Health Insurance and Abortion

It seems often the case that a heated political debate causes people to suddenly focus on issues which had previously been essentially ignored. One recent example of this in Catholic circles has been the way in which the debate over the Stupak Amendment to the House health care reform bill suddenly focused scrutiny on the question of abortion coverage in health care insurance.

To recap briefly: From the beginning, one of the concerns that many pro-lifers had expressed about “government health care” was that it would result in government funding for abortion. As the various reform bills coalesced, it became clear that no “government health care” per se would be offered, but rather an exchange on which private health insurance plans which fit specific government-set criteria would be offered. Given this situation, pro-lifers (and in particular, pro-life Democrats, who clearly had the prime say here since Republicans were unlikely to support the bill either way since they saw its overall structure as detrimental to the common good) insisted that one of the stipulations for the private health insurance policies offered via the exchange (and qualified for government subsidy for lower and middle-income Americans) be that the plan not cover abortions.

Pro-choice Democrats of course hated this provision. Some progressive Catholics also seemed eager to explain why the bill would be just fine even without Stupak, doubtless in order to avoid a situation in which pro-life advocates (backed by the bishops) successfully made the case to conservative Democrats that supporting a bill without language similar to the Stupak amendment was unacceptable for Catholics and other pro-lifers. The primary argument that surfaced was, “Most private insurance policies already cover abortion, so even without Stupak’s language, the status quo does not change. More people just get health care, and that’s good, right?”

The extent to which abortion is abetted by private health insurance is a semi-open question. Planned Parenthood on the one hand reports that 80% of health insurance policies cover abortion in at least some circumstances, but on the other hand that only 40% of abortions are actually paid by via insurance.

Obviously, even 40% of abortions is a huge number, and not something that the pro-life movement should ignore. Some progressive pro-lifers have latched hard onto this point in recent weeks. On several occasions, recently, I’ve seen progressive-leaning Catholics make the point that, “The pro-life establishment has long ignored that big business is funding abortions through big insurance. If they truly cared about life, this would be their primary focus rather than the supreme court and congress.”

There are various considerations here, and for lack of a better approach I’ll list them off separately.

- I don’t think it’s accurate to say that pro-lifers don’t care about “big insurance” funding abortions. The primary political focus of the pro-life movement has been working to legally restrict abortion, both via small steps in the interim and via larger ones that would be made possible through the overturning of Roe v. Wade. Obviously, if abortion was legally restricted as a medical practice, the fact that health insurance used to pay for abortions in some circumstances wouldn’t do anything to make them more legal. So if pro-lifers won on the legal front, it would take an end run around any insurance coverage of abortions. In the non-political arena, pro-lifers are primarily occupied with pro-life crisis pregnancy centers and with clinic protests and sidewalk counseling. All of these are certainly as applicable to someone planning to use insurance to pay for an abortion as otherwise, so it’s hard to see how one can accuse them of neglect here.

- The fact that insurance had been little discussed in regards to abortion before this particular health care reform bill made it a national issue probably has a lot to do with the cultural understanding of abortion out there. Most of us, I imagine, have as some time heard some co-worker or classmate talk about getting a woman pregnant and “giving her money to take care of the situation”. When people think about the abortion issue, it’s often in terms of this kind of situation, and the idea of insurance doesn’t really come into the stereotype. This is probably compounded by the fact that the demographic which procures the most abortions (single people in their teens or early 20s with lower or middle incomes) is the group of people least likely to have their own insurance.

- The question of abortions paid by insurance vs. abortions paid in cash probably also ties very closely to another of the issues relating to abortion in America which is not necessarily discussed a great deal. There are two worlds of abortion: Voluntary abortions are essentially the “I don’t want to have a baby right now” variety. They spring from “surprise” pregnancies and are (like any other strictly optional procedure) generally not going to be paid for by insurance. This is the area in which the pro-life movement seems to be gaining increasing traction as painful experience teaches society that abortion is not a painless get-out-of-pregnancy card. The much more difficult battle for pro-lifers, however, is against so-called “therapeutic” abortions, where there is either some real or likely medical problem with the unborn child or where the pregnancy represents an unusually high health risk to the mother. These situations are much more likely to be covered by insurance, the abortions often take place in hospitals rather than at abortion clinics, and many people who oppose abortion “in most circumstances” will get all wishy-washy about these situations.

