In an attempt to project some semblance of party unity and momentum, House Speaker Paul Ryan unveiled the latest Republican road map for replacing the Affordable Care Act this week. It is not the most detailed document—more a collection of broad-stroke ideas than a concrete policy plan—and it's unclear how much support it would find in Congress. But at least one thing is obvious from this outline: Republicans are looking to turn Obamacare repeal into an assault on abortion access.
Here's how they'd go about it: To make health insurance (somewhat) affordable, Ryan's plan would offer tax credits to all Americans purchasing coverage on the individual market. However, women would not be allowed to use those subsidies to buy plans that paid for abortion. Given that the vast majority of customers would want to use their tax credits, most carriers would likely drop abortion coverage from their offerings.
“It seems pretty clear that this would drastically scale back or possibly eliminate abortion coverage in the individual market,” Adam Sonfield, a senior policy manager at the Guttmacher Institute, told me. He added that the rule could also have “spillover effects” on employer-based insurance, because of the way the Republican idea could affect COBRA coverage.
Reproductive health advocates faced down a similar threat when Congress was crafting Obamacare in 2010. Back then, the House of Representatives passed the notorious Stupak amendment, which would have banned Americans from using the ACA's tax credits to buy coverage that included abortion benefits. The worry then was that if insurers couldn't sell subsidized plans that covered abortion, they wouldn't bother selling any. One analysis from the George Washington University School of Public Health suggested that would spark an industrywide change in standards that would end coverage of medically necessary abortions “for all women, not only those whose coverage is derived through a health insurance exchange.” Before Obamacare became law, however, the Stupak amendment was subbed out for a watered-down replacement proposed by Florida Sen. Bill Nelson.
The map of abortion coverage under the ACA is complicated. Thanks to the Hyde amendment, which prevents federal money from being used to fund abortions, Medicaid can't cover abortion anywhere. Meanwhile, 25 states currently restrict or ban insurance plans sold on Obamacare's insurance exchanges from covering abortion, according to Guttmacher. Ten states limit it on all private insurance plans. But in others there are no restrictions on abortion benefits in the private market at all.
The new Republican plan is a bit like the Stupak amendment on steroids. After all, Obamacare's subsidies are only eligible to those with incomes up to 400 percent of the poverty line. The Republican tax credit would be available to anybody in the individual market, meaning insurers would likely expect pretty much everyone to use one, and tailor their offerings accordingly. (For those wondering: No, Ryan has not said how much the credits would be worth, and since they'd be universal, they'd also likely be pretty small.) You would expect abortion coverage to disappear from the whole individual market rapidly. Like the GW team argued years ago, it's possible that the change in industry norms would lead insurers to drop the benefits from the plans they sell to employers. Some might suggest that women could purchase special riders to cover abortion, but those sorts of add-ons haven't worked particularly well in health insurance, since they tend to be extremely expensive.
It's hard to quantify how deeply the GOP plan would damage abortion access. “Even when women do have private insurance coverage, most of them end up paying out of pocket [for abortions]. What is not clear is why,” Sonfield told me. However, driving abortion coverage out of the individual market would certainly make the procedure less affordable for many, while further stigmatizing a procedure that should be considered a standard part of reproductive care.
Of course, that might be the only part of health reform every Republican will be able to get behind.