fundamentalist groups are likely to organize and campaign militantly for the supremacy of their positions.

Religious and moral considerations aside, policymakers have been faced with very concrete issues demanding immediate and practical decisions. For example, under Medicaid (Title XIX of the Social Security Act [SSA]) the federal government reimburses the states for a portion of their expenditures for "necessary medical services" on behalf of the eligible population. Abortions and sterilizations, if they are deemed necessary by the attending physician, could therefore be paid for routinely by the states and reimbursement could be claimed from the federal government. As the use of contraceptive sterilization increased among the general population, its popularity also rose among Medicaid recipients, and demand for the procedure grew.1 Abortions began to be reimbursed after a dozen states legalized abortion or reformed their abortion laws between 1967 and 1973; claims also increased after the U.S. Supreme Court decision of 1973. At the same time, Congress adopted amendments to the SSA in 1972 that specifically required the states to provide "family planning services and supplies" to all Medicaid recipients desiring these services, including "minors who can be considered sexually active." To encourage the states to do so, Congress also provided a preferential federal matching rate to the states of 90 percent. In June 1973, a few months after the landmark Supreme Court decision legalizing abortion throughout the United States, the U.S. Department of Health, Education and Welfare (now the U.S. Department of Health and Human Services) published a set of regulations intended to implement the 1972 SSA amendments. These regulations described the purpose of family

1  

The debate over sterilization that took place in the 1970s did not focus on its legitimacy as a method of birth control, but rather on its potential for coercion and its actual coercive use among minority or low-income women. Although the overall rate of contraceptive sterilization is not substantially different among the poor than among the more affluent population, it is heavily skewed by age and sex. Among the poor and minorities, among whom the use of vasectomy is minimal, virtually all contraceptive sterilizations are undergone by women. Also, sterilizations tend to take place at relatively young ages among women who start childbearing early and often experience repeated unintended pregnancies. Thus, thorough counseling as to the permanent nature of the procedure is particularly important for this group of women who may come to regret their decision if they experience a change in circumstances later in life or a change of heart. However, in some instances, counseling has clearly been perfunctory, offered, for example, during the throes of childbirth. There have even been reported instances of operations performed without the consent or knowledge of the patient. In 1978, to prevent such abuses, federal regulations were promulgated that require documentation of full informed consent and a waiting period of 30 days between the time that the patient's consent is obtained and the surgery is actually performed.



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