The reconciliation bill has given Republicans a way to target abortion access in states that legally protect it: threatening their federal health care funding.
House Republicans added a last-minute provision to their reconciliation bill via a manager’s amendment that would block certain Affordable Care Act funds from going to state health plans that cover abortion services. There are currently 13 states — California, Colorado, Delaware, Illinois, Maine, Maryland, Massachusetts, Minnesota, New Jersey, New York, Oregon, Vermont and Washington state — with laws in the books that require insurers to cover abortion.
If the provision becomes law, it could force state officials to choose between maintaining abortion accessibility and ensuring that residents maintain their health care coverage. After years of arguing abortion policy should be left to the states, some congressional Republicans acknowledged they want to have a say in what the states do — at least when it comes to funding.
“It’s reasonable for us to be concerned about how federal dollars are flowing to jurisdictions, how they’re being used,” Rep. Chip Roy told NOTUS.
Rep. Chris Smith, co-chair of the House Pro-Life Caucus, told NOTUS that he never felt abortion policy should be left entirely to the states
“I read the [Dobbs] decision by the Supreme Court very carefully. Us and the states — us being federal — are equally empowered to protect life,” Smith said.
But many Republicans have emphasized state decision-making powers on abortion policy and pushed back on Democrats who accused conservatives of trying to ban abortion nationwide. This provision goes against that messaging, some Republican lawmakers acknowledged.
Rep. Kevin Hern, chair of the House Republican Policy Committee, said that the reconciliation bill is not “the perfect bill,” so compromises had to be made — including adding a measure that goes against party messaging.
One House Republican, who said he was unaware of the provision, put it bluntly: “The longer I’m here, I’m never sure that anybody follows anything anymore.”
Democrats said the reconciliation bill’s abortion provision was just another effort to ban abortion nationwide.
Republicans “are going to do a national abortion ban in every single way they can, without coming out directly and saying it,” House Democratic Whip Katherine Clark told NOTUS. Instead of going for an outright ban, she said, Republicans will “go after the funding.”
The Hyde Amendment already bans federal funds from being used directly on abortion. The Affordable Care Act prohibits recipients from using cost-sharing reductions — financial assistance to lower the out-of-pocket costs for low-income individuals — to pay for abortions.
However, the reconciliation bill takes that limitation further, saying that health plans that cover abortion services cannot receive federally funded cost-sharing reductions at all. That could threaten financial assistance for all residents of a state. In 2024, half of all people enrolled in an ACA health plan qualified for cost-sharing reductions, per the Centers for Medicare and Medicaid Services.
“It wouldn’t ban insurers from providing coverage for abortion care, but it would make it more difficult for insurers to provide such coverage,” said Katie O’Connor, senior director of federal abortion policy for the National Women’s Law Center. Ultimately, she added, “it would result in a lot of disruption to abortion coverage generally.”
After this story was published, a spokesperson for Speaker Mike Johnson’s office disputed the notion that the provision would restrict access and told NOTUS in a statement,
“The assertions made in this story are false. The cost-sharing reduction payments policy in the reconciliation bill are about lowering premiums, not abortion.”
The spokesperson added that the abortion provision was nothing more than reiterating “Hyde Amendment protections.”
The day before House Republicans passed the reconciliation bill, 18 insurance regulators sent a letter to House leaders that the legislation would lead to a “sicker, less financially secure American public.” The anti-abortion provision, which was added a few hours before the House voted on the legislation, exacerbated those concerns since it’s written in a way that seemingly excludes plans that include “coverage of abortion.”
“Let me start by saying, I hope that this provision does not pass and come out in the final reconciliation bill,” Marie L. Grant, Maryland’s insurance commissioner, told NOTUS. “I think that would raise concerns about the availability of coverage for [abortion] services in Maryland’s market.”
While Maryland requires insurers to cover abortion, Grant noted that state law has an exception that says if requiring insurance to cover abortion “may adversely affect the allocation of federal funds to the State, the Commissioner may grant an exemption … to the minimum extent necessary to ensure the continued receipt of federal funds.”
If the provision is enacted, Grant said, “we would be looking at a situation where we would need to evaluate that section and see what is possible under my authority.”
As it stands now, the bill “creates barriers to essential services,” said Jason Lefferts, a spokesperson for the Massachusetts Health Connector, the state’s official ACA marketplace.
“We are monitoring the bill as it progresses, and would be very concerned by any restrictions on coverage for reproductive health care,” Lefferts added.
Other insurance regulators say that this provision opens some legal questions.
“Because of the timing of when this manager’s amendment came out and everything else, we’re quite frankly still reviewing,” said Julia Dreier, Minnesota’s deputy commissioner of insurance. “We’re still sort of evaluating what this all means in terms of interaction between federal and state law. We have a state law that requires that the coverage be there, and so we’re trying to figure out … how that plays out.”
Some Democratic attorneys general are keeping a close eye on whether the abortion provision becomes law.
“The 800,000 New Jerseyans that utilize our state’s Affordable Care Act exchange are entitled to all eligible forms of care, including abortion care,” said New Jersey Attorney General Matthew Platkin. “We will always protect the rights of our residents and stand ready to fight any threats to their care.”
The California Department of Justice said it is “closely following the legislative developments in Washington D.C., and broadly speaking, remain committed to protecting abortion coverage in California.”
Some blue state Republicans who voted for the reconciliation bill were either unfamiliar with the provision or interpreted it differently.
“It has to do with Hyde,” Rep. Mike Lawler of New York told NOTUS.
Rep. Nicole Malliotakis, another New York Republican, said she thought the provision would increase ACA funds going to New York. When told that her state would likely be barred from cost-sharing reductions because of its state law, she said, “I’ve got to look at the bill.”
Rep. Kevin Kiley of California said he looked closely at that provision and that his interpretation of the text was that it would “not adversely affect the state.”
Rep. David Valadao, another California Republican, expressed a bit of worry after being told about the provision, which he said he didn’t know if he had read.
When asked if he was concerned that the language would impact Californians’ access to ACA health plans, Valadao said, “I imagine so.”
“I need to look into that a little bit better,” Valadao said.
This story has been updated with a comment from Speaker Mike Johnson’s spokesperson.
—
Oriana González is a reporter at NOTUS.