Aborting Health Reform

In September 1993, as Hillary Clinton lobbied Congress to pass her health-reform bill, she plainly addressed the looming controversy over reproductive care. "It will include pregnancy-related services, and that will include abortion, as insurance policies currently do," she told the Senate Finance Committee. Conservatives were incensed. But as the history books record, it was industry pressure and legislative malaise that killed Hillarycare, not debate over women's rights.

On the campaign trail, Barack Obama did not shy away from the issue of abortion, pledging, "On this fundamental issue, I will not yield." In the context of health reform, though, the president and his staff have been reluctant to directly address reproductive rights. In a March interview with the Christian Broadcasting Network's David Brody, the White House's chief domestic policy adviser, Melody Barnes -- who once sat on the board of Planned Parenthood -- claimed she had never spoken to the president about whether abortion services should be covered under a universal health-care system. "We haven't proposed a specific benefits package or a particular health-care proposal, so we're going to be engaging with Congress to have this conversation," she said. When Office of Management and Budget Director Peter Orszag was asked by Fox News in July whether the public insurance plan should cover abortion, he was vague. "I'm not prepared to rule it out," he said. The president finally addressed the issue himself in a July 21 interview with Katie Couric, in which he bucked reproductive rights groups by saying he would consider deferring to the "tradition" of "not financing abortions as part of government-funded health care."

Perhaps in response to the failure of the Clintons' highly detailed plan, Obama's strategy has been to leave the nuts and bolts of health reform up to the legislative branch, saying only that the resulting bill must fulfill three goals: lower costs, provide Americans with more health choices, and assure quality. That lack of detail has shoved Congress deep into the weeds. Predictably, the president's vagueness hasn't prevented anti-choicers from seizing upon the possible inclusion of reproductive-health services as a vehicle to activate their base against reform. "A vote for this legislation, as drafted, is a vote for tax-subsidized abortion on demand," wrote Douglas Johnson, the National Right to Life Committee legislative director, in a letter to Congress. That message penetrated. At a July 14 press conference, Rep. Joe Pitts, a Republican from Pennsylvania, claimed health reform undermined Americans' "right to life. Let's make it explicit that no American should be forced to finance abortions." As the health-care debate reached a fever pitch in the weeks before Congress' summer recess, Fox News featured daily segments on the threat of "subsidized abortion."

Meanwhile, Obama declared in his July 18 radio address that he would not sign any reform bill that did not include a public health-insurance program. A public plan is central to progressives' goals of lowering costs by giving private insurers real, high-quality competition. A government-funded insurance option might, eventually, serve as the shell for a single-payer health-care system similar to those of Western Europe. But if Congress acquiesces to abortion opponents and passes a public plan that does not provide reproductive-health services comparable to what Americans can purchase in the private market or obtain through their employer, it will be a weaker plan with a smaller constituency. After all, the typical woman spends five years of her life pregnant, or trying to become so, but a full 30 years avoiding pregnancy. Without good reproductive-health coverage and strong buy-in from women -- who use more health care than men -- it is difficult to see how a public plan would gain strength over time.

Contrary to conservative hand-wringing, reproductive rights have been under constant assault in the health-reform debate. At stake is not only whether a potential public plan covers contraception or abortion but also whether existing private health insurers, 87 percent of which currently offer some abortion access, will be able to continue to do so once they are operating within the new health-insurance exchanges. The exchanges will house both public and private plans after reform and will be regulated by the federal government.

This increased government intervention in the health sector both excites and terrifies advocates for better reproductive care. The potential upside is that through a public plan, an expansion of Medicaid, and more competition among private insurers, many more women will be able to afford good reproductive health care. But the potential downside is stark: A politicization of which reproductive-health services insurers can cover, meaning that under anti-choice administrations, abortion and even contraceptive limitations or bans could become the norm.

For millions of American women, insurance-subsidized abortion is already off limits. After Roe v. Wade legalized abortion in 1973, one of the religious right's first successes in limiting access to the procedure was the passage of the Hyde Amendment. Since 1976, Hyde has banned Medicaid -- the federal health-insurance program for poor women and children -- from paying for abortions, except in the most extreme cases when a woman's physical health or life is in danger. Medicaid covers 7 million American women of reproductive age, or 12 percent of women in that cohort. Federal employees, members of the U.S. military, Peace Corps volunteers, and prisoners are also barred from using their government health coverage to access abortion.

