The law that bans federal funding for Medicaid coverage of most abortions is now in the spotlight some 40 years after it was passed by Congress, emerging as an election issue in the national debate over the procedure.
First approved in 1976, and renewed annually ever since as part of the congressional appropriations process, the Hyde Amendment makes exceptions in cases of rape or incest, or when a pregnancy endangers a women's life.
For most of its existence, the amendment had broad bipartisan support in Congress, but that's now changed. At their recent national convention, Democrats for the first time included in their platform a call for the Hyde Amendment to be repealed. Their presidential nominee, Hillary Clinton, is embracing that stance, even as it risks creating friction within the party.
The amendment's supporters depict it as essential in ensuring that taxpayers who oppose abortion do not have to subsidize it. Critics assail the policy as discriminatory, making it difficult for low-income women to obtain a legal medical procedure that's readily accessible for more affluent women.
"Access to abortion shouldn't depend on your zip code, and it shouldn't depend on your pocketbook," said Nancy Northup, president of the Center for Reproductive Rights.
For now, repeal of the Hyde Amendment is a long-term goal, not an imminent likelihood. Even if Clinton wins, Democrats would need improbably large gains in Congress to have a chance of ending the policy during her first term.
An extra complication: A handful of Democratic senators support the amendment, including Bob Casey of Pennsylvania, Joe Manchin of West Virginia and Clinton's own running mate — Tim Kaine of Virginia. Abortion-rights leaders were dismayed when Kaine reiterated his personal opposition to repeal.
"We sincerely hope that he will continue to educate himself on what Hyde means to the most vulnerable women in this country and join us in fighting this injustice," said Ilyse Hogue, president of NARAL Pro-Choice America.
In the House, Democrats have introduced a bill that would nullify the Hyde Amendment and require the federal government to ensure abortion coverage in public health insurance programs, including Medicaid. No one from the chamber's Republican majority is among the measure's 119 co-sponsors.
Despite the political obstacles, advocates of repeal are upbeat as they succeed in drawing more attention to the amendment.
"I don't think we're as far away as people might think," said Rep. Diana DeGette, D-Colo., a leading abortion-rights supporter. "We got tired of tacitly accepting that a ban on Medicaid money was acceptable."
The amendment is named after its initial sponsor, Republican Rep. Henry Hyde of Illinois, who made clear from the start that the policy would target low-income women.
"I certainly would like to prevent, if I could legally, anybody having an abortion, a rich woman, a middle-class woman or a poor woman," he told Congress in 1977. "Unfortunately, the only vehicle available is the (Medicaid) bill."
According to the Guttmacher Institute, a research group that supports abortion rights, about half of U.S. women getting abortions have family income below the federal poverty line. The typical $500 cost for a first-trimester abortion is burdensome to many of them.
Guttmacher estimates that if Hyde were repealed, the number of annual abortions among Medicaid-covered women would likely rise by about 33,000.
MEETING THE DEMAND
Yamani Hernandez, executive director of the National Network of Abortion Funds, one of the groups urging the amendment's repeal, said the network gets about 116,000 inquiries per year, and is only able to help about 30,000 women. Its abortion assistance in 2014 totaled $3.5 million.
Hernandez says women calling the network's hotline are often mothers already struggling financially to raise children who worry that bearing another child would push them deeper into poverty.
"We have to trust people's decisions," Hernandez said. "Wealthy people get to do that all the time — make the choices that are right for their families. People with lower incomes are expected to have their choices dictated to them."
ACTING BEYOND HYDE
Even with the Hyde Amendment in place, there are 15 states — acting either voluntarily or under court order — that cover a wide range of abortions for low-income women with state Medicaid funds. These states are Alaska, California, Connecticut, Hawaii, Maryland, Massachusetts, Minnesota, Montana, New Jersey, New Mexico, New York, Oregon, Vermont, Washington and West Virginia.
In Illinois and Arizona, court rulings say state Medicaid funds should cover all medically necessary abortions. However, abortion-rights activists say relatively few women in those two states end up receiving such abortion coverage.
The remaining states restrict Medicaid coverage of abortion to the limited cases allowed under the Hyde Amendment. South Dakota goes a step further, barring coverage even in cases of rape and incest.
With Congress unlikely to repeal the amendment any time soon, action is expected at the state level. In Illinois, some Democrats are pushing legislation that would expand the availability of Medicaid-covered abortions. In West Virginia, abortion-rights supporters are braced for efforts by abortion opponents to make such abortions less available.
The Susan B. Anthony List, an anti-abortion group, is mounting a door-knocking campaign in three battleground states that emphasizes Clinton's views.
The group's president, Marjorie Dannenfelser, says the repeal issue has the potential to divide Democrats, and she would like to see Republican nominee Donald Trump speak out in support of the Hyde Amendment.
"He's insane if he lets that go by the wayside," Dannenfelser said.
On the other side, abortion-rights activists are eager to maintain momentum after achieving a major victory in June when the Supreme Court struck down tough anti-abortion restrictions in Texas.
"Hyde is one of the harshest remaining barriers to abortion," said Destiny Lopez of All above All, a coalition seeking the amendment's repeal. "Young people, people of color — they understand this is about their communities unfairly bearing the brunt."