83 Counties: The Status of Women’s Reproductive Health Care Access in North Carolina

A recent report released by the NC Department of Administration entitled “The Status of Women in North Carolina: Health and Wellness” reveals a dire situation for women’s reproductive health in our state.[i] The report’s findings state that, “Wide disparities persist in the health of women by race and ethnicity, as well as by geography.” The report also states that policy makers have the power to improve health and wellness. However, in the case of reproductive health care, it appears that policy makers in the General Assembly have instead made every effort over the last several years to make it more difficult for women to access the full spectrum of care.

One of the first findings of the report states an important and essential fact for this discussion. “Reproductive rights — having the ability to decide whether and when to have children — are essential to the social and economic well-being and overall health of women.” This truth cannot be overstated or repeated enough. Without reproductive freedom and access, women will not have true equality and are prevented from being fully productive and healthy citizens of our state. The authors of the report make several policy recommendations to reduce the healthcare disparities that exist among women of different races, ethnicity, and geography. Specifically regarding reproductive health, the report’s policy recommendation is powerful:

“Ensuring women have access to reproductive health services and rights to enable them to make health care decisions and determine the timing and size of their family. North Carolina can enhance women’s reproductive rights by eliminating barriers that make it difficult for women to access contraception and abortion and to obtain the full range of reproductive health services and information they need.”

The report notes that North Carolina has a total of 37 abortion providers operating in only 17 counties, meaning 83 counties in North Carolina do not have an abortion provider. Incredibly, this leaves 43% of women aged 15–44 without an abortion provider in their county, notably higher than the national average of 34%. To put this statistic in perspective, nearly 2.4 million women living in North Carolina must travel significant distances and across county lines to receive abortion care. Because of the absence of providers and the need to travel to access abortion care, an “additional financial burden has been placed on women who earn low incomes,” widening the disparities between women living in urban and rural communities.

How has North Carolina become a state where all women do NOT have full access to reproductive health services? What policies and laws have been passed by the NC General Assembly that have resulted in these wide disparities? Let’s examine the findings as published in the report and the legislation that has gotten us here.

Required counseling and 72 hour waiting period

When it was filed in 2011, HB 854 was a red alert bill for reproductive rights advocates.[ii] In its first edition, the bill instituted a 24 hour waiting period for women seeking an abortion. The waiting period would begin immediately following a mandated counseling session, in which the patient seeking an abortion would be provided with orated information about the procedure as well as an information pamphlet that prominently displayed the sentence,

“The life of each human being begins at conception. Abortion will terminate the life of a separate, unique living being.”

After several edits in committee (and in the course of what seemed to be a win for the bill’s opposition, who held a minority in the General Assembly at the time), the pamphlet language was deleted and several reporting requirements for abortion providers were also removed.

Otherwise known as the “Woman’s Right to Know Act,” the final version of HB 854 (SL 2011–405) [iii] required that a woman seeking an abortion must orally receive the following information from her medical provider 24 hours in advance of the procedure, before North Carolina law would recognize that she could consent to the abortion:

· the gestational age of the fetus

· the medical risks of abortion, including adverse psychological effects

· that the woman has other alternatives to abortion

· that there may be medical assistance available to her for prenatal, childbirth, and neonatal care

· that the father is liable to assist in the support of the child, even if the father has offered to pay for the abortion

A committee substitute to the bill also added that a woman seeking an abortion must be shown the “real-time view” of the fetus four hours before an abortion. [iv] “Real-time view” would require that the woman be shown an ultrasound of the fetus while her medical provider provides an explanation of its size and location, as well as an educated estimate of the number of internal organs that the fetus has developed. Additionally, the medical provider must provide the woman a chance to listen to the fetal heartbeat. Although the real-time view requirement has been under review in federal courts since 2014, the provision is still in effect in NC.

In 2015, HB 465 (SL 2015–62) was filed as the “An Act to Clarify and Modify Certain Laws Pertaining to Abortion” [v] but later reemerged as the “Women and Children’s Protection Act of 2015.” [vi] The new bill contained language from its first edition that increased the informed consent waiting period for abortions from 24 to 72 hours and required that clinics submit ultrasound images to DHHS from abortions conducted after 16 weeks.