- I don’t see why it’s unreasonable for pro-lifers to ask for one of the regulations placed on insurance policies in a government regulated “health care exchange” be that the policy not cover abortion. Many other groups with strong ideas about what insurance should or should not cover had already entered the mix to try to mandate what policies on the exchange should cover, what percentage of care they would pay for, what the maximum you would have to spend on “your share” of medical expenses per year would be, etc. It’s not as if no one else was seeking to control what sort of insurance would be offered on the exchange, and while these questions were open, I think it’s entirely appropriate for pro-life legislators such as Stupak to seek to ban abortion coverage from those policies.

- Now that the issue has achieved this prominence, I think it would be a mistake to simply drop the question. While getting private insurers to change their policies to exclude abortion would clearly not be easy (since there are dozens of insurers offering a plethora of policies, each with different coverage restrictions) I think pro-lifers should indeed seek for ways to encourage insurers to offer abortion-free policies, and Catholics business owners to select those policies. There might also be a chance of achieving this effect through regulation. Health insurance is a very highly regulated industry, with all states having laws about what must be covered by different types of health care plans. Seeking to have abortions specifically classified as not being necessary medical care would strongly encourage insurers to skip covering abortion as a cost savings measure.

25 Responses to Health Insurance and Abortion

  • Faustina says:

    If the information about which private health insurance plans do and do not cover abortion would be a great help. For a start prolifers could offere incentives to drop insurance coverage of abortion by voting with their wallet.

  • Gabriel Austin says:

    As pregnancy is 99% a self-inflicted condition, it is unclear why the insurance companies should pay for it.

    Or as Senator Barbara Boxer once asked “since when is pregnancy a disease?”.

  • WJ says:

    This is a great post. And it would be a very good thing if the more traditional, beltway type professional pro-lifers were able to work together with more politically liberal progressive pro-lifers on an issue which could unite them in a common purpose, rather than putting them at policy loggerheads, as often seems to happen.

  • Foxfier says:

    Not sure I’d call my little girl a self-inflicted condition– her father might object, for starters– but it’s covered by insurance due to the hideously wide range of things that can go wrong, as a way to make sure the insurance company gets a relatively healthy new customer and, on a practical level, because even if they pay zero just having an insurance company takes off a huge chunk of the cost.

    Kit would have cost some $40,000 if billed to my husband and I directly; we literally have statements that read “charge- 1,500; negotiated price, $25″ and such. As most folks can’t go by cash-only medical providers, service like this is our only option.

    That won’t be changed until health insurance, whichever section you believe causes this insane charge imbalance.
    *glares at Medicare and Medicaid’s billing practices*

  • Donald R. McClarey says:

    I agree with Foxfier that pregnancy is never a solely self-inflicted condition. It is also a totally necessary condition for the survival of mankind. The costs of even routine pregnancies are high and without insurance coverage would bankrupt quite a few parents to be.

  • M.Z. says:

    Getting in a car wreck is a self inflicted condition. The at fault party is given total liability for the actions he could have prevented in the ideal scenario. It is still insurance.

    When people speak of not insuring self-caused events, they are talking about the principle of moral hazard. In auto insurance, the idea is that people drive more recklessly if they are insured. In health care, the idea is that people seek ‘unneeded’ care because they don’t bear a burden. With the large expense centers in health care like heart disease and cancer, the only generally agreed upon unneeded care that the patient is competent to seek himself is an extra screening. Of course, the patient could choose to forgo regular screenings, and we’d see that as a bad thing, even though we’d see a reduction in cost.

  • I’m unclear whether Gabriel is making the argument:

    a) Pregnancy is the natural result of intercourse and so asking for your insurance to get you out of the “surprise” with an abortion is inappropriate or

    b) No pregnancy related expenses should be covered by insurance, since becoming pregnant in the first place is “optional”.

    I have some sympathy with the former approach, though I think it’s much wiser to make the moral than the utilitarian argument here since if one wants to get seriously utilitarian abortion is cheaper than childbirth.

    In regards to the latter — As my wife and I are currently going through the third round of paying out of pocket for a midwife deliver rather than going with the more expensive (but more troublesome) insurance paid hospital approach, I can see certain virtues towards a less insurance-heavy approach to childbirth. However, I don’t in the end think it’s a very good approach to take given anything like our current health insurance regime. Health insurance as it exists in the real world here and now does not take into account whether your medical predicament was predictable. (Say, whether bad eating habits over decades leads to expensive-to-treat strokes or heart attacks.) It simply deals with whether procedures are necessary to your health. (In regards to which, childbirth is necessary, while lasik or breast augmentation isn’t.) And whether expenses are large, which delivery at a hospital certainly is.

