in the case above -- the cost has become prohibitive. (While some might find the clinic's response coldhearted, in fact abortion costs have remained remarkably flat since 1973 -- and many clinics already offer a considerable amount of subsidized care.)
To be sure, there are unqualified triumphs in the hotline room as well, when patients beat the odds with a combination of luck and tenacity. Laura tells me of a woman from a mid-Atlantic state with a mind-numbing series of problems. Already the mother of several young children, she was in the midst of a difficult divorce from an abusive husband, against whom she had acquired a restraining order. "My husband would kill me if he found out I was pregnant," she said. She was about to be evicted from her home, because of difficulty in paying the rent. She had become pregnant after being given a "date rape" drug. The woman had duly reported the rape to police and was determined to get her state's Medicaid program to pay for her abortion.
This involved a massive effort on the patient's part. Though so poor that her phone was disconnected (communications with the hotline took place via a neighbor's phone), she managed to find a public internet connection and download the necessary form for a Medicaid payment for an abortion involving a rape. Then she embarked on a Kafkaesque series of phone calls with state Medicaid officials, all of whom were determined to prevent approval of her abortion. Through the help of a public interest lawyer in the hotline's network, the patient finally was able to access someone high enough, and sympathetic enough, in the Medicaid hierarchy who could approve her request.
The next obstacle was to find a provider in her rural area who would accept a Medicaid-paid abortion. Neither her "anti-abortion" primary care doctor nor her equally anti-abortion OB/GYN were any help. Finally, after much frantic calling around, with the hotline's help she located a clinic that performed her abortion. "And all this calling and arranging happened in just four days!" Laura marveled.
The stories of many of the women asking the hotline for financial help suggest situations so challenging that affordable abortions would hardly solve their problems. In the long run, only in a society that provides what is now lacking in contemporary America -- affordable housing, living wages, better child care and domestic violence programs, and above all, national health insurance -- would these women and their children have a shot at a decent life.
In the short run, however, accessible and affordable contraception and abortion would make an enormous difference. The Centers for Disease Control states in a recent report that 98 percent of heterosexual women use contraception "at some point." But this number masks the fact that use of birth control use is gradually decreasing, especially among poorer women. The Guttmacher Institute, the leading research organization on reproductive health, has pointed out that, between 1994 and 2001, 33 states cut funds for birth control and that half of all poor women who need birth control services are unable to afford them.
In what might seem like a ray of hope, House Democrats have just introduced legislation, the Reducing the Need for Abortions and Supporting Parents Act, that would require states to cover contraceptives for women with incomes of up to 200 percent of the federal poverty level. The bill would also establish grants for sex-education programs that include information on both contraception and abstinence. It also contains various other family-friendly measures, including increasing funding for health care for low-income women with children, providing no-cost visits from nurses to teens and women who have given birth for the first time, expanding tax credits for adoption and increasing child care funding.
No Republicans publicly support this effort, and it is opposed by the Democrats for Life caucus, "because of the pregnancy prevention emphasis." This lack of support for what should logically be common ground in the abortion wars reflects the new aggressive stance by much of the anti-abortion movement. Contraception itself is now being reframed as another form of abortion. This bill has virtually no chance of passing in the current political climate. And the calculus for the hotline callers just keeps on getting sadder.
Carole Joffe is professor of sociology at the University of California-Davis and a senior fellow at the Longview Institute.