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A central puzzle of the health reform debate is why Rep. Bart Stupak, D-Mich., keeps saying that the Senate-passed bill allows taxpayer dollars to be spent on abortions. The U.S. Conference of Catholic Bishops says it, too. This dispute concerns (or at least pretends to concern) matters of fact, not belief. The question of whether the government funds a given medical procedure is not like the question of whether human life begins at conception. It's empirical, not ideological. And Stupak happens to be wrong. Stupak's and the bishops' claim is important because abortion is the single likeliest issue to scuttle the bill. Stupak says that "at least" 12 pro-life House members who previously voted aye on health reform, including himself, will vote against President Obama's package, which is based on the Senate bill, unless it contains abortion language that he inserted into the House bill. The trouble is, Stupak's language can't be shoehorned into President Obama's package, because it's nonbudgetary and therefore ineligible for inclusion in a budget reconciliation bill. Republican Scott Brown's Massachusetts Senate victory made reconciliation the only possible vehicle for passing health care reform.
If House Speaker Nancy Pelosi loses a dozen pro-life votes, then health care reform will fail. Already health reform's five-vote House victory margin in November is down to three due to the resignations of three representatives and the death of a fourth. Take away just Stupak and Rep. Joseph Cao of Louisiana (the only Republican who voted aye, who is similarly threatening an abortion-based nay vote), and health reform lacks even that narrow majority. Pelosi may pick up a few Democrats who voted against the bill last time, but it's extremely doubtful that she can pick up 11, which is what she'd need to compensate for losing 12. (That's before we even consider possible attrition among Blue Dog Democrats who voted aye last time, or the possible resignation of the pro-reform Rep. Charles Rangel, D-N.Y., who's in hot water for breaking the House gift rule and just gave up the chairmanship of the House ways and means committee.)
Given these stakes, it's worth making some effort to find out what led Stupak and the bishops to think that health reform would spend federal funds on abortion.
"If you go to Page 2069 through Page 2078 [of the Senate bill]," Stupak told George Stephanopoulos on March 4 on Good Morning America, "you will find in there the federal government would directly subsidize abortions, plus every enrollee in the Office of Personnel Management-enrolled plan, every enrollee has to pay a minimum of one dollar per month toward reproductive rights, which includes abortions." Stupak is here referring to the exchanges created under health reform and to a nonprofit plan managed by the Office of Personnel Management that would be sold through the exchanges. The latter was a consolation prize to supporters of a public-option government health insurance program that didn't make it into the bill.
Let's go to Page 2069 through Page 2078 of the Senate-passed bill. It says, "If a qualified plan provides [abortion] coverage … the issuer of the plan shall not use any amount attributable to [health reform's government-funding mechanisms] for purposes of paying for such services." (This is on Page 2072.) That seems pretty straightforward. No government funding for abortions. (Except in the case of rape, incest, or a threat to the mother's life—the same exceptions granted under current law.) If a health insurer selling through the exchanges wishes to offer abortion coverage—the federal government may not require it to do so, and the state where the exchange is located may (the bill states) pass a law forbidding it to do so—then the insurer must collect from each enrollee (regardless of sex or age) a separate payment to cover abortion. The insurer must keep this pool of money separate to ensure it won't be commingled with so much as a nickel of government subsidy. (This is on Pages 2072-2074.)
Stupak is right that anyone who enrolls through the exchange in a health plan that covers abortions must pay a nominal sum (defined on Page 125 of the bill as not less than "$1 per enrollee, per month") into the specially segregated abortion fund. But Stupak is wrong to say this applies to "every enrollee." If an enrollee objects morally to spending one un-government-subsidized dollar to cover abortion, then he or she can simply choose a different health plan offered through the exchange, one that doesn't cover abortions. (Under the Senate bill, every insurance exchange must offer at least one abortion-free health plan.)
One dollar exceeds health insurers' actual cost in providing abortion coverage. In fact, it's entirely symbolic. The law stipulates that in calculating abortions' cost, insurers may consider how much they spend to finance abortions but not how much they save in foregone prenatal care, delivery, or postnatal care. (This is on Pages 2074-2075.) This is to keep insurers from pondering the gruesome reality—one they surely know already—that covering abortions actually saves them money. For health insurers, the true cost of abortion coverage is less than zero, because hospitals and doctors charge less to perform abortions than they do to tend pregnant women before, during, and after childbirth. (Ironically, only the Senate bill—not the House bill—provides some small counterweight to this calculus by increasing aid for adoption assistance.)