Two New Analyses Show Women Have “Much at Stake” Under Stupak Amendment


Two new analyses, one by the Kaiser Family Foundation (KFF) and the other by George Washington University, show just how much the Stupak Amendment would undermine women’s basic human rights to exercise choice over childbearing, to access comprehensive reproductive health care, to access abortions (a legal procedure in the United States), and to ensure they are covered by insurance for unanticipated pregnancy-related conditions that could, absent coverage, leave them and their families with enormous debt.

The Kaiser Study

"Women have much at stake in the ongoing national debate on health reform," states a new brief by KFF, which continues:

Comprehensive coverage and the scope of benefits are at the heart of making health care accessible to women. The decisions that policy makers enact regarding access and coverage of abortion are sure to be the subject of tremendous discussion and debate, and could affect care for millions of women today and in the future.

The KFF brief compares the bill passed 10 days ago by the House of Representatives with those still working their way through the Senate.  (It was written prior to release today of the omnibus Senate bill by Majority Leader Harry Reid.)

"The way that the final House bill addresses abortion coverage has
the potential to affect many women," notes KFF, underscoring the incorrect ways in which the media has portrayed this issue. 

"[A]bortion is one of the most common surgical procedures performed on women. In 2005, there were more than 1.2 million abortions in the United States. It is estimated that at current rates, about a third of women will have had an abortion by age 45." 

The Kaiser brief first reviews current law, noting:

  • Current federal law bans the use of any federal funds for abortion, except in the event of rape, incest, or the woman’s life endangerment, as specified in the federal Hyde Amendment, which has been in effect since 1977.
  • This amendment is not a permanent law but is attached annually to Congressional appropriations bills, and has been approved every year by the Congress.
  • The broadest reach of the Hyde Amendment is on Medicaid, basically limiting federal Medicaid funding for abortions to life endangerment, rape, or incest cases in most states. States can choose to broaden the circumstances to cover other “medically necessary” abortions for women on Medicaid with their own funds and 17 states do, but in the majority of states women on Medicaid only have coverage in cases of rape, incest, or when the pregnancy is documented by a physician to be a threat to the life of the woman. Over the years, the Hyde Amendment has been broadened to limit federal funds for abortion for federal employees, in the Indian Health Service, and women in the military.

 

The House bill expands coverage to many of the nation’s uninsured by extending Medicaid eligibility to all qualifying individuals with incomes up to 150% of the federal poverty level and establishing a national health insurance exchange–a sort of marketplace where individuals with incomes above 150% of poverty can purchase insurance coverage. Initially, the Exchange would be open to all qualifying people who are uninsured and employees of some small businesses, with the possibility of opening it to more people over time. It would offer multiple insurance plans from which individuals can choose including at least one publicly financed plan as well as several privately operated plans. To help individuals purchase insurance, the federal government will provide subsidies (in the form of premium credits) to eligible individuals and families with incomes between 150% and 400% above the poverty level.

The House bill also extends premium credits to individuals with employer-sponsored insurance if their share of premiums exceeds 12% of their income, which could make an additional 1 million people eligible for purchasing coverage in the Exchange.

"In total," notes Kaiser, "it is estimated that 86% of participants in the Exchange would receive subsidies."

Kaiser notes:

The House bill places a number of restrictions on coverage of abortion, with the most direct impact on the plans that will be offered in the new Health Insurance Exchange. According to the legislation, the public plan within the Exchange would be prohibited from providing coverage for abortions beyond those permitted by current federal law (to save the life of the woman or in cases of rape or incest). The House bill also prohibits federal premium credits that low-income individuals will receive from the federal government from being used to purchase a health plan in the Exchange that includes coverage for all but federally permitted abortions. Although it is not required, private insurers may opt to offer a plan in the Exchange that covers abortions beyond those permitted by federal law. These insurers, however, will be required to also offer an identical plan that does not cover abortions for which federal funding is prohibited.

Private plans participating in the Exchange may choose to offer
supplemental coverage for abortions in the form of riders that are totally
separate from other benefits, but that coverage must be paid for entirely with non-federal funds. Furthermore, the plans must be separately operated to assure that federal funds are not used to administer or operate plans that cover abortions.

