Abortion wars versus reform

DURHAM -- No issue in our culture is more difficult to reasonably discuss than abortion. Persons on different sides rarely hear anything other than their own voice. And this issue is now front and center in health reform, increasing the chance of no reform whatsoever.

Late Saturday night, the House approved the Stupak amendment, ensuring that enough moderate Democrats would vote for HR 3962, kicking the issue to the Senate and keeping the discussion alive. The amendment both codifies existing bans on the use of federal money for abortion and goes further by banning the inclusion of abortion in any private insurance policy bought with federal subsidy through the newly created health insurance exchanges.

There has been a tacit agreement between pro-choice and pro-life politicians that the status quo regarding abortion would be maintained in reform. The status quo is represented by the Hyde amendment, which prevents the use of federal money to directly fund abortion. It has been in force since 1976.

Hyde bans the use of federal Medicaid money from paying for abortions, except in pregnancies caused by rape or incest or where the life of the mother is in danger. However, 17 states pay for abortions via Medicaid by funding the procedure with state monies only. The Hyde amendment also prevents coverage of abortions by private insurance policies provided as a benefit of employment to federal employees.

The creation of insurance exchanges in HR 3962 produced new ground over which to fight the abortion wars.

The Stupak amendment passed the House by a vote of 240-194 (64 Democrats and all but one Republican voted for it) and bans any private insurance plan that covers abortion from being sold in the health insurance exchange if the purchaser receives federal subsidies. The CBO says 21 million persons would be newly insured via policies bought through exchanges by 2019, most with the help of federal subsidies based on a sliding income scale (families with incomes between $32,000 and $88,000 would get decreasing amounts of subsidy).

Deleting a Tax Subsidy from the EquationThe initial language of the bill banned outright the coverage of abortion in the public option but allowed individuals buying private policies to pay extra premiums with their own money to add abortion coverage if they wished. This is similar to what some states do in Medicaid - stating that state money, not federal dollars, pay for abortion. But opponents argued that money is fungible and any subsidy of exchange-purchased policies would have the effect of subsidizing abortion.

If this logic were applied consistently, then the practice of states claiming that state and not federal money is used for abortions in Medicaid is suspect. And the tax exclusion of employer-paid health insurance premiums - which resulted in a $250 billion subsidy of private insurance by the federal government this year alone - is an example of federal money directly subsidizing abortion because some private insurance policies cover the procedure. Of course, both of these realities have been the case for the entire history of the Hyde amendment.

How big a change would the Stupak amendment represent? Around 1 in 10 nonelderly Americans would be eligible to shop in the exchanges, and for these persons private insurance coverage of abortion might be hard to obtain. Developing a stand-alone policy that covers one procedure to be paid for by individuals may not be worth the trouble for insurers.

The amendment wouldn't alter a woman's right to receive and pay for an abortion out of pocket, the manner in which most abortions are now financed. The Guttmacher Institute reports that only 13 percent of abortions are financed by insurance of any type. Further, the Kaiser Family Foundation notes that only half of all employer-based private insurance policies in force today cover abortion (five states ban private insurance from covering abortion). So there may be little practical effect to the policy change.

However, symbolic changes often result in the greatest consternation. And the movement of abortion politics to the fore could easily scuttle reform altogether.

Donald H. Taylor Jr. is an assistant professor of public policy. His blog www.donaldhtaylorjr.blogspot.com is available for discussion of this article and health care reform in general. This is part of a series of articles by Donald Taylor exploring aspects of the health care reform issue originally published in the News & Observer