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Health-care reform and abortion coverage: Questions and answers
House amendment includes restrictions, heats up debate

By Alec MacGillis
Washington Post Staff Writer
Sunday, November 15, 2009

After the House passed its health-care bill last weekend, debate exploded over an amendment by Reps. Bart Stupak (D-Mich.) and Joe Pitts (R-Pa.) that restricts abortion coverage.

Confusion was rampant all week, but on this both sides agree: The debate reflects the conflict between the rule banning federal funding for abortions and the expansion of the government's role in health care. Universal health care is a Democratic and liberal goal, but as long as the ban stands, increasing government support for those who lack insurance likely means more restricted coverage for abortions.

Richard Doerflinger of the U.S. Conference of Catholic Bishops has been trying to explain this irony to religious conservatives who worry "that when the federal government takes over health care, it'll be pro-death." In fact, he said, "When you expand the reach of federal funds, you expand the reach of federal policies" on abortion.

Here are answers to some questions about the amendment.

1. What is the status quo? Under the 33-year-old federal ban, there is no abortion coverage under Medicaid, the federal employee health benefits plan or the Tricare plan for military families, except where the life of the mother is endangered. Seventeen states use their own funds to provide abortion coverage for Medicaid recipients. A study co-authored by the Guttmacher Institute, which backs abortion rights, found that one in four women who would other get an abortion carry an unwanted pregnancy to term if they lack abortion coverage.

Abortion coverage is widespread among private insurance plans -- at least half of people with private coverage have abortion coverage, according to surveys by Guttmacher and the Kaiser Family Foundation. Guttmacher found that only 13 percent of abortions are billed directly to a private insurer, though many women bill their insurers separately. An abortion at 10 weeks costs $400, though it can be far more costly later on.

2. What does Stupak-Pitts say? Under the House bill, people without employer-provided coverage and small businesses would choose among private insurance plans and a government insurance plan, or "public option," offered in a new marketplace, or "exchange." As initially written, these plans would pay for abortions out of people's premiums, and not with any subsidies that would be extended to families who earn up to $88,000 annually.

Abortion rights opponents derided this as an accounting gimmick, and turned to Stupak-Pitts. It decrees that abortion may not be covered in the public option or in any of the exchange's private plans that take the subsidized customers. There is an exception if a woman's life is in danger or in cases of rape or incest.

Private plans could offer abortion coverage to those without subsidies, but that will be a small subset of the 30 million people expected in the exchange. Women could also buy a "rider" for abortion coverage, as is now done in a few states where employer-based plans are not allowed to cover abortion. Abortion rights supporters say relying on such riders is unrealistic and offensive, given that few women expect to have an abortion.

3. What does it mean for women? For women who do not have health insurance, gaining subsidized coverage will mean they will be much better off overall, while still lacking abortion coverage. But there are many women who now have coverage on the individual market that is overpriced and low-quality but does cover abortion. Their subsidized coverage under the legislation will be superior in general, but they will lose their abortion coverage, unless they buy a rider. Abortion opponents note this outcome is no different than when Democrats now push to expand Medicaid in the 33 states without abortion coverage.

The impact is less clear for women buying coverage on the exchange without subsidies. This will include higher-income women and those working for small businesses, who likely will not qualify for subsidies since their employers will be helping pay. For these women, the availability of a plan covering abortion will depend on whether insurers decide to offer a plan that is open to only some people and differs from other plans only in covering abortion -- not the easiest distinction to market.

Such a plan could also upset the balance envisioned for the exchange, with costs shared across plans; the plan would draw members unlike any other -- wealthier and with more women of child-bearing age.

Some higher-income women may choose to go without abortion coverage, on the assumption that they could pay for it out of pocket. But they could then find themselves facing the high cost of an abortion with complications.

4. Are there broader implications? Abortion rights advocates worry abortion foes will apply the amendment to other federal funds in the bill, such as tax credits for small businesses or subsidies for companies with early-retiree plans. But the amendment's supporters say this is not their intent. Abortion rights advocates also worry that as insurers introduce plans on the exchange without abortion coverage, they will for convenience's sake drop it from their employer-provided plans. Abortion opponents counter that insurers customize many of their plans today.

Most notably, larger businesses will eventually be able to join the exchange, and more people may come to the exchange on their own if their employers drop coverage outright. As the exchange grows in size, the abortion restrictions will apply to more people -- though the market for plans limited to the non-subsidized customers will also grow.

5. Will the amendment stick? Many Senate Democrats hope to pass language closer to the original House language, paying for abortions out of premium funds. Separating private and public funds in the exchange's plans, abortion rights supporters say, is no less an accounting scheme than the Catholic Church's segregation of federal funds it gets for school costs from its religious operations, a comparison abortion foes reject. Forty House Democrats now say they will reject a final bill with the amendment.

But at least one Senate Democrat, Nebraska's Ben Nelson, wants the amendment. And Democrats are struggling to find language that is less restrictive and yet satisfies the two dozen House Democrats who voted for the bill but want assurance that it truly upholds the federal ban.

President Obama has said he wants the bill to uphold the status quo on federal funding and abortion, but also said that he thought Stupak-Pitts went too far -- leaving him in the same bind as many fellow Democrats.

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