According to Kaiser, an estimated 12.4 million women ages 15 to 44 are uninsured, 94% of whom would qualify for federal assistance (61% through Medicaid—7.5 million women; and 33% for federal
premium credits subsidies to purchase coverage—4.1 million women).

Impact of the House Bill:

Kaiser states that provisions in the House bill would "have direct effects on women seeking coverage in the Exchange as well as on plans that
offer coverage in the Exchange."

  • Women who choose the public option would not have abortion coverage nor would they have access to a rider.
  • Women who receive any level of federal subsidy cannot purchase coverage from a plan that offers abortion coverage, but they do have the option of purchasing a separate rider for abortion coverage alone, if offered by the plan.
  • Women who do not receive federal subsidies and seek coverage in the Exchange could be able to buy coverage from a plan that offers an abortion benefit, if such a plan is available.

Kaiser underscores what others have also noted:

It is unclear whether a woman would necessarily seek or know to buy a service-specific rider for abortion when she is choosing her insurance plan, or whether women without subsidies would necessarily know whether they are buying coverage from a plan that covers abortion or not. It is also unknown what the price differential would be between the two plans and how much the rider would cost, if offered. The House bill goes beyond the Senate committee bills by requiring the sale of a distinct insurance product that is designed specifically for those receiving subsidized coverage. For insurers, the House bill sets a number of restrictions, particularly the requirement to isolate federal dollars from private funds because a plan that receives any federal funds cannot provide abortion coverage. Although it is hard to predict the response of insurance plans to this type of law, some legal scholars contend that given the size of the potential pool of women and their families that will be eligible for federal subsidies under the exchange and other complexities, this might limit he development of insurance plans that offer either abortion coverage or a rider, and ultimately carry over to products offered in the employer market.

Many women who now have coverage for abortion care would lose it.

This complex combination of restrictions means that many women who will obtain coverage under health reform either through Medicaid or the Exchange would have to pay for an abortion out-of-pocket, the cost of which varies depending on factors such as location, facility, timing, and type of procedure.

A clinic-based abortion at 10 weeks’ gestation is estimated to cost
between $400 and $550, whereas an abortion at 20-21 weeks’ gestation is
estimated to cost $1,250-$1,800. The vast majority of abortions are
performed early in pregnancy. In 2004, 89% were in the first twelve
weeks of pregnancy and only 1% were at 21 weeks or later.  In general,
abortions performed in hospitals are more expensive than those
performed at clinics.

The House bill dramatically expands the Medicaid program, and extends insurance to qualifying uninsured individuals with incomes below 150% of the federal poverty line.

"The Medicaid program already serves millions of low-income women," notes Kaiser, "and is a major financier of reproductive health services. It is estimated that two-thirds of adult women on Medicaid are in their reproductive years."  In 33 states and the District of Columbia, state Medicaid programs do not pay for any abortions beyond the Hyde restrictions.  In these states, an estimated 4.5 million women ages 15-44 are currently uninsured and also have incomes less than 150% of the
federal poverty level.  Many of these women would likely qualify for Medicaid under the new House bill.

They will be forced to pay for their insurance with their rights.

The George Washington University (GWU) Study

This study, conducted by the George Washington University School of Public Health, focused on the implications of the Stupak Amendment for the health benefits industry on the whole; the growth of the public market for supplemental coverage: and the implications for covering abortions that are a consequence of an unexpected condition.

The study concludes that:

  • The treatment exclusions required under the Stupak/Pitts Amendment will have an industry-wide effect, eliminating coverage of medically indicated abortions over time for all women, not only those whose coverage is derived through a health insurance exchange. [emphasis added]. 

 

Stupak-Pitts, according to the authors:

Can be expected to move the industry away from current norms of
coverage for medically indicated abortions. In combination with the
Hyde Amendment, Stupak/Pitts will impose a coverage exclusion for
medically indicated abortions on such a widespread basis that the
health benefit services industry can be expected to recalibrate product design downward across the board in order to accommodate the exclusion in selected markets.

  • The Amendment will inhibit development of a supplemental coverage market for medically indicated abortions. 

