Public funding of elective abortions versus contraceptive access policy

Reducing Abortion and Protecting Contraception

Policy Issue Paper

Policy Issue Paper: Reducing Elective Abortions and Protecting Access to Contraception

Policy Issue Paper: Reducing Elective Abortions and Protecting Access to Contraception

On February 12, 2013, U.S. District Judge Neil Wake ruled unconstitutional an Arizona law that prohibited any health care provider who offers abortions services from receiving Medicaid reimbursements (Rau, 2013). The intended goal of this law was to make it difficult for abortion providers caring for Medicaid beneficiaries to stay in business, even if the care provided were unrelated to abortion or abortion-related services. With nearly 17.7% of the U.S. population enrolled in Medicaid (Mackun and Wilson, 2011; Klees, Wolfe, and Curtis, 2012) and Medicaid expenditures representing 33% of all federal dollars spent on health care, the impact on health care providers who also provide abortion services would be substantial.

On February 20, 2013, the American Family Association (AFA) filed suit in the U.S. District Court for Northern Mississippi against the U.S. Department of Health and Human Services (HHS), alleging violation of their religious freedom (PR Newswire, 2013). The HHS has mandated that all employees are required to have health insurance, which includes coverage for abortion counseling and abortifacients. In essence, AFA members believe it violates HHS employees' religious and moral rights to be forced to participate in health plans that include abortion services.

The above court cases represent a tiny sample of the skirmishes that take place between anti-abortion groups and abortion rights advocates. This war predates the U.S. Supreme Court's decision in Roe v. Wade (1973), which established a woman's right to obtain a first trimester abortion. Since then, anti-abortion advocates have focused their efforts on ending the policy of using public funds to pay for abortions for low-income women. This policy issue paper will present an argument that public funding of elective abortions should be eliminated, while at the same time protecting the public's access to contraceptives.

Policy Problem

One of the main arguments against the public funding of abortions is that taxpayer dollars are supporting family planning organizations under Title X. Chuck Donavan of the Heritage Foundation argues that public dollars awarded to family planning organizations, like Planned Parenthood, supports all the activities the organization is engaged in, including elective abortions (Miles, 2011). Close to 4,500 family planning clinics serving five million Americans nationally receive Title X grants, which amounted to $317 million in 2010. The less controversial services these organizations provide include contraceptives, venereal disease testing, cancer screenings, vasectomies, prenatal care, and educational services related to reproductive health. Since many family planning organizations also provide abortions and abortion-related services, Title X money supports these services as well. As Republican lawmakers point out, why should taxpayers, who are morally and religiously opposed to abortion, be forced to pay for abortions and abortion-related services. For others who may be more middle-of-the-road on the abortion issue, the idea that some women, with the consent of their treating physicians, are using abortion as a form of birth control is morally abhorrent. The use of tax dollars to support this practice has motivated many Americans to advocate for alternatives to abortion.

Background

The war over abortion has raged for decades, but following the 1973 U.S. Supreme Court decision in Roe v. Wade, a woman's (qualified) right to have an abortion was established under the Fourteenth Amendment's due process privacy protections. For the next four years, Medicaid covered the costs of all abortions requested by low-income beneficiaries (NAF, 2006). Title X money is therefore not the only source of federal funds supporting family planning organizations (Miles, 2011). The lion's share of funding for family planning spending comes from Medicaid, which represented 71% of all federal dollars received by family planning organizations in 2006. By comparison, Title X money represented only 12%. During fiscal year 2010, $1.8 billion was given to family planning organizations by the Centers for Medicare & Medicaid Services (CMS) through Medicaid (Guttmacher Institute, 2012). This represented close to 75% of the operating budgets for family planning organizations that year and almost 0.5% of all Medicaid spending.

Three years after the Roe v. Wade (1973) decision, a compromise was reached in the form of the Hyde Amendment (NAF, 2006). This federal legislation limited federal coverage of abortions to cases of rape, incest, and when the life of the mother was in danger. Since 1976 the Hyde Amendment has undergone repeated revisions, from more to less restrictive depending on the political winds at the time, but the current version resembles the original (Mann, 2011).

A recent estimate suggests that close to seven million