UPDATE ON WOMEN AND FAMILY ISSUES IN CONGRESS VOL. 14, NO. 3 April/May 1994 Freedom of Access to Clinic Entrances Act Signed into Law Women and health care workers gained important new protections from blockades and violent protests at abortion clinics when President Clinton signed the Freedom of Access to Clinic Entrances Act on May 26. Originally passed by the House and the Senate late last year, completion of the legislation was slowed by action on the omnibus crime bill and by dilatory tactics from the bill's opponents. In addition to barring the threat and use of force outside abortion clinics, the new law establishes criminal and civil penalties for those who use physical obstruction to injure or interfere with someone who is providing or obtaining abortion- related services. Both abortion clinics and abortion alternative counseling centers are protected. Those convicted of a violent offense face fines of up to $100,000 and one year in prison for a first offense; subsequent offenses could be penalized with up to $250,000 and three years in prison. Immediately after the signing, two anti-abortion groups filed a court challenge, arguing that the law interferes with their right of religious freedom and free speech. During House debate, Rep. Jim Bunning expressed this same viewpoint, "The Freedom of Access bill would make an individual's pro-life conviction a thought crime and it would put a congressional stamp of approval on the pro-abortion side of the debate. It was designed, not to prevent violence, but to discourage pro-life protests." "Democracy rests on a foundation of liberty and tolerance and respect," countered Rep. Nancy Johnson. "Matters of conscience are sometimes hard as the abortion issue demonstrates, but differences honestly held, though deeply in conflict, cannot be resolved by denying the rights of others. This bill's goal is to balance the rights of all so that the right to dissent is protected while the right of access is honored." On May 5, the House voted 241-174 to accept the Senate provisions which set lower penalties for nonviolent offenses and extend the bill's jurisdiction to places of religious worship. Those found guilty of obstructing access to a clinic face fines of up to $10,000 and six months in prison; for subsequent offenses, penalties are increased to $25,000 and 18 months in prison. The final Senate vote on May 12 was 69-30. The legislation also allows state and federal Attorneys General to issue injunctions or award damages. Rep. Constance Morella, one of the bill's chief sponsors, explained that these federal remedies were necessary after the Supreme Court ruled in Bray v. Alexandria Women's Health Clinic (January 1993) that federal injunctive relief is no longer possible under civil rights laws. Prior to this decision, states and localities used the so-called Ku Klux Klan statute to discourage blockades and anti-abortion violence. "FACE will give the federal government the power to act when state and local authorities cannot or will not act," continued Rep. Morella. In the final version of the legislation, the House agreed to limit the right to file a private civil suit to those directly affected by protests: health care workers and women seeking abortion-related services. The Senate agreed to extend an equivalent restriction to the religious worship provision. Senate conferees agreed to have the legislation amend the criminal code rather than the Public Health Service Act. In April, the Supreme Court heard oral arguments in a Florida case, Madsen v. Women's Health Center Inc., which involves a state court injunction placing a 36-foot buffer zone around an abortion clinic within which anti-abortion demonstrators are forbidden to protest. The injunction also prohibits anti-abortion demonstrators from approaching women entering the clinic within a 300-foot buffer zone unless the woman invites discussion. The Court will decide whether buffer zones around clinics and health care workers' homes violate the First Amendment's protection of freedom of speech and association. Because it is more narrowly drawn than the Florida injunction (barring the use of force or physical obstruction) the Freedom of Access to Clinic Entrances Act is not expected to be overturned by a future Supreme Court's ruling on Madsen. Nevertheless, the House and Senate conference committee added a "severability clause" to the legislation so that if any one component of the law is found to be unconstitutional, the remaining provisions will still be enforceable. Guaranteed Health Benefits for Women and Children Expanded The House Education and Labor Subcommittee on Labor-Management Relations began its mark-up of the President's health care reform bill, H.R. 3600, on April 21. Five weeks later on May 25, the subcommittee approved a modified version of President Clinton's plan drafted by Subcommittee Chair Pat Williams. On a strict party-line vote of 17-10, Members endorsed the Williams bill which would give states flexibility to establish either mandatory or voluntary insurance purchasing cooperatives, or no cooperatives at all. Greater premium