In any supplemental coverage arrangement, it is essential that the supplemental coverage be administered in conjunction with basic coverage. This intertwined administration approach is barred under Stupak/Pitts because of the prohibition against financial comingling. This bar is in addition to the challenges inherent in administering any supplemental policy. These challenges would be magnified in the case of medically indicated abortions because, given the relatively low number of medically indicated abortions, the coverage supplement would apply to only a handful of procedures for a handful of conditions. Furthermore, the House legislation contains no direct economic incentive to create such a market [and would leave in doubt] states’ ability to offer supplemental Medicaid coverage to
women insured through a subsidized exchange plan.  

  • "Spillover" effects as a result of administration of Stupak/Pitts will result in dramatically reduced coverage for potentially catastrophic conditions.

 

The authors write: "The administration of any coverage exclusion raises a risk that, in applying the exclusion, a plan administrator will deny coverage not only for the excluded treatment but also for related treatments that are intertwined with the exclusion."

The risk of such improper denials in high risk and costly cases is great in the case of the Stupak/Pitts Amendment, which, like the Hyde Amendment, distinguishes between life-threatening physical conditions and conditions in which health is threatened. Unlike Medicaid agencies, however, the private health benefit services industry has no experience with this distinction. The danger is around coverage denials in cases in which an abortion is the result of a serious health condition rather than the direct presenting treatment.

Noting that the entire industry may be pushed toward using life-threatening conditions as "the standard," the authors note that "it is likely that all women will risk coverage denials, regardless of the market in which their coverage is obtained," and will lose coverage for medically indicated abortions that may well threaten both health and ultimately life.

Under these circumstances, what is the norm today in the employer-sponsored market – broad coverage of medically indicated abortions – is likely to narrow considerably as the industry seeks to restructure its product design to meet the most restrictive demands. If this consequence flows, then the industry, confronting the challenges of distinguishing between enrollees for a handful of covered procedures and specific conditions, can be expected simply to eliminate certain procedures and conditions from coverage altogether, leaving women and families exposed.

"Stupak/Pitts and Hyde…presume that abortion is the immediate subject of the claim for coverage," note the authors. 

But this is not always the case.

High risk pregnancies themselves could be identified as potentially
abortion-related.

Conditions such as diabetes (observed in 1% of pregnancies) which are poorly controlled can lead to serious health consequences for both the woman and the fetus, including major congenital abnormalities, and a higher risk of spontaneous loss, which might in turn trigger an abortion if the pregnancy cannot be saved. Management of recurrent pregnancy loss or complicated multi-fetal pregnancies (increasingly prevalent with widespread use of assisted reproductive technologies) may also be considered abortion-related conditions. Similarly, uncontrolled hypertension, trauma during pregnancy, seizure disorders and other conditions, all require complex management and may
persist beyond the pregnancy, and may result in abortion-related care. These concerns have increasing individual and public health consequence as age at pregnancy, body mass index and associated metabolic and cardiovascular abnormalities, Cesarean section rates, multi-fetal pregnancy rates, and use of assisted reproductive technologies have all increased dramatically in recent years.

Additionally, state the authors, "in response to more limited access to abortion services, there may be an increase in self-induced abortion, potentially through increased self-administration of misoprostol. Coverage for treatment of complications such as hemorrhage and incomplete abortion in such cases could be denied."

In these circumstances, how are plan administrators to distinguish between the abortion procedure and the rest of the treatment? Will the entire cost of a course of treatment (e.g., surgery to repair a damaged pelvis following an automobile accident) be denied if violation for paying for the excluded abortions, may elect to deny the treatment altogether, claiming that it is all related to the excluded treatment.

"As the denial is appealed, the financial consequences for patients potentially will be enormous."

"One of the great challenges in insurance reform is the unintended consequences of regulation," write the authors.

The Stupak/Pitts Amendment is intended to reach only a specific part of the market. But the cumulative effect of the provision, in combination with existing federal laws governing Medicaid and federal employee health benefits (as well as the law of certain states) inevitably can be expected to move the entire health benefits industry away from its current inclusive coverage norms and toward a new norm of exclusion. The provisions of the legislation, as well as the technical challenges that arise in benefits administration, militate against the creation of a supplemental coverage market. Thus, if the result of national health reform is to move millions of women into a market that operates subject to the exclusion, then it is fair to predict that the entire market for coverage ultimately will be affected as a product tipping point is reached and virtually no supplemental market appears.

