Policy Analysis of the C.A.R.E. Act: H.B. 1914 (2010)

Modified: 06/03/2010

(Sponsor: Oxford)

When Missourians learned in 2006-2007 that rape victims in their state were being forced to pay for their own rape kits (sometimes up to $1,500), the outcry was forceful enough that the government acted. The legislature passed a bill requiring the Department of Health and Senior Services to pay for the forensic portion of the rape kit and Governor Matt Blunt issued Executive Order 08-04 to the same end. What was not clear at the time was that the administration only gave citizens half of what they were asking for – while the Department of Health did take up payment for the evidence-collection portion of the rape kit, the medical portion is still unfunded and therefore left to the whim of individual hospitals. This oversight means that there is no statewide mandatory protocol for STI and pregnancy prophylactic treatment.

Emergency contraception, also called EC or “the morning-after pill,” is the preferred method of pregnancy prophylaxis and is 75-89% effective when used within 120 hours after intercourse.[1] EC is not an abortifacient. It is simply a concentrated dose of regular birth control pills which cannot terminate a pregnancy or harm a fetus. Almost all hospital emergency rooms offer forensic rape examinations and medical treatment for victims of rape and sexual assault. Many hospitals have S.A.N.E. (Sexual Assault Nurse Examiner) programs, meaning that some or all of their nurses are specially trained to administer the rape kit and to respond sensitively to rape victims.

In Missouri, less than half of hospitals provide EC onsite in the emergency room to victims of rape and sexual assault. Of those hospitals that do not provide EC onsite, 43% also do not provide solid and consistent referrals to a place where the victim may obtain the medication. In 2008, there were 1,605 forcible rape incidences reported to Missouri law enforcement.[2] The U.S. Department of Justice estimates that over 60% of rapes are never reported to the police.[3] Based on those statistics, one could assume that over half of the potential 3,370 rape victims in Missouri last year were not provided with the option of preventing an unwanted pregnancy. When a woman is raped, pregnancy becomes a medical risk. Responsible medical providers are expected to inform patients of all risks and to recommend treatment based on possible outcomes. Rape victims should expect the same protocol to be applied to them.

Though victims of rape and sexual assault react in extremely diverse ways, most will experience some of the following reactions to varying degrees: anxiety, depression, apathy, flashbacks, hypervigilance, social withdrawal, hypersexuality, helplessness, mood swings, etc.[4] Many victims develop Post Traumatic Stress Disorder. The American Medical Association, the American College of Obstetricians and Gynecologists, the American College of Emergency Physicians, among other medical societies, recommend that EC be offered to all sexual assault victims, citing the victim's psychological health as one of the principal reasons.[5] All of these organizations recognize that emergency contraceptive treatment should be part of basic, compassionate care for rape victims. For most medical professionals and organizations, withholding information that could allow a rape victim to avoid becoming pregnant by her assailant is not even an option.

Not surprisingly, Missouri voters strongly support EC access for rape survivors. In fact, 82% of Missourians support EC in the ER, and 57% say the issue is very important to them. [6] This same sample of people self-identifies as only 49% pro-choice, clearly demonstrating that the average voter does not see EC for rape survivors as connected to abortion.[7] Sixteen states and the District of Columbia already have state laws on the books that require hospitals to dispense emergency contraception to all rape victims who want it.[8] Even some traditionally conservative states like Utah and Arkansas have state laws that mandate EC access for rape victims. Some states have exemptions for Catholic hospitals, demanding only that they provide objective information about EC to the victim. Other states, like New York, have policies that require Catholic hospitals to provide transportation and assistance to the victim should she want EC.

The Compassionate Assistance for Rape Emergencies (C.A.R.E.) Act, H.B. 1914, offers a reasonable and effective solution to Missouri's lack of EC access for rape survivors. The C.A.R.E. Act requires that hospitals do the following: (1) provide every sexual assault victim with medically accurate information about EC; (2) orally inform every sexual assault victim of her right to be provided EC at the hospital; (3) immediately provide the complete regimen of EC at the health facility if the victim requests it; and (4) follow the Department of Justice protocols for HIV/STI prophylactic treatment. The goal of these regulations is to ensure that no sexual assault victim suffers more than she already will due to out-of-date hospital policies that deny access to relevant medical information.

The C.A.R.E. Act offers sensible solutions that are reflective of standard medical protocol for other emergencies. It is reasonable to expect that hospitals will provide “medically accurate” information to patients, regardless of the topic. Rather than infusing EC discussions with “moral” judgments and religious views, health professionals should be prepared to discuss the medication objectively, delivering “moral” decisions into the hands of the patient. Notably, nothing in the statute prohibits doctors or nurses who object to the policy from finding other health professionals on duty that will complete the necessary tasks in a timely manner.

Finally, the C.A.R.E. Act makes sensible adjustments to geographic healthcare disparities. Though hospitals that do not provide EC onsite are scattered around the state, nearly half of them are clustered in the deep southern portion of Missouri. The C.A.R.E. Act makes the standard of care consistent across the state, guaranteeing that rape victims in rural Missouri and rape victims in suburban St. Louis will have equal access to quality sexual assault care.

The C.A.R.E. Act is smart public policy that ensures fair and consistent treatment for victims of sexual assault in Missouri, allowing them to take their futures into their own hands rather than having nurses and doctors make those decisions for them. Each year, 25,000 women become pregnant as a result of rape – if all of those women had prompt access to EC after the assault, we could lower that number to 3,000.[9] The savings to the health system of averting all those unwanted pregnancies could be enormous.[10] The C.A.R.E. Act is a commonsense way to provide women with good healthcare while also reducing the number of abortions. Not only would the C.A.R.E. Act bring Missouri in line with national recommendations for best practices when treating sexual assault victims, but it would also set a statewide standard for treating rape victims with compassion and recognizing their autonomy.

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©NARAL Pro-Choice Missouri