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Health overhaul opens new abortion fights

By N.C. Aizenman
Washington Post / March 20, 2011

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WASHINGTON — A year after its passage, the federal health care overhaul is opening fresh battlefields in an old and bitter debate. Almost immediately after the law took effect, five states passed bills that will prohibit private insurance plans sold on new state-based marketplaces from covering abortion, except in dire circumstances such as to save the mother’s life.

Now 22 more states are considering similar abortion measures.

The impact of those bills would be limited to individuals and small businesses that buy insurance on the so-called exchanges. But nearly half of those states are also contemplating an even more far-reaching proposal: making it illegal for all private plans to cover abortion, regardless of whether they are sold on exchanges.

That step, which has become law in four states, would affect the type of plan used by the one-fourth of women ages 18 to 45 — 14.5 million of them — whose insurance is obtained for them by midsized and large employers, according to Paul Fronstin of the Employee Benefit Research Institute.

None of the pending state legislation would affect plans that very large employers sponsor directly and that are regulated by Congress.

But the scale and scope of the current legislative push is unprecedented, say activists on both sides.

“I don’t remember the last time I saw [so many] states try to do one thing on abortion,’’ said Rachel Sussman, who tracks state-level antiabortion efforts for the Planned Parenthood Federation of America.

The effort represents a new battleground in the long-running struggle over how much states should regulate abortion. Since the Supreme Court declared the procedure legal in 1973, antiabortion activists have mounted legislative attacks on its accessibility and funding.

The current state-level push to ban abortion coverage in the exchanges is a response to the controversial attempt by drafters of the federal health care overhaul to ensure that it complies with longstanding congressional policy against using federal money to pay for abortion.

That challenge produced a dramatic showdown last year between Democrats who oppose abortion and those who support abortion rights, and the law was saved with a compromise:

Insurers are allowed to include abortion coverage in their exchange plans, but everyone who buys such a plan must make two premium payments — one covering the bulk of the policy and another, as little as $1 per month, for the plan’s abortion coverage. Any federal subsidies can be applied only to the first payment.

Antiabortion groups deride that arrangement as little more than an accounting gimmick.

The money all goes into the same pool, said Mary Spaulding Balch, state legislation director at National Right to Life. So unless states make it a priority to exercise their option to ban abortion coverage on the exchanges, she said, the health care law will usher in a major expansion of federal funding of abortion.

Advocates of abortion rights, however, counter that the two-payment rule could lead many insurers to opt against offering abortion coverage in the exchanges because the dual payment system is too cumbersome and consumers may consider it bizarre and objectionable.

And they fear that any additional state-level bans would have ramifications far beyond the plans that are specifically regulated.

“This is part of a larger political effort to discredit abortion as basic health care and make the case that it shouldn’t be part of health care coverage,’’ Sussman said.

It is difficult to predict the effect on women’s access to abortion because there’s little solid information on how many private insurance plans cover abortion, according to specialists at the Guttmacher Institute, a nonprofit reproductive health research center that gathers the most comprehensive data on the subject in the United States.

Statistics on how many women use insurance to pay for abortions are almost as murky.

According to a 2008 Guttmacher survey, about a third of women who obtain abortions are uninsured — the population most likely to be served by the exchanges.

Another third have Medicaid, the state-federal insurance program for the poor, which restricts abortion coverage to narrow circumstances.

The remaining third of women have private insurance — employer-based coverage or plans they buy themselves. Yet the vast majority still pay for their abortions out of pocket.

The reason is unknown. It’s possible that their plans do not cover the procedure or have high deductibles. It’s also possible that they have privacy concerns.

Whatever the case, only 12 percent of women who have abortions use private insurance to pay for them.

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