In addition, state the authors:

Given past experience and the sanctions that arise from a violation, it is reasonable to predict that in interpreting and applying the exclusion, health plan administrators will err on the side of coverage denial. This is because the legal risks associated with coverage determination are all on the side of incorrectly awarding coverage, not erroneously denying it. This balancing of risks can be expected to lead insurers to calibrate coverage determinations in a way that works against women whose medical conditions ultimately lead to an abortion that they never willingly sought. 

In short, as many have already argued, women will bear the brunt of a policy created based on ideology and discrimination, not public health, pushed through by those who appear to care little for either women’s rights or their lives and health.

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  • truthandwisdom

    Have you seen the video of the baby (fetus) fighting for its life when being aborted. It is a shocking expose’ of what abortion really is. No one can make Americans pay for this to happen. That would be a violation of my rights and, by the way, the murder of a helpless person. If a woman decides that it is OK to kill a baby -her own flesh and blood- she is going to have to do it without my money. Period, the end.

  • kate-ranieri

    Dear TruthandWisdom,

    A bit of understanding about videos, photography and editing might enlighten your sense of truth when you claim that a fetus is fighting for its life. While I cannot begin to critique the video you are mentioning, without a title or even an accurate description, I can tell you the ethics in imaging is so highly revered in prolife videos that it is rarely considered. Further, your claim that this fetus is fighting for its life, assumes that YOU know what it is thinking and that you know that this fetus is a sentient being. Films like Silent Scream and later pieces have been deconstructed by scholars for their propaganda techniques. And they are very effective for the gullible or those who refuses to use their God-given critical thinking faculties. 

  • amie-newman

    The Hyde Amendment already prohibits federal dollars from paying for abortion except in the cases of rape, incest or when the woman’s life or health is in danger by continuing with the pregnancy. We have upwards of twenty different articles or posts on this site alone that can explain to you what Stupak-Pitts does but it does far more than simply prohibit federal funds from being used for abortion care. According to George Washington University’s School of Public Health AND Kaiser Family Foundation, Stupak Pitts would essentially result in a complete ban on insurance coverage of abortion for millions of women in this country, taking away abortion coverage they already have. That has nothing to do with "your money."

    On the other hand, there is no "violation" of your rights when federal dollars pay for a LEGAL procedure, in certain cases cited above. You may not agree with abortion but your rights are in no way violated. Are my rights violated because federal dollars are spent on abstinence-only-until-marriage HIV prevention programs in Africa – programs with absolutely no evidence to support their effectiveness and only in place because of Christian evangelical influence on our federal government? Are my rights violated because the federal government grants millions of dollars to crisis pregnancy centers, run by faith-based organizations, providing inaccruate and misleading "medical" information to pregnant women? 

    You have every right to maintain an anti-abortion stance but your understanding of federal funding for abortion services and exactly what the Stupak Amendment does and doesn’t do is just wrong. 

    Amie Newman

    Managing Editor, RH Reality Check

  • adolmd

    1. T/W – you may believe that an abortion kills a life. but there are others of the same religion that believe that life begins at birth or at "first breath."

    because of religion, we will never agree when life begins.  Thus, your body, your choice. My body, my choice. Do not impose your religious beliefs on me.

     

    2.  Also, our funds go towards the war in iraq and the death penalty. that is killing people. we cannot opt out of paying for certain things, though we wish we could.

     

    3. As stated by  others, the Hyde amendment already forbids any federal $$ from being spent on abortion. What stupak does is forbids poor women from buying with their own $$ insurance in the exchange that covers abortion. And that is wrong. Why should poor women have fewer choices than rich women?

     

    4.T/W have you seen what a 7 week-10week abortion looks like?  it still has a tailbone like a lizard, a yolk sac, and is less than 2 inches and <5 grams.

