How to Defuse the Abortion Issue on Health Care Reform

Lost in the vitriol about abortion is a surprising development: key pro-life and pro-choice leaders both say they don't intend to use health care reform to shift the balance of power in their direction. Activists have said health care reform should reflect the status quo in the abortion stalemate.

Less surprisingly, while both sides agree on that goal, they look at the same words in the same bills and come to opposite conclusions about what they mean. For instance, the bill passed by the House Energy and Commerce Committee declares, "Nothing in this Act shall be construed as preventing the public health insurance option from providing for or prohibiting coverage" for abortion in the "public option." Pro-choicers say that this neither-this-nor-that language is self-evidently neutral. Pro-life activists argue that since abortion "could" be covered, it will be covered, a not unreasonable assumption given that, as written, it would be up to the Obama administration to make the determination.

My personal view: the legislation passed by the House Energy and Commerce Committee does not mandate abortion coverage, as pro-life groups claim, but does leave open the possibility that the government might pay for abortion. And the "neutral" amendment offered by pro-lifers didn't achieve neutrality either, as it would potentially roll back abortion coverage in private insurance plans.

Of course it's easy me to criticize everyone for not coming up with a neutral solution. It's always more fun to carp than be constructive. So here's my best effort on how to make health care reform neutral on abortion.

First, we need to recognize that part of the problem in being neutral is that health care reform would introduce some new features so you really can't just freeze the status quo. Instead, one has to look at general principles. In general, the federal government is currently prohibited from directly paying for abortion but allowed to indirectly support abortion.

Indirect support happens in a variety of ways. For instance, the federal government set up the Medicaid program, pays for much of it, and then allows states to pay for abortions. The government provides support to hospitals, which perform abortions. The government gives money to family planning clinics for maternal health care, even though those clinics might also do abortions. In each case, the primary purpose of the spending is not encouraging abortion but by supporting institutions that also, with their own money, do abortions. That's the status quo.

First, let's apply this principle to the "public option" -- a new, government-backed insurance plan that may or may not be included in a final health reform bill. Congress could decree that the basic public insurance option doesn't include abortion but then offer consumers the ability to buy, with their own money, a rider to the policy that would cover abortions. Then the full direct cost of abortion coverage would be unambiguously carried by the consumer who chooses it.

Would there be an indirect subsidy? Yes, in the sense that the whole structure wouldn't exist without government support, but since the purpose of the structure is providing health care in general, not promoting abortion, it seems like a valid indirect subsidy consistent with the operating principles of the status quo stalemate.

Some pro-choice folks might say, well, no one plans an unintended pregnancy so it's not realistic for people to make that choice when buying health insurance.

But I don't plan on having auto accidents and yet I buy car insurance; I don't intend for my house to burn down, yet I buy homeowners insurance.

And perhaps there's a way of having this special abortion rider also include extra benefits to pay for contraception. That would give a second reason to buy the plan, and might even prevent more unintended pregnancies and abortions.

Most health bills also include subsidies to help people buy either private or public insurance if they can't afford it on their own. Pro-lifers have complained that government will end up subsidizing plans that cover abortion.

One solution would be to have the subsidies take the form of vouchers to individuals rather than government checks to specific plans. If individuals choose plans that cover abortions, that's their choice. Pro-lifers wouldn't complain if the government gave a general tax cut, which an individual then used to pay for an insurance plan that covered abortion. It's like when the government gives a Pell grant to someone who then uses it at a Catholic College. That's not viewed as a direct subsidy of a religious entity -- which would be a violation of separation of church and state -- because it is first and foremost aid to a person not an institution. Let's apply the same principle to health care aid.

It seems to me this approach would allow many plans to cover abortion but never put pro-life citizens in the position of feeling that their tax dollars are going to pay for abortions.

Well, what do you think? Have we found neutral ground yet? What do you suggest?

UPDATE: Some positive reaction from the pro-life community to this proposal. Bill Donohue of the Catholic League said "it could break the deadlock in Catholic circles" and Richard Doerflinger of the Bishops Conference said, "such a crazy idea that it might just work."

UPDATE 2: It occurs to me you could use the "rider" concept not only for the public option part but the subsidies-for-private-insurance section of health care reform too. You could say that prohibit plans that are in the exchange from covering abortion but then make available a supplemental rider that consumers could buy, with their own money, to pay for abortion.

Adapted from an article on Wall Street Journal Online