“Religion” and “reason.” I never imagined that these two words would become central to my everyday clinical practice as an OB-GYN. Yet day in and day out, I am constantly thinking about how these two concepts affect my patients’ lives and their health care—especially during “National Women’s Health Week,” which the U.S. Department of Health and Human Services (HHS) has been celebrating since May 13. This, despite the fact that because of Trump’s HHS, women’s health, and reproductive health in general, is increasingly under siege.

A woman whom I’ll call Alice came to see me at 18 weeks’ gestation for an abortion. After years of emotional abuse which had recently turned to physical violence, she knew that it was time to leave her relationship. Ending this pregnancy, to her, was the way out.

Alice used Medicaid for her insurance coverage. At the time, in the state of Illinois, Medicaid would only cover her abortion care for three very particular reasons: if the pregnancy was a result of rape or incest, or if, in my professional medical opinion, the abortion was necessary to protect her life.

Unfortunately, many diagnoses don’t fit into these categories: fetal anomalies, maternal heart failure, or severe anemia are just a few reasons that have been denied by Medicaid. This, all despite the fact that the risk of death associated with childbirth is known to be 14 times higher than with legal induced abortion. No matter someone’s life circumstances, no matter where they live or why they want to access this care, they should be able to get their abortion care when they need it, where they need it, and at a price they can afford.

I argued with the medical director of her insurance provider that the reason for Alice’s abortion was in fact to potentially save her life, given the escalating physical violence in her relationship. He robotically ran through the list of required checkbox questions.

Ultimately, he denied her coverage because it did not fit neatly into one of these three categories.

Without insurance coverage, the cost of the procedure was out of Alice’s reach. She left that day to try to gather up enough money from her friends and family to pay for the procedure. The next time I saw her was in the emergency department, 35 weeks pregnant, covered in bruises and clearly broken. I, too, felt broken. Our safety net and system to care for those at their most vulnerable had failed this patient.

I wish I could say this was the first and last time something like this happened. Unfortunately, the very next day, Maria (also a pseudonym) presented at 22 weeks for an abortion. The pregnancy was a result of rape. Her emotions surrounding the pregnancy were extremely complex, as she desperately wanted to have a child, but felt guilt, shame, and isolation after the assault. She initially decided that she would continue the pregnancy, thinking it would help her grieving process to grasp onto something positive after such an unimaginable and traumatic experience. But after her anatomy scan at 20 weeks, she was devastated to learn that the fetus had multiple anomalies. Ultimately, she decided to end the pregnancy.

Given her circumstance, I had no doubt that her insurance company would cover her care. I was wrong. The abortion coverage was denied because the insurance company was owned by a religiously affiliated organization.

These stories are heartbreaking and too common. I fear that they will only multiply as reproductive freedom faces the Trump administration’s new definition of religious freedom. Under the Trump administration, the priorities of HHS have clearly shifted: A draft strategic plan for fiscal years 2018-2022 stated that the agency will be “serving and protecting Americans at every stage of life, beginning at conception.” This guideline could encourage insurance providers, hospitals, doctors, nurses, and other individuals and institutions to deny a patient standard medical care based on their personal beliefs, not based on what is best for the patient.

Thankfully, in Illinois, proactive legislation was passed that helps to safeguard a person’s right to choose. HB 40, passed in 2017 and enacted in January 2018, provides state health insurance and Medicaid coverage for abortions. I have seen firsthand over the past five months how dramatically this legislation affects patients’ lives and their health. Now, a woman who is enrolled in Medicaid in Illinois can make the most personal of decisions no matter what reason she is deciding to do so.  

While this is a huge step in the right direction, it does not help patients who have insurance coverage that is administered through religiously affiliated organizations or otherwise does not cover abortion, or those who live in states that restrict coverage. The Hyde Amendment, of course, also restricts federal funding of abortion care, affecting veterans, those who use the Indian Health Service, and others. Beyond issues of insurance coverage, there are also countless people around the country who can’t access abortion care because of their state’s specific restrictions or other issues.

I have the honor to care for patients throughout their lives, through happy events, difficult experiences, and complex decisions. I am especially honored to care for people through their decision-making process surrounding whether or not to parent. For some, the decision to end a pregnancy is clear. For others, the decision is ambiguous or difficult. The point is that no matter the circumstance or the reason, it is their decision to make. My job is to provide compassionate and competent care for that person no matter what they choose or why they choose it.

Religion and a patient’s reason should not determine their access to abortion care.