     

     5. T/W have you seen what a self-induced abortion looks like? a woman with pus coming out of her uterus, dying? and her husband and kids around her crying?  I am pro-choice because I am pro-life. If you don’t fund abortion, then sometimes people take things into their own hands and they botch it. 

     

    As an aside, personally, I think the Hyde amendment should be deleted because again,  Why should poor women have fewer choices than rich women?

  • prochoiceferret

    Thus, your body, your choice. My body, my choice. Do not impose your religious beliefs on me.

    Yep yep! And ex-nay on the idiocy that allowing the choice constitutes imposition of "our" religious beliefs.

    Also, our funds go towards the war in iraq and the death penalty. that is killing people. we cannot opt out of paying for certain things, though we wish we could.

    All too true. That would be interesting, wouldn’t it? "We’re not saying you can’t go to war. It’s just that if you want to go to war, it’ll have to be without using federal funds, because many Americans are pro-peace." ^_^

    T/W have you seen what a 7 week-10week abortion looks like? it still has a tailbone like a lizard, a yolk sac, and is less than 2 inches and <5 grams.

    Well, hey, if a single-celled organism can be a human being, then so can a two-inch vaguely proto-human-looking thing—whether it has gill slits or not!

    T/W have you seen what a self-induced abortion looks like? a woman with pus coming out of her uterus, dying? and her husband and kids around her crying? I am pro-choice because I am pro-life. If you don’t fund abortion, then sometimes people take things into their own hands and they botch it.

    And T/W will probably say "Well, obviously that’ll teach ‘em not to do that," because to him, pregnant women dying is an acceptable outcome.

  • paul-bradford

    Jodi,

     

    What I notice, above everything else, is the mistrust each side has for the other.

     

    Before Stupak was added, when we had Capps, folks on the right were carping about ‘fungibility’ and claiming that Capps allowed taxpayer money to be used for abortions.  The left promised that no taxpayers would have to pay for abortions under the amendment.  My concern was that the argument would kill the bill entirely.

     

    When Stupak was added the measure passed with two votes to spare.  I’m absolutely convinced that, without Stupak, the House would have voted the bill down which would mean that millions of uninsured women would have no abortion coverage even in the event of medical necessity.

     

    Now, with Stupak, the left is proving that they can stir the fear pot as well as the right does.  Stupak will usher in a new age where even medically necessary abortions aren’t covered.  As you quoted from the GWU report: 

     

    The treatment exclusions required under the Stupak/Pitts Amendment will have an industry-wide effect, eliminating coverage of medically indicated abortions over time for all women, not only those whose coverage is derived through a health insurance exchange.

     

    Where does this come from?  The amendment specifies that medically necessary abortions are covered but you heighten people’s fears by suggesting that all kinds of necessary procedures will be declined.  The argument doesn’t rest on logic, it rests on the deathly fear you have of the Pro-Life movement.

     

    The American people are convinced that taxpayer funded insurance policies should cover medically indicated abortions but should deny elective abortions.  The trouble is, "How do you word the regulation?"  When the folks on the Choice side word the amendment, the folks on the other side raise fears that taxpayers will pay for elective abortions.  When the folks on the ‘Life’ side word the amendment, the folks on the other side terrify each other by invoking images of desperately ill women being denied care.

     

    Universal Health Care will mean both fewer abortions and fewer women being endangered by pregnancy complications.  Everyone should want Universal Health Care — but folks on both sides of the abortion debate want to believe that the folks on the other side are all devils and fools.

     

    Paul Bradford

    Pro-Life Catholics for Choice

  • jodi-jacobson

    Paul,

    Forgive me but I think you fail, and have continued to fail to grasp the difference between law and implementation, and between the interpretation in real life of language such as that included by the Stupak amendment.  You also have failed to appreciate that we now have the Kaiser Family Foundation, The George Washington University School of Public Health, numerous legal experts, and numerous insurance experts–among others–analyzing the real economic and legal impacts of this amendment, none of whom are part of the "pro-choice" community.  They are experts in their field.

     

    This is perhaps the greatest single difference between the anti-choice and pro-choice communities.  One relies on ideology; the other on evidence.  This is evidence now from a wide range of sources and areas of expertise. 

