Solving the health reform/abortion conundrum

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To subsidize coverage of abortion services or not to subsidize, that is the question. Pro-life activists and legislators don’t want health insurance reform to provide a back door for federal funding of abortions. However, not only could that make it impossible for some taxpayers to obtain coverage for abortion services that private insurers now offer, but it could also run up against legal requirements in some states that abortions services be available to women who can’t afford them. The answer: federalization.

As Ezra Klein argues, the core of the reform proposals making their way through Congress is the health insurance exchange, a regulated market where consumers can go to purchase the best plan for them. The exchange would require providers to meet certain standards for marketing and coverage, and permit them to compete on price and additional coverage offered. Currently under consideration are a single national exchange or individual state exchanges, such as the Commonwealth Connector that is part of the Massachusetts health plan passed under Mitt Romney. The Massachusetts plan, by the way, does cover abortion services.

State health insurance exchanges could be easily be differentiated in such a way as to cover or not cover abortion services, depending on the preferences–and dollars–of the state in question. The model for such differential treatment is Medicaid coverage. The problem is that state insurance exchanges are a much weaker option than a national exchange. For starters, the pools of customers would be much smaller, and they are therefore far less likely to generate the savings that national pools would. But in principle, there’s no reason a national exchange couldn’t be set up to allow for different state requirements–in this case on abortion. The minimum, federally subsidized coverage standard would be what’s currently required under Medicaid: federal funding in cases of rape, incest, and endangerment to the life of the pregnant woman. Subsidies for any additional abortion services mandated by individual states would have to come from those states.

Would such a approach fly? On June 25, 19 pro-life Democrats wrote a letter to Nancy Pelosi saying that they could not support “any health care reform proposal unless it explicitly excludes abortion from the scope of any government-defined or subsidized health insurance plan.” That would seem to exclude a federalized solution. Last week, however, a group of five more centrist Democrats led by Ohio Rep. Tim Ryan (of Ryan-DeLauro) sent their own letter to Pelosi advocating an approach that maintains the current status quo in the private insurance market while not permitting federal funds to be used to pay for abortions. Such an approach seems more amenable to federalization, assuming the willingness of the sponsors to accept the Medicaid standard. Call it a common ground solution, if you must.

Update: Both Dan Gilgoff and Jacqui Salmon call attention today to President Obama’s apparent ruling out of government funding of abortions, in an interview with Katie Couric:

I’m pro-choice, but I think we also have the tradition in this town,
historically, of not financing abortions as part of government-funded
healthcare. My main focus is making sure that people have options of
high-quality care at the lowest possible price.

But, as noted above, the tradition in D.C. (since 1993) has been to fund abortions under Medicaid in certain circumstances. Is the president aware of that?