Federal subsidization of insurance coverage for abortion services was among the most contentious issues in the healthcare debate. Pro-life groups stood firm in their opposition to such funding, to the point of opposing the entire legislative package unless it was fully and definitely removed from the bill. Moreover, they worked tirelessly as the legislation was under consideration to advance language that would have made it absolutely clear that direct federal funding of elective abortions would not be a part of the reformed system.
In the end, those efforts came up short because the pro-lifers' supposed congressional allies on the Democratic side abandoned them when it mattered most. The result is that the new law does provide taxpayer funding of elective abortions, for the first time in many years.
But passage of the new law did not end the debate, on abortion coverage or health care more generally. As was evident in the 2010 midterm election, a plurality of Americans remains strongly opposed to the bill that passed. Scores of the new law's most ardent supporters were swept out of office by the voters. Now, a strong movement is building to repeal what was passed and replace it with a reform program more consistent with American values. The push for “repeal and replace” will almost certainly be among the most prominent themes of the new Republican House come January.
However, Richard Stith, a pro-life law professor at Valparaiso University, is urging his fellow pro-lifers to stay off the “repeal and replace” bandwagon. In an article for First Things online, he has suggested that a more promising approach for pro-lifers is amending the new law with clear pro-life language.
His logic goes something like this. In the healthcare marketplace of today (before the new law's provisions take effect), private insurance, including plans organized by employers, more often than not covers elective abortions. Under the new law, the government will start running a larger share of the insurance marketplace in 2014, and subsidize it explicitly with tax dollars. That means more Americans who are now in today's private insurance market will get their coverage in the future through a system organized by the government. Because taxpayer money will be involved, pro-lifers sought to extend the prohibition against funding of elective abortions — a prohibition that now applies to other tax-financed health care like Medicaid — to the new government-managed marketplace too. Had they not been defeated in that effort, they would have successfully removed elective abortions from insurance coverage for millions of people who are in plans that pay for such abortions today. So, Stith argues, the solution here is not to revert to the anti-life status quo of today's private insurance market, but to extend the pro-life protections which apply to taxpayer-funded health care to the entire government-managed marketplace that will emerge in 2014.
Stith has a point. It's true that many Americans are unknowingly subsidizing elective abortions through their private health insurance premiums today. They often have no choice in the matter, as their employers are making the decisions about what's covered and what's not in employment-based plans. Stith's perspective is certainly a legitimate position for a pro-lifer to take, given where things stand.
But is it the only legitimate position for pro-lifers? The answer is most definitely “no.”
The issue of how a healthcare system addresses abortion provision is of course of paramount concern. Indeed, it is a necessary condition of an acceptable program that it not force Americans to subsidize the elective abortions of others. That is a non-negotiable first principle that pro-lifers have rightly made their top priority.
But for many Americans, including many pro-lifers, that is a necessary but not sufficient criterion for determining the acceptability of a reform program. There's much, much more to consider. For many pro-lifers, even if the new healthcare law were amended to include the Hyde Amendment (against funding abortion) and Weldon Amendment (conscience protections), the amended law would still be so flawed, because of what it would do to the American economy as well as American health care, that the only remedy is its full repeal and replacement with economically sound reform that is also pro-life. Of course, pro-lifers are under no obligation to share this point of view. It is not a precondition for pro-life sentiments. But neither are pro-lifers under any obligation to accept at face value the supposed benefits of the new law when reason tells them otherwise.
The basic premise of the new healthcare law is that the federal government has the capacity to allocate resources in the health sector to promote equity and efficiency. There is abundant evidence that demonstrates this to be a very dubious assumption. Instead of promoting quality and efficient health care, the government pursues budget cutting with arbitrary, across-the-board payment-rate reductions for those providing medical services. There's no effort to distinguish based on how well or badly they treat their patients. Everyone gets cut at the same rate, and the predictable result is that willing suppliers of services leave the marketplace. The only way to then reconcile supply and demand is with queues and waiting lists, which are commonplace in Canada and the United Kingdom. Putting the government in the cost-control driver's seat is a recipe for a long-term decline in the quality of American medicine.
Further, the new law is based on deceptive budgetary and economic assumptions that mask the true costs of what was passed. The official cost projections are alarming enough — $1 trillion in spending over the next decade, financed by $500 billion in Medicare cuts (mainly in the form of lower payments for services) and another $700 billion in tax hikes. But the reality will be far worse than that. The centerpiece of the new law is a very generous new subsidy program for health insurance, available to families with incomes between 133 and 400 percent of the federal poverty line. Census data shows there are 111 million people in that income range, but official estimates assume only 20 million or so will get the new subsidies. The assumption is that many millions of otherwise qualified people will stay in job-based coverage, and thus lose out on thousands of dollars in federal support. That's never happened before with an entitlement program, and not likely to happen this time. One way or another, the vast majority of those eligible for financial support will end up getting it, and the cost of the new law will soar, by another $1 trillion over ten years according to one estimate.
There are many other important reasons to have deep reservations about the new law. It will discourage hiring by employers, especially among low-wage workers, because employers will get penalized with fines if those workers end up in government-subsidized insurance. It creates new penalties for marriage, by handing out more subsidies to unmarried couples than to married ones with similar incomes. And it hands over to the government vast new power to insert itself into medical decisions.
Proponents of the new law will argue that its main achievement is covering about 30 million people with insurance who do not have it today. The truth is that many of those people who would gain coverage would do so only because they were forced to sign up or else pay a new fine to the federal government. Many of them are younger and far healthier t
han the average American, which is why they hadn't signed up previously. The number of very sick Americans who would gain new coverage under the proposal is far, far less than 30 million.
There are much better ways to address the genuine needs of the uninsured than what was passed. The fundamental problem in American health care is insufficient productivity by the health sector. The solution is not top-down micromanagement from Washington, D.C., but a functioning marketplace in which the government provides oversight but consumers and patients direct the allocation of resources. That can be done by converting today's federal support for insurance into support that the beneficiaries themselves direct and control. Indeed, a crucial reform would be to give all American households a fixed tax credit — about $6,000 per family — that must be used for the purchase of an insurance plan. This would take the place of today's tax preference for job-based plans and would guarantee insurance coverage to the entire U.S. population. It would do so in a way that then engendered the kind of dynamic response in the marketplace that could transform American medicine for the better. And it could be an absolutely pro-life step by inclusion of a clear prohibition against coverage of elective abortions in any plan purchased by the credit.
No one suggests that all pro-lifers must adhere to this kind of thinking and support “repeal and replace.” But, at the same time, it should not be expected that all pro-lifers will be satisfied with adding a Hyde-like amendment to what has already been passed. Pro-lifers in Congress would certainly support that step. But there's a genuine debate still underway in this country about the best way to fix American health care, and many pro-lifers believe firmly that a sensible “repeal and replace” program is the most prudent and principled course.
James C. Capretta is a fellow at the Ethics and Public Policy Center.