Abortion and Health Care Reform

Abortion has been a part of human existence since human beings first took their place on earth. There have always been women who needed to end pregnancies, for uncountable reasons — and there always will be. Moreover, abortions have not always and in all places been illegal. As Jeffrey Toobin points out in a very trenchant comment published in The New Yorker (and this is something I’ve known for years), abortion in this country — both in colonial times and after the formation of the United States — was perfectly legal and widely available until about the middle of the nineteenth century, when the medical field started to become institutionalized, and doctors began to feel the need to protect their professional investment from the informal network of providers (mostly women, many of whom were midwives) who had done the procedure up until that time. States began to pass anti-abortion laws, and by the start of the last century, abortion had been criminalized pretty much everywhere in the United States.

Which is, of course, not to say that women no longer had abortions. And so it will remain, regardless of what happens with the law. But the same cannot be said about insurance coverage for abortions. In the remainder of his piece, Toobin addresses this point, and the larger issue of this one specific medical procedure that, in varying ways throughout U.S. history, has been treated as if it somehow had nothing to do with health care:

Throughout this long legal history, the one constant has been that women have continued to have abortions. The rate has declined slightly in recent years, but, according to the Guttmacher Institute, thirty-five per cent of all women of reproductive age in America today will have had an abortion by the time they are forty-five. It might be assumed that such a common procedure would be included in a nation’s plan to protect the health of its citizens. In fact, the story of abortion during the past decade has been its separation from other medical services available to women. Abortion, as the academics like to say, is being marginalized.

Toobin then turns his attention to the Stupak amendment, and its implications for abortion coverage for all women, not just poor ones:

A clear understanding of the structure of the health-care proposals currently under consideration shows why the Stupak amendment is such a threat to abortion rights. At the heart of the proposals is the idea of an exchange, where consumers will be able to select among competing insurance plans. Theoretically, the exchange will increase consumer choice, promote competition, and (somewhat more theoretically) lower costs for everyone. If there is a public option, it will be offered through the exchange. At first, many of the people using the exchange will be those who are unable to pay for health insurance on their own. For them, the government will offer a sliding scale of subsidies. It is largely these subsidies which will increase the availability of insurance; estimates of how many people will gain coverage vary, but it may be close to forty million.

Restrictions on the use of federal funds for abortion go back to the Hyde amendment, which became law more than thirty years ago; for example, there has long been a ban on abortions under Medicaid or in military hospitals. But the implications of the Stupak amendment are broader, because of the structure of the exchange. To start with, Stupak states that anyone who buys insurance with a government subsidy cannot choose a plan that covers abortion, even if that person receives only a small subsidy, and even if only a tiny portion of the full premium goes for abortion care. And the influence of the amendment reaches beyond the recipients of federal subsidies. Stupak would prohibit the public option from offering any plans that cover abortion. Further, it is expected that each year more Americans will use the exchange, including people who don’t need subsidies, but under the Stupak amendment insurance companies would have no incentive to offer those people coverage for abortion services, since doing so might cost them the business of subsidized customers. Today, most policies cover abortion; in a post-Stupak world, they probably won’t. With a health-care plan that is supposed to increase access and lower costs, the opposite would be true with respect to abortion. And that, of course, is what legislators like Stupak want—to make abortions harder, and more expensive, to obtain. Stupak and his allies were willing to kill the whole bill to get their way; the liberals in the House were not.