    Given that, there’s no practical justification for insurance not covering pregnancy related expenses — and as pro-lifers I think it should be pretty clear to us that insurance companies specifically excluding pregnancy expenses would be a very serious negative.

  • Mike Petrik says:

    Darwin,
    I agree with you completely. I would add that the reason our health care system is in a mess is because we are using a risk sharing system (insurance) inappropriately. A four party payment system (employer pays insurer who pays provider to service a decision-making user) cannot be economically efficient. Insurance is only sensible when trying to spread unacceptable financial risks. Now, when we have a cold or flu, a simple doctor’s visit has insurance implications. That is not sensible. I would address pregnancy and child birth, but don’t have the time.

  • M.Z. says:

    I’m not sure where you are finding the impossibility. There is nothing intrinsic about complex systems that causes inefficiencies. The opposite is actually the case. As bureaucracies become more complex, the cost of a standard transaction goes down. For a basic office visit, the administrative cost on the claim is, if I remember correctly, is less than what VISA and Mastercard charge. While the specifics are always dependent, generally it is better to move one’s costs to fixed from on demand. It allows for such things as specialization.

    Health insurance as it exists in the real world here and now does not take into account whether your medical predicament was predictable.
    That is simply wrong. There is no retroactive analysis, but there is a reason you give your medical history, give your height and weight, and your blood pressure. If you have a group plan, you might not have gotten into that much detail, because there isn’t the need for as much specificity with large numbers.

    It simply deals with whether procedures are necessary to your health.
    Yes, when you are coverage includes reasonable medical expenses, your plan seeks to verify that they are reasonable. People in insurance do not care if an expense is rare. They actually hate those. The only thing insurance companies care about is if an expense is predictable. That is how rates are determined. If we have three pools of a thousand people, there will not be enough variation in the number of office visits those three pools have over a year to make a real difference in rates. The ideal insurance function is a converging function where as n increases it approaches s.

  • Mike Petrik says:

    M.Z.,
    The inefficiency is not a function of complexity. It is a function of the remoteness between the payor and the user. This is a feature of almost any insurance, and it distorts incentives and behavior. Health insurance is worse than most because a fourth party , the employer, is implicated.

  • MZ,

    I think we might be talking slightly at cross purposes. My point is not that insurance companies pay no attention to how behaviors are likely to affect your health, but rather that once they have insured someone they are not able to decide whether or not to treat a condition based on whether it was the person’s “fault” in some sense.

    Thus, for instance, a some health insurance applications ask if you drive a motorcycle, and may take that into account in your rates, but they’re not allowed to refuse to treat your injuries if you have a motorcycle accident on the theory that it’s an optional and high risk behavior.

  • M.Z. says:

    If the contract excluded coverage from injuries resulting from a motorcycle accident, they would be excluded if the contract specified them. Many states proscribe insurance companies from excluding ordinary activities. If you have your health plan doc in front of you, you should see a section titled “Exclusions and Limitations of Coverage,” or something to that affect. I must confess though of being unaware of anyone claiming that Americans have higher health care costs because they participate to a greater extent in health risking activities.

    Mike Petrik,
    I recognize a moral hazard argument when I see one. The major premise of such an argument is that a person receiving a benefit would not seek that benefit were it not present. With national parks we do not see people widely exploiting them to their detriment despite not directly paying for them. My problem is that you seem to believe that the hazard is widespread and costly and therefore leading to inefficiency. I do not believe the numbers support the argument.

  • Foxfier says:

    With national parks we do not see people widely exploiting them to their detriment despite not directly paying for them.

    I’m afraid you’re quite wrong at that– it just doesn’t get as much attention. I’ve got pictures here of what’s left after some folks exploited a park for “enjoyment.”

  • If the contract excluded coverage from injuries resulting from a motorcycle accident, they would be excluded if the contract specified them. Many states proscribe insurance companies from excluding ordinary activities. If you have your health plan doc in front of you, you should see a section titled “Exclusions and Limitations of Coverage,” or something to that affect.

    Um, well, yes. But I’m not sure how that relates to my point in response to Gabriel, which was that excluding pregnancy care from insurance as a general practice was neither in keeping with the general way insurance works in the US nor a good idea.

    I think you and I are basically in agreement on that, aren’t we?

    I must confess though of being unaware of anyone claiming that Americans have higher health care costs because they participate to a greater extent in health risking activities.

    I’ve heard people argue that Americans have a lower life expectancy and poorer health care outcomes as a result of higher rates of violence, auto accidents, and unhealthy living — but I don’t think I’ve heard anyone argue that’s a major source of our higher health care expenses.