During a July 14 interview on MSNBC, Sen. Chuck Grassley, the ranking Republican on the Senate Finance Committee, contended that when it comes to abortion and health reform, "what we're trying to do is maintain current policy." Yet because any potential public health plan would be funded by the federal government, what anti-choicers would really like to ensure is that Hyde would also apply to any new public insurance programs.

That isn't likely to sit well with the public. Though past polls have shown Americans are resistant to the concept of "taxpayer-funded abortions," the public seems to see health reform under a different light. According to a poll by the Mellman Group on behalf of the National Women's Law Center, 71 percent of Americans support coverage for reproductive health, including contraception, under a public plan. Sixty-six percent support coverage for abortion in a public plan.

None of the health-reform proposals being considered by Congress explicitly threaten Hyde or the other existing federal bans on abortion funding. In fact, reproductive-health-care advocates reluctantly admit that the repeal of Hyde, although a long-term priority, is not on their current agenda. After all, some Democrats, including Vice President Joe Biden, have a history of support for the ban. "Hyde is discriminatory against poor women, and we'd like to see it overturned," says Adam Sonfield, a senior policy associate at the Guttmacher Institute. "But it does not seem to be a political priority right now."

To protect against disruptions in American women's access to reproductive medicine, advocacy groups are recommending that an independent council of medical experts -- not a political appointee -- define which services will be covered by insurance plans participating in the exchanges. Such a commission would likely argue for the inclusion of abortion and contraceptive services. Though politically volatile, family planning is rather uncontroversial in the insurance industry and among public-health experts. For every $1 spent on public family-planning services, the government saves $4.02. The public sector alone saves $4.3 billion in medical costs each year thanks to the family-planning coverage the federal government already provides poor women through Medicaid and Title X. That's because birth control and abortion are simply much less costly than pregnancy.

The final health-reform bill will likely establish a council of experts to advise the health and human services secretary on what benefits should be covered. But in both the House and Senate proposals, the council's power is limited; it is still the HHS secretary who makes the final call. This means that under anti-choice administrations, abortion and contraceptive access could be threatened within the health-insurance exchanges. "The potential there is that many, many women could lose the coverage they presently have," said NARAL: Pro-Choice America President Nancy Keenan in July, as hundreds of Senate amendments were being filed on health reform, many of them seeking to prevent abortion coverage.

Another risk is that even if abortion services are covered, health clinics that provide abortion -- such as the Planned Parenthood network -- could be barred from participating in the exchange, meaning they would not be able to offer insured services to patients in either public or private plans. An amendment to the Senate Health, Education, Labor, and Pensions (HELP) bill from Barbara Mikulski, a Democrat from Maryland, would protect the status of clinics, but it attracted opposition even from some Democrats, such as Sen. Bob Casey of Pennsylvania, who identifies as pro-life.

For many congressional Republicans -- and some of the 19 moderate House Democrats who joined their cause -- fanning the flames of the abortion debate is, at least in part, a tactic for delaying reform. To be fair, some family planning opponents do support the broader goal of universal health care -- the Catholic Church chief among them. But according to Marilyn Keefe, director of reproductive-health programs at the National Partnership for Women and Families, "The pressure [on reproductive rights] largely comes from people who don't support the larger health-reform effort."

Advocates were able to ensure that both the House tri -- committee bill and the Senate HELP bill made it through committee without any amendments limiting access to reproductive care. But as Tina Tchen, director of the White House Office of Public Engagement, told a July 15 Planned Parenthood conference -- perhaps in an effort to tamp down expectations -- "That was not easy. It was not easy in committee. It won't be easy to hold on the House floor. It won't be easy to hold on the Senate floor."

Women's organizations find themselves in the strange position of playing defense, even as a pro-choice president sits in the White House and both houses of Congress have pro-choice majorities. "Depending on some of the things that are being proposed, we could be worse off" after health reform than before it, Planned Parenthood President Cecile Richards said at the conference. "That is untenable. Those are some of the tough conversations we're having, frankly, with the White House and Congress. We can't be worse off."

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