Health Care Reform and Abortion

So what's the deal with this Stupak amendment? Is it just political theater? Should it make pro-life people favor health care reform, as long as it includes Stupak language?

Assume that health care reform + public option + Stupak language passes. Therefore anyone who buys insurance through the exchanges, and gets a government subsidy to do so, is forbidden from buying a plan that covers abortion.

Some have argued this will reduce the abortion rate. Is this true? If so, how much? Here are some (potentially) relevant facts:

• According to a recent study on abortion demographics, 75% of abortions are obtained by women at or below 300% of the poverty line ($44,000), meaning that this group accounts for roughly 1 of the 1.3 million abortions that occur in America each year.
  
  
• This level of income is the roughly the same level that at which people will qualify for assistance in the reform plans that congress is considering
  
  
• According to census.gov, there are about 85 million women who make at or below $44,000 per year
  
  
• According to the CBO, around 6 million people (3 million women?) are likely to use federal assistance for health care
  
  
• Also accourding to the CBO another 12 million are likely to get health insurance through the exchanges, but not get federal assistance

Keeping those numbers in mind, I have heard some people arguing that by getting lower-income people into an exchange plan, you make them pay out of pocket for abortions instead of having it covered by insurance, and that this should make the abortion rate go way down amongst the group most likely to get abortions. Three million of the 85 million women (4%), a group whose rate accounts for 75% of abortions. So this group should account for about 1.3 million x 0.75 x 0.04 = 39,000 abortions. Not a trivial number of lives to save each year, if you hold the pro-life position. Now surely, some people would still pay out of pocket. But how many?

Actually, unless I am stupidly missing something, 100% of these people would be willing to pay out of pocket - because they already are! By definition, these lower-income people who will get insurance through the exchanges were without health insurance in the first place. So these people aren't losing abortion coverage...they never had it in the first place! So in terms of direct effects, Stupak would be unlikely to have any direct effect on the abortion rate.

But I can imagine several, more indirect ways in which Stupak langauge could have an effect on the abortion rate:

1. Insurance companies on the exchanges might find it laborious or inefficient to offer both types of plans (one that covers abortion, one that does not), and to enforce it such that the right people buy the right ones and don't cheat the plan. Since they MUST offer the no-abortion plan, they just decide to offer only no-abortion plans. As a consequence, now the vastly larger number of people who buy insurance through the exchanges can no longer buy coverage that includes abortion. That would make the pool of people paying out of pocket for abortion go up. But again, how many of these people would have had insurance covering abortion in the first place. Many of these people are also uninsured, or buying bare-bones plans which also do not cover abortion, due to the current high cost of being self-insured. So its debatable whether this, even if it did come to pass, would affect the abortion rate.
   
   
2. One issue which could decisively affect the abortion rate is: what will people do when they have a choice between the exchange an employer-based plan. Say they start off in the exchange, then get a job that offers them insurance, but for whatever reason elect to stay with their exchange-based plan. These are truly people who are opting for a plan that doesnt cover abortion over one that would. I doubt many would consciously factor this into their decision, but many would just decide to stay with the plan they know rather than switch.
   
   
3. Lastly, one conservative concern is that the the public option will become "popular" (due to unfair competition) and grow to become a bigger and bigger percentage of the market. Employers will stop offering insurance, insurance companies won't be able to compete and will go out of business, etc. To the extent that this is true, this will force people into plans that do not cover abortion. So in one sense, the small government advocate's nightmare (a gradual move toward a single payer system), could end up resulting in a case where everyone who wants an abortion must purchase it out of pocket. That would be an interesting case of "unintended consequences"...