    Not sure how we got on the topic though…

  • cminor says:

    I’ve never understood why health insurance providers aren’t friendlier towards midwife care as it would cut down their costs considerably. Are they not covering it at all now? All my midwife-managed births were covered, though on occasion I had to do a little educating to get bills paid.

  • Foxfier says:

    I think it depends, cminor; my dad’s masseuse is a registered midwife, but she often has to work in a hospital because of the risks.

    Getting gov’t less involved in hospitals might be a good idea– I know that Sacred Heart in Spokane just got permission, after five years, to add five maternity beds to their design. They’d asked for 15.

  • They’re willing to pay for midwife services in a hospital or some birthing centers, but not for a homebirth midwife — which as you say is odd because the ~2.5k cost is much less than they pay for a hospital delivery.

    After dealing with hospitals the first couple time MrsD was tired of that routine, and our babies tend to come so fast that staying put it much more reassuring. It’s expensive, but paid over seven months it’s doable.

  • Mike Petrik says:

    MZ,
    I don’t know what “numbers” you’re talking about, but if you think that people would make the same medical decisions (e.g., opt for the same number of MRIs and CT scans) if they were using their own money then we just disagree. Both doctors and patients are influenced by the fact that the patient has little financial interest in selecting options. I find it hard to believe that there are “numbers” that can demonstrate otherwise. Many common medical decisions involve lifestyle considerations. For instance many knee and hip replacements are elective in the sense that a relatively normal life can often continue without them. The decision to have these procedures is often influenced by the degree to which the patient will not bear the cost. People do make decisions based on costs and benefits, and the costs they weigh are only their own.

  • M.Z. says:

    Foxfier,

    Child abuse isn’t evidence that parents don’t generally love their children. Certainly there instances of abuse and destruction of public resources as there are of private ones.

    Petrik,
    I’m more interested in decisions that are in their best interests. The RAND Institute has found that people will choose less care when they have to directly pay for it. The same study showed that they did not discriminate between needed care and unneeded care.

    Doctors do have an interest in not ordering more and unnecessary tests. It is called the insurance exclusion for charges that are not reasonable and customary. Good luck to the doctor recovering a claim denied for U&C. Such isn’t to claim that greater efficiencies couldn’t be wrung.

    I hope you are never a candidate to have a knee or hip replacement. This is of course another area that isn’t breaking the medical system.

  • Foxfier says:

    MZ-
    you’re assuming that what I posted pictures of was out of the norm, rather than just a very visual example of the norm.
    Check out Chief Joe’s grave some time– if you can find it, in all the trash. Talk to the folks who do upkeep on state campgrounds. Look at a park that hasn’t had grounds keepers on it recently. For fun, look at how much of it is only a few steps from an empty garbage can.
    There’s a reason that I tend to defend pigs when folks say that humans are pigs– pigs are clean if they’re given a chance.

    Shoot, go on one of the bike trails– you’ll find piles of human fecal matter in the middle of the trail, and I wish I was joking.

  • Well, also, a lot of national and state parks either aren’t free or are free but only allow a certain number of people into the park each day. Unless society has massively reformed from my boy scout days, the parts of national parks that people could actually get near without at least an hour or two of hiking tended to be rather threadbare. (And the bloody Sierra Club with their mules carrying supplies for Yosemite “hikers” who had too much money and didn’t want to carry their own food made the trails pretty foul for those of us doing real back packing.)

    Doctors do have an interest in not ordering more and unnecessary tests. It is called the insurance exclusion for charges that are not reasonable and customary. Good luck to the doctor recovering a claim denied for U&C. Such isn’t to claim that greater efficiencies couldn’t be wrung.

    True, but there’s a wide range of what doctors can get away within the range of what is “necessary” and “customary”. Obama, at least, certainly seemed to think in a number of his early talks on cost control that doctors are incented to defer towards extra care — and the studies on how salaried doctors prescribe less care for equal outcomes also suggest there’s some sort of effect going on there.

  • Foxfier says:

    They’re willing to pay for midwife services in a hospital or some birthing centers, but not for a homebirth midwife — which as you say is odd because the ~2.5k cost is much less than they pay for a hospital delivery.

    Can’t believe I didn’t remember this before– at least in Washington state, the insurance company really wants to minimize even the most out-there risks for the baby because the baby MUST be covered by the mother’s insurance for something like a month after birth.

Follow TAC by Clicking on the Buttons Below
Bookmark and Share
Subscribe by eMail

Enter your email:

Recent Comments
Archives
Our Visitors. . .
Our Subscribers. . .