     

    This amendment will result in interpretations and economic decisions that will drive all coverage for abortion care out of the market.  If you don’t think the post accurately describes the research, then I recommend you read the research in its entirety—which is why i have linked it here for you and others.

     

    And I find your conclusions hard to believe on their face.  This bill does not even mandate coverage for contraception.  How exactly is that "good for women" (or men for that matter) and how exactly is that going to result in a reduction in unintended pregnancies?

     

    I–and the millions of women in this country–have to live in the real world.

     

    Jodi

  • progo35

    Frankly, the way these studies and the people on this blog have conflated the Stupak ammendment makes me angry. There is nothing in Stupak that prohibits abortion in the case of the woman’s life, and you shouldn’t portray it as such.

    "Well behaved women seldom make history."-Laurel Thatcher Ulrich

  • crowepps

    When the folks on the Choice side word the amendment, the folks on the other side raise fears that taxpayers will pay for elective abortions.

    You may have missed the thread, but Progo objects to taxpayers funding abortions in cases where the fetus is anencephalic because she considers THAT ‘elective’. Apparently some people have a problem with any abortion whatsoever unless the woman is actually in the process of hemorrhaging to death right that second.

     

    http://www.rhrealitycheck.org/blog/2009/11/19/more-outrage-over-stupakpitts-a-federal-employee-speaks-out

     

    I’m not so sure the problem is the shrillness of the voices, in some cases it seems to be the fact that the sides are assigning unique definitions to words. As evidenced by the statement made in a thread here a while back that a D&C or D&X in the case of a ‘miscarriage’ isn’t an abortion but the exact same operation on a voluntary basis is. I also understand that in medical terminology, ANY operation that is scheduled rather performed on an emergency basis is ‘elective’.

     

    I’m not sure that distinction is clear to some ProLife activists who don’t seem to grasp that it is possible to recognize a serious threat to the mother’s life and for her physician to take action to meet it on an ‘elective’ basis without the pregnancy itself having been ‘unwanted’ in the first place. A good example of that is ectopic pregnancy. Unless the fallopian tube has actually BURST, the treatment for an ectopic pregnancy is ‘elective’ even though it is absolutely necessary, because there is the alternative of crossing your fingers and wishing really hard that the misplaced zygote will be in the half that spontaneously abort naturally or waiting until that tube bursts and the treatment can be labeled emergent.

  • paul-bradford

    This is perhaps the greatest single difference between the anti-choice and pro-choice communities. One relies on ideology; the other on evidence. This is evidence now from a wide range of sources and areas of expertise.

     

    Jodi,

     

    I can’t see how you can make a statement like that and keep a straight face.

     

    Pro-Choice and Pro-Life extremists are identical in temperament.  They both think all the angels are on their side.  Imagine reading this on Jill Stanek’s ‘site: "This is perhaps the greatest single difference between the pro-abortion and pro-life communities. One relies on ideology; the other on evidence."  I can feel the heads nodding in agreement. Everyone is convinced that their point of view is rational, scientific and ideology-free.

     

    The extremists are mucking up the Health Care Bill.  Americans want women to have access to quality OB/GYN care.  Americans want the abortion rate to go down.  Universal Health Care will advance both aims.  But….  The extremists want a bill that has everything they want and nothing they don’t want — so passage is in peril.

     

    Do you want to know why Stupak was added to the bill?  The Democrats allowed it so they could shut Pro-Lifers up.  Now they’re going to have to come up with something to shut Pro-Choicers up.  The biggest contribution either side can make to health care in America is to learn to be still.

     

    PLCC believes that women’s health and protection for the unborn are not mutually exclusive goals — we can have both, but to do that we’ve got to lower the volume of noise. 

     

    Paul Bradford

    Pro-Life Catholics for Choice

  • adolmd

    Progo, threat to life is not the same has threat to health

    There is nothing that allows for abortion if it is a threat to a woman’s health.  

    Also, if a woman as an anencephalic baby, why should she be forced to continue for another 3 months, give birth to a larger mass and risk her future fertility? this should be covered!

    She wanted the pregnancy. it just went wrong.she should be able to terminate and move on (like have her next baby) rather than be a forced incubator for something that will die upon birth or shortly thereafter.