To be clear, the 72 hour informed consent waiting period means that the nearly 2.4 million women in North Carolina who live in a county without an abortion provider will likely have to travel substantial distances and rent a hotel room or find another safe place to sleep while waiting for their abortion. This policy also means that women have to travel much further away from their support networks, who often drive women to and from their abortion provider on the day of their procedure. As a result, the 72 hour informed consent period isolates rural women from their support systems and burdens them with more financial barriers to abortion access than any other women in our state.

State funding for abortion/insurance coverage

In order to bring these disparities into focus, let’s zoom in. The cost of an abortion varies depending on a woman’s stage of pregnancy and the type of abortion she needs. The median cost for an early term abortion is $500, but the price can range from as low as $10 to as high as $2,908.[vii] However, some later term procedures can cost between $500 and $3,275, [viii] with some procedures costing more than $10,000. [ix] Although many clinics offer financial assistance to patients in need, their levels of assistance vary and often depend on a patient’s income and family size, as well as the clinic’s location.[x]

In the four years following the passage of S.L. 2011–405, the North Carolina State Legislature passed three other pieces of legislation that furthered the reach of the original bill. In 2011, the General Assembly inserted language in the State Budget bill that removed abortion coverage from the State Health Plan (SL 2011–145 s 10.53).[xi] In 2013, SB 353 (SL 2013–366) barred private insurance companies on the Affordable Care Act exchange from offering abortion coverage.[xii] The bill also barred counties and cities from offering abortion coverage greater than that of the State Health Plan, effectively prohibiting abortion coverage for city and county employees across North Carolina unless the pregnancy was the result of rape, incest, or if the life of the mother was at risk.

For perspective, 18% of women of child bearing age in NC either have Medicaid or some other type of public health insurance, and 14% of women of child bearing age are uninsured in NC.[xiii] This brings us to a total of nearly 1.4 million low income women of child bearing age who do not have insurance coverage for abortion care. Additionally, we know there are many more thousands of women in NC of child bearing age who are covered under the State Health Care Plan, the ACA and private insurance who do not have coverage for abortion care. The laws passed in NC since 2011 have imposed burdensome and financially restrictive requirements to access reproductive healthcare in North Carolina.

A Strategic Plan to Block Women’s Health Care Access

To be clear, the types of restrictive policies that lawmakers have passed over the past few years have not been the kind of knock-out, inflammatory policy punches we have grown accustomed to in political theater. It is not the case that lawmakers passed an omnibus abortion restriction bill that led to the current findings in the DOA’s report on the Status of Women. Instead, legislative leadership has slowly enacted and strategically edited policies since 2011 with the goal of systematically blocking women’s ability to access to the resources and care that they need.

Meanwhile, the North Carolina Department of Administration has continued to propose policies that would rollback these unwise and harmful policy decisions, including in the 2019 report. Previous reports in 2013[xiv] and 2016[xv] on the Status of Women in NC and the South have also concluded that policies like North Carolina’s create financial barriers to accessing abortion care, especially for low-income and rural women. Evidenced by these reports’ findings, we know that policy makers are doing all they can to rollback women’s access to the full spectrum of available reproductive health services instead of working towards improving reproductive healthcare access as our DOA suggests.

Bills like the legislation we’ve seen passed since 2011 serve as further evidence of a deeper problem: our legislature’s apathy towards the real needs of women in North Carolina. Women in North Carolina need better access to reproductive health services, not increased involvement of politicians in private conversations with physicians. Women need laws that uplift their right and ability to make health care decisions that determine the timing and size of their families, not laws that deem them incapable of parsing information related to the timing of when they have children. Women need laws that make reproductive health care more accessible and less expensive, not laws that are passed with the intention of removing a woman’s ability to pay for health care. And most importantly, women need legislators who listen to experts and enact the policy proposals coming out of our state agencies.

In closing, the NC General Assembly has a history of enacting policies in direct contradiction to proposals from the state agencies that study and specialize in improving women’s access to equitable health care. And because of the laws enacted by our General Assembly since 2011, many women in rural areas face undue obstacles and financial burden to access abortion care. Now is the time to hold the line for abortion access, and more importantly, now is the time for legislative leaders to listen to our Department of Administration and eliminate the barriers and paternalistic policies that have restricted women’s full and unencumbered access to reproductive health care.

