Does Insurance Coverage of Abortion Matter?

Does Insurance Coverage of Abortion Matter?

Carole Joffe: Does Insurance Coverage of Abortion Matter?

The issue of insurance coverage for abortion almost derailed the passage of health care reform last year. Pro-choice Democrats insisted that the abortion measure they supported was ?abortion neutral??that is, it neither increased nor decreased the already extremely limited use of federal funds to pay for abortions, restricted to cases of rape, incest, and threats to the life of the pregnant woman. But Republicans and some anti-abortion Democrats insisted that the new measure would increase public funds used for abortion care.

Ultimately the Patient Protection and Affordable Care Act passed only after President Obama reaffirmed, by executive order, the Hyde amendment, which is the basis for the current status of abortion funding. Pro-choice Democrats, unwilling to let the entire bill lapse, accepted additional language. These additional restrictions, often called the Nelson Amendment (after its sponsor, Senator Ben Nelson of Nebraska), stipulate that any insurance plan offering abortion coverage through the ?exchanges? to be set up under the new health care act must make provisions for the purchaser to pay for the abortion part separately, and that the insurer must establish separate accounts for this coverage.

The Republican takeover of the House of Representatives in January 2011 has led to a rash of new proposals on restricting abortion, which go far beyond what was agreed to when the health reform originally passed in the spring of 2010. In particular, H.R. 3, the ?No Taxpayer Funding for Abortion Act,? as analyzed by Jessica Arons of the Center for American Progress, would no longer allow the separate premium solution, mentioned above, and instead would ban abortion coverage altogether in the new health care exchanges.

Among other things, the bill would also impose tax penalties on those individuals and employers who purchase insurance with abortion coverage privately, by denying credits or tax deductions. Even before this latest radical legislation was introduced, health policy experts had warned that the health reform?related conflicts about abortion would likely lead insurers to simply give up coverage of abortion, as such coverage had clearly become a new front in the abortion wars.

Currently, over 80 percent of insurance plans cover abortion. Given the likely prospect of insurance plans dropping this coverage, the question becomes: how much will such a development matter, and whom will this hurt? Abortion clinic directors have often told me that many women who have such coverage fail to use it, as they are wary of having a paper trail that would let their employers and/or family members know of their abortions. In a study several years ago of women receiving medication abortions, my colleagues at UCSF documented a very low usage of existing insurance plans by those patients.

So is it really such a big deal if such coverage disappears?

The answer, in a word, is yes. True, abortion costs have remained remarkably low compared to other health care procedures: in 2009 the average cost of a first trimester abortion, when about 90 percent of all abortions take place, was about $470, according to the Guttmacher Institute. That is a manageable sum for many women, though often very difficult for those who live at the poverty level in any of the thirty-five states that have chosen not to use their own Medicaid funds to pay for abortions.

There is another group for whom the loss of abortion coverage would be devastating. This is the relatively small but still significant number of women who receive abortions later in pregnancy, typically because of much-wanted pregnancies that have gone horribly wrong?either because of serious or lethal fetal anomalies or serious maternal health conditions, such as the sudden diagnosis of cancer. Only about 1 percent of abortions in the United States take place after twenty weeks of gestation. Not all of these are for the reasons above, but many of them are.

I first became familiar with the particular nightmares?financial as well as emotional?faced by those needing later abortion in the fall of 2009, when I had the opportunity to interview three women who had been brought to Washington by the National Abortion Federation to lobby against abortion restrictions in health care reform. All three had faced heartbreaking news about their pregnancies.

At twenty-eight weeks, Dana?s baby (and for women carrying much desired pregnancies, ?baby? rather than ?fetus? is the term typically used) was found to be missing the crucial band of tissue that connected the right and left hemispheres (the agenesis of the corpus callosum, in medical terms). Christie, five months pregnant with a second daughter, found out via ultrasound that the baby had a serious birth defect called congenital diaphragmatic hernia, a hole in the diaphragm that prevented her lungs from developing. After years of undergoing fertility treatment, Mary was pregnant with a boy, only to find out at twenty-two weeks of pregnancy that due to the atrophy of his lungs and kidneys (a condition called Potter?s syndrome), there was virtually no chance of his survival beyond a few hours after birth. As Mary told me through tears, if she had continued the pregnancy, ?my baby would have suffocated to death.? Dana and Christie were similarly motivated to terminate their pregnancies to relieve the suffering their babies were already undergoing.

These women were alike in the heartbreaking course of their much-wanted pregnancies, but each had a different experience paying for the very expensive procedures they obtained. Christie?s private insurance paid the $10,000 cost. Mary was stunned and enraged to learn that because her husband (through whom she was insured) was a federal employee, her abortion, also around $10,000, would not be covered. Mary and her husband, both lawyers, decided to appeal, and after a protracted legal struggle, they quite surprisingly won. At the time I met her, Dana, whose abortion at thirty-one weeks at an out-of-state clinic cost $17,500, was both still grieving her lost pregnancy and fighting her insurance company.

Recently, Dana and Mary again came to Washington, to tell their stories at a congressional hearing. (Listen to Dana?s and Mary?s eloquent testimony.) I was relieved to learn that after hiring a lawyer and going through an exhausting round of negotiations, Dana finally did get her insurance company to pay. But we must remember that not all women have the resources to fight their insurance companies, as Dana and Mary did. Moreover, if insurance companies indeed are driven to drop abortion coverage altogether, the future will see women who similarly are in need of later abortions facing financial catastrophe at the saddest moment in their lives.

An earlier version of this post appeared at Advancing New Standards in Reproductive Health Blog.