Dropping the ‘A’ Bomb

This expanded federal oversight and use of federal dollars raises several thorny issues: will plans offered through a federally regulated exchange be required to include covering abortion as a standard benefit, or will they be prohibited from offering abortion coverage? Will patients in a public plan or who buy private insurance with federal subsidies have coverage for abortion, or would they have to use their own funds so taxpayers won't feel they are subsidizing abortion? Will doctors and hospitals receiving federal dollars be required or prohibited from offering abortion? And will religious organizations and individuals—from Roman Catholic hospitals to employee health plans purchased by churches to a pro-life doctor—be able to opt out of paying for or facilitating an abortion?

Both abortion-rights advocates and abortion opponents claim they are not seeking changes to the status quo. President Obama promised those who had coverage they likely would not lose it under a reform package, so abortion-rights groups claim coverage for abortion should continue to be widely available. The other side points out that federal dollars only cover abortion in limited circumstances, and they believe new federal health-care dollars should not cover abortion beyond Medicaid's restrictions.

The health-care-reform plan President Clinton put forward in 1993 did specify that services for pregnant women would be covered, which was meant to include abortion without spelling it out. The legislation also included a so-called "conscience clause" to allow doctors to opt out of performing the procedure, provided they referred patients to another provider.

Unlike the Clinton plan, the two versions of a reform bill currently on the table—one from the House and another from the Senate's Health Committee—do not list covered benefits, and that could make it easier to finesse the abortion issue. They leave coverage decisions up to an independent commission or the Department of Health and Human Services. On the other hand, this could increase pressure from pro-life groups because they believe, according to Tony Perkins of the pro-life Family Research Council, that "if a specific prohibition [on covering abortion] is not included in the health-care plan, then abortion is in this plan." While such a provision might win support from Republicans and pro-life Democrats, a survey by the National Women's Law Center found ruling out coverage for abortion and other family-planning services would be opposed by 62 percent of Americans.

Sources involved in drafting President Clinton's reform package in 1993—who were speaking on background because they currently hold politically sensitive jobs—implied they would have considered themselves lucky if abortion had been the factor that derailed their effort instead of popular revolt over the plan's very structure. "We were worried abortion would blow thing up," one said, "but we cratered before that could happen."

With Congress closer to a reform package than ever before, there's a chance lawmakers may get the chance to test how explosive these abortion questions will be. But if they get stuck tangling over an issue that the Republican negotiator says is "not compromisable," these summer's negotiations are going to be even longer than was feared.

© 2009