[i] “The Status of Women in North Carolina,” The Institute for Women’s Policy Research; The Council for Women & Youth Involvement: NC Department of Administration; The State of North Carolina Department of Transportation; Status of Women in the States. 2019. (https://files.nc.gov/ncdoa/cfw/documents/R592_NC_Health_Report_Final.pdf)

[ii] “Abortion — Women’s Right to Know Act,” HB 854v0, 2011 Biennium, 2011 Reg. Sess. (N.C. 2011). (https://www.ncleg.gov/Sessions/2011/Bills/House/PDF/H854v0.pdf)

[iii] “Women’s Right to Know Act,” HB 854v6, 2011 Biennium, 2011 Reg. Sess. (N.C. 2011). (https://www.ncleg.gov/Sessions/2011/Bills/House/PDF/H854v6.pdf)

[iv] “Abortion — Women’s Right to Know Act,” HB854-PCS90109-RK-70, 2011 Biennium, 2011 Reg. Sess. (N.C. 2011). (https://webservices.ncleg.net/ViewBillDocument/2011/872/0/H854-PCS90109-RK-70)

[v] “Clarify & Modify Certain Abortion Laws,” HB 465v0, 2015 Biennium, 2015 Reg. Sess. (N.C. 2015). (https://www.ncleg.gov/Sessions/2015/Bills/House/PDF/H465v0.pdf)

[vi] “An Act to Enact the Women and Children’s Protection Act of 2015,” HB 465v6, 2015 Biennium, 2015 Reg. Sess. (N.C. 2015). (https://www.ncleg.gov/Sessions/2015/Bills/House/PDF/H465v6.pdf)

[vii] Jerman, Jenna, and Rachel K. Jones. “Secondary Measures of Access to Abortion Services in the United States, 2011 and 2012: Gestational Age Limits, Cost, and Harassment.” Women’s Health Issues, vol. 24, no. 4, 2014, p. e421., doi:10.1016/j.whi.2014.05.002.

[viii] Fisher, Theresa. “How Much Does an Abortion Cost? Well, from $0 to $3,275.” Clear Health Costs, 3 Aug. 2019, (clearhealthcosts.com/blog/2014/06/much-abortion-cost-draft-theresas/)

[ix] Cowles, Charlotte. “What to Know About the Cost of an Abortion.” The Cut, The Cut, 20 Nov. 2018, (www.thecut.com/2018/11/how-much-does-an-abortion-cost.html)

[x] Parenthood, Planned. “How Much Does an Abortion Cost?” Planned Parenthood, (www.plannedparenthood.org/learn/teens/ask-experts/how-much-does-an-abortion-cost)

[xi] “An Act to Spur the Creation of Private Sector Jobs; Reorganize and Reform State Government; Make Base Budget Appropriations for Current Operations of State Departments and Institutions; and to Enact Budget Related Amendments,” HB 200v9 Section 10.53 “Repeal State Abortion Fund,” 2011 Biennium, 2011 Reg. Sess. (N.C. 2011). (https://www.ncleg.gov/Sessions/2011/Bills/House/PDF/H200v9.pdf)

[xii] “An Act to Modify Certain Laws Pertaining to Abortion, to Limit Abortion Coverage Under Health Insurance Plans Offered Under A Health Benefit Exchange Operating in North Carolina or Offered by a County or Municipality…,” SB 353v5, 2013 Biennium, 2013 Reg. Sess. (N.C. 2013). (https://www.ncleg.gov/Sessions/2013/Bills/Senate/PDF/S353v5.pdf)

[xiii] “Health Insurance Coverage of Women 19–24,” Kaiser Family Fundation, 2017, (https://www.kff.org/other/state-indicator/nonelderly-adult-women/?dataView=1&currentTimeframe=0&selectedDistributions=employer--non-group--medicaid--other-public--uninsured--total&selectedRows=%7B%22states%22:%7B%22north-carolina%22:%7B%7D%7D%7D&sortModel=%7B%22colId%22:%22Employer%22,%22sort%22:%22asc%22%7D)

[xiv] “The Status of Women in North Carolina,” The Institute for Women’s Policy Research, 2013. (https://iwpr.org/wp-content/uploads/wpallimport/files/iwpr-export/publications/R360-Full%20report.pdf)

[xv] “The Status of Women in the South,” The Institute for Women’s Policy Research, 2016. (https://iwpr.org/wp-content/uploads/wpallimport/files/iwpr-export/publications/R462%20Status%20of%20Women%20in%20the%20South.pdf)