The fight over abortion insurance is smaller than it looks.

The fight over abortion insurance is smaller than it looks.

The fight over abortion insurance is smaller than it looks.

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Dec. 23 2009 8:57 AM

All Abort

The fight over abortion insurance is smaller than it looks.

Left: Bart Stupak. Right: Ben Nelson.
Bart Stupak and Ben Nelson

After trillions of dollars, decades of debate, and months of legislative haggling, the fate of health care in the United States is coming down to an old-fashioned moral issue. Pro-lifers and pro-choicers are fighting over insurance coverage of abortions. Each camp seems capable of killing the legislation pending in Congress. Abortion, we're told, is different from other issues caught up in the health care debate. It's a question of ultimate values, impervious to compromise.

William Saletan William Saletan

Will Saletan writes about politics, science, technology, and other stuff for Slate. He’s the author of Bearing Right.

Nonsense. Lawmakers on both sides have already agreed on principles for working out the abortion question. The differences among the competing proposals are almost entirely technical. Zealots may care about the details, but most Americans don't. Let's cut a deal and move on.

None of the proposals under discussion would ban abortion. None would take away your right to buy abortion coverage with your own money. None would force you to pay for somebody else's abortion. These are the conceptual parameters on which all sides have, for the time being, agreed.

When the health care debate started, the big problem was the public option. If it covered abortion, pro-lifers would feel coerced to pay for killing babies. It it didn't cover abortions, pro-choicers would feel robbed of their rights. But now the public option is kaput. So the debate has narrowed to how we treat the mixture of public subsidies with private premiums in federally supervised insurance exchanges. This is a more manageable problem. The framework for addressing it has been broadly accepted: We have to keep public money from getting mixed up in abortions. The question is how.

The original House bill said "affordability credits"—federal subsides for purchasing private health insurance—could "not be used for payment" of elective abortion costs. Pro-lifers found that language too vague. So pro-choicers offered the Capps amendment, which required insurers to prove their compliance with the separate-funds rule through "assurances satisfactory to the Commissioner" of the health insurance program. That, too, was vague. But the Capps amendment began to make compliance measurable. It required the commissioner to calculate the cost of abortion coverage and define the limits of the abortion premiums pool.

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Pro-lifers remained unsatisfied, so Rep. Brad Ellsworth, D-Ind., offered a compromise amendment. It imposed "segregation" of abortion funds based on "generally accepted accounting requirements, circulars on funds management of the Office of Management and Budget, and guidance on accounting of the Government Accountability Office." Some House pro-lifers were willing to go for that, but others, led by Rep. Bart Stupak, D-Mich., refused. They saw Ellsworth, like Capps, as a bookkeeping stunt. Insurers would take federal subsidies with one hand and write abortion checks with the other hand.

Stupak held out for his own amendment, which prohibited any money "authorized or appropriated" by the House health care bill from paying "any part of the costs of any health plan that includes coverage of abortion." That sounded quite strict. But Stupak permitted individuals, cities, and states to buy abortion-inclusive insurance plans or "separate or supplemental coverage for abortions" as long as the money didn't flow through federal coffers.

The House adopted Stupak's amendment. But in the Senate, Majority Leader Harry Reid issued a bill with language more like Capps or Ellsworth. Reid's version said insurers that covered abortions had to "segregate an amount" of money sufficient to cover these procedures. Pro-lifers countered with a clone of the Stupak amendment, but it failed. Finally, in backstage talks brokered by Reid and White House emissaries, three key senators cut a deal. Pro-choice Sens. Barbara Boxer, D-Calif., and Patty Murray, D-Wash., agreed to language negotiated with pro-life Sen. Ben Nelson, D-Neb.

The language—let's call it the Nelson amendment—requires insurers to "collect from each enrollee" a "separate payment" for any abortion coverage they wish to buy. The insurer then has to "deposit all such separate payments into separate allocations accounts." Nelson's language, like Reid's and Capps', adds complex rules to make sure no hidden costs of abortion coverage are passed along to taxpayers.

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Advocates on both sides hate the Nelson deal. Pro-life groups are demanding that the bill be killed unless Nelson's language is changed to Stupak's. Pro-choice groups are  demanding that the bill be killed unless Nelson's language is changed to Capps', Reid's, or Ellsworth's. With just 220 votes in the House and 60 in the Senate, Democratic leaders are at the mercy of abortion hard-liners. Either side can sink the bill.

This is preposterous. Look at the competing amendments. They all segregate abortion money. The only difference is in who does the segregating and when this takes place. Nelson and Stupak would do it up front, when you pay your premiums. Nelson lets the government regulate abortion-insurance transactions; Stupak doesn't, lest the government be complicit. Capps and Reid let you write a single check and leave it to insurers to separate the funds. Ellsworth specifies a bunch of bookkeeping rules to keep the accounts separate. These variations are hardly cosmic. Each version has pros, cons, and complications. But the pros, cons, and complications are technical. They can be worked out.

Abortion advocacy groups, accustomed to epic struggles, exaggerate the differences. The National Right to Life Committee dismisses Nelson's amendment as a "bookkeeping requirement." So what? Stupak's amendment is a bookkeeping requirement, too. On the other side, Planned Parenthood claims, "There is no sound policy reason to require women to pay separately for their abortion coverage other than to try to shame them and draw attention to the abortion coverage." Come on. Everyone, including Planned Parenthood, has agreed to keep federal money out of abortion in health care reform. To do this, you have to distinguish the money that goes to abortion. Separate premiums are an obvious way to do it. Are they cumbersome? In the age of paper checks, sure. But in the age of iTunes, it's manageable.

Each side has legitimate worries. Pro-choicers fear that insurers will abandon abortion coverage. Pro-lifers fear that insurers will be forced to include it. Pro-choicers fear that women won't buy abortion coverage if the premiums are separated up front. Pro-lifers fear that abortion opponents will be suckered into abortion coverage if the premiums aren't separated up front. We'll have years of studies, hearings, legislation, and lawsuits to follow up on these concerns and fine-tune the policy. The complications are worth raising. But they aren't worth killing the bill.

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