Muddying the Water

Muddying the Water: The New England Journal of Medicine (NEJM), Health Care Reform and Abortion The NEJM in its 12-31-09 issue granted George J. Annas, JD, MPH a platform to defend the Senate version of health care reform as meeting President Obama’s promise that no federal funds would be used for abortion. Because passage of the bill may hinge on abortion, Mr. Annas makes his argument by providing understanding of the Stupak amendment and the current laws on federal funding for abortion. He rightly states the Stupak amendment prohibits use of federal funds for abortion and prohibits funding for health benefit coverage of any plan that includes coverage of abortion services. Abortion would be permitted if the pregnancy endangered the mother’s physical life or if the pregnancy resulted from rape or incest. Mr. Annas sites the influence of Catholic bishops and, more importantly, a Christian group of political leaders who meet together outside of Congress as primarily responsible for the Stupak amendment. He refers to this Christian group of leaders as a fundamentalist, previously-secret group called the Family or the Fellowship. He states abortion opponents defend the Stupak amendment as merely continuing the Hyde amendment, an amendment attached to every HHS Appropriation Act since 1976. He acknowledges that the Hyde amendment prohibits federal funding for any “health benefits coverage that includes abortion.” He further acknowledges the health bill requires states to offer at least two health plans to the uninsured, one allowing abortion and one not. The plan allowing abortion must “segregate out” the source of funding allowing only state money, not federal money, be used for abortion. Additionally, insurance companies would receive subsidies, including those companies offering abortion. The Secretary of HHS would set the price to cover abortion services. He adds that Senators Hatch and Brownback who have promoted the Stupak amendment in the Senate would oppose health care reform in general and therefore would vote against it even if the bill outlawed federal funding of abortion. He then asks and answers three questions: Do the health care reform bills meet President Obama’s no federal-funding promise? Do they follow the Hyde Amendment tradition? And do they represent good public health policy? In response, Mr. Annas’ views regarding the influence of the Catholic bishops and this Christian group of leaders in promoting and passing the Stupak amendment ignore public feeling regarding government funded abortion in the new health bill. A Quinnipiac poll of likely voters found 72% opposed government funding of abortion in any new health care system created by the government. Is such overwhelming public opposition insignificant? Certainly not. Does public opposition influence legislation? Yes, of course. In addition, are private meetings of Christian leaders allowed outside the halls of Congress? Isn’t freedom of association one of our most basic rights? Yet, Mr. Annas implies a sinister motive behind their association. Mr. Annas has no trouble dispatching the abortion opposition of Senators Hatch and Brownback as disingenuous since they oppose this health care bill in general. However, his argument makes little sense. Just because they oppose the bill in general does not lessen their desire to eliminate abortion coverage from the bill. Regarding his three questions, he answers yes to the first, assuring us the health care reform bill fulfills the Presidents wish of no federal funds for abortion. He explains the plan would require funds for abortion come from insurance companies or the states, not the federal government. He adds opponents call this language a “bookkeeping trick.” However, the contention that the funds for abortion come only from the other sources clouds the truth. The federal government provides funds to state plans for the uninsured including those offering abortion and provides funds to insurance companies who offer abortion. The federal government claims innocence as if one hand does not know what the other is doing. But the federal funds are there, subsidizing these plans which offer abortion. A “bookkeeping trick” is an accurate assessment of this proposal. He then equates the salary a federal worker gets from the government as the government funding abortion. His statement ignores what everyone knows. Once a person receives a paycheck, the money belongs to that person to use as he or she would please and is no longer a government fund. Private use of private funds is not government funding of abortion. Also, since the secretary of HHS sets the price the states will pay for abortion services, what is to prevent the secretary from setting the price at any rate? The states and insurance companies contribution for abortions could be next to nothing depending on the whim of that one person. To the second question Mr. Annas implies the Stupak amendment goes far beyond the Hyde amendment in restricting abortion. A closer look finds otherwise. With the Stupak amendment, any insurer on the government-mandated, government-approved exchange could not offer abortion services effectively eliminating expansion of abortion much like the Hyde amendment. Without the Stupak amendment, however, the government could approve admission to the insurance exchange for a plan offering abortion service and deny admission to the exchange for a plan not offering abortion services since the bill mandates government approval of plans. Thus, abortion coverage could be greatly expanded, the opposite of the effect of the Hyde amendment today. Had the government required approval for every health plan in the US in 1978, the Hyde amendment would have been worthless. Mr. Annas answers his third question by contending the Stupak amendment eliminates medically necessary abortion, defining medically necessary as allowing abortion for the health of the mother. Therefore, the Stupak amendment is not good public health policy. But, the health exception opens the door for abortion for nearly any reason, reasons as minor as “I’m stressed by the pregnancy.” That statement qualifies as anxiety, a diagnosis which would allow abortion to improve the woman’s “health.” The Stupak amendment rightly closes that door. In spite of President Obama’s recent assurances, his past statements make clear his commitment to seeing abortion included in any health care reform law. The Senate version clearly allows that. Matt Anderson, MD, AAPLOG Board