subsidies for small businesses and low income workers would also be provided. As identified by Chair Williams in his opening statement, one of the main changes in the bill is enhanced health services for women. The proposed benefit package includes mammograms every two years for women aged 40-49, annual mammograms for women over age 50, and annual clinical breast exams for all women. The bill would also expand coverage of pap smears and pelvic examinations to annual visits for women of childbearing age. All of these services would be covered without deductibles or co-payments. Family planning benefits are also improved. Visits would be covered at no cost to the patient, and contraceptives would be provided without charge for families with incomes under 200 percent of poverty. Women would be guaranteed access to obstetrician- gynecologists without a referral by a primary physician. Some children's health needs are also addressed more fully in the bill approved by the subcommittee. Outpatient rehabilitation services would be expanded to include coverage of chronic and congenital conditions rather than just those due to injury or illness. Coverage for hearing aids for children was also added. In addition, the provision of "wrap around benefits" or supplemental benefits that would be provided to the Medicaid-eligible population was expanded to cover children of families below 200 percent of poverty. Other benefits for women and children remain the same as in the President's bill. During subcommittee consideration on May 4, Members approved by voice vote an amendment offered by Rep. Donald Payne to extend Medicaid "wrap around benefits" to pregnant and post-partum women up to 185 percent of the federal poverty level. Currently, Medicaid pays for enhanced services such as nutritional counseling, transportation to medical appointments, and home visits for eligible women. The President's bill would eliminate these benefits for women who receive Medicaid but who do not receive the cash benefits of Aid to Families with Dependent Children (AFDC) or Supplemental Security Income (SSI). "This amendment would address the gap in coverage for the people who most need it -- non-cash assistance population of pregnant and post-partum women -- and shore up services for people that require additional support," explained Rep. Payne. On May 18, committee members approved an amendment, offered by Rep. Jolene Unsoeld, to expand the basic benefits package to include smoking cessation classes for pregnant women. Subcommittee members rejected two attempts by Rep. Major Owens to enhance provisions for the poor. One amendment which would have reduced co-payments for those earning less than 150 percent of the federal poverty level was defeated by a vote of 12-15. Members rejected, 12-14, a second amendment which would have provided additional benefits to those under 150 percent of poverty while increasing premiums for the remainder of the population. Senate Labor and Human Resources Committee The Senate Labor and Human Resources Committee began its consideration of health care reform legislation on May 18. The draft bill proposed by Committee Chair Edward Kennedy, S. 1757, modifies the President's bill by diminishing the role of insurance purchasing alliances and including an expanded basic benefit package. Like the President's legislation, the Kennedy bill requires that employers pay 80 percent of their employees' insurance premiums. However, individuals and businesses with up to 1,000 workers would have three options to buy health insurance: from a state- wide purchasing alliance, from private insurance companies, or from the current Federal Employees Health Benefits Plan. The proposed guaranteed benefit package expands on the President's version to include improved benefits for low-income families, women, children, the disabled, and those needing mental health and substance abuse treatment. Women over 50 would receive annual mammograms with women aged 40-49 eligible every two years. The legislation also authorizes $7.9 billion in additional funding for research on women's health including heart disease, breast cancer, and osteoporosis. Co-payments are reduced to $2 for individuals below the poverty level and to $4 for individuals whose incomes are below 200 percent of the federal poverty level. In addition, co-payments and deductibles would be eliminated for family planning services. The Kennedy proposal would have provided $150 million in FY97 for specified services at school-based health clinics. On May 26, the committee unanimously approved a compromise amendment on school-based clinics, offered by Chair Edward Kennedy and ranking Sen. Nancy Kassebaum, to strip out specific mention of pregnancy prevention programs and screening for sexually transmitted diseases. However, proponents argued that these services could still be provided under general prevention and health screening programs. Parental and community involvement in clinic planning is required. The amendment cut funds for school-based clinic grants to $100 millon and would allow elementary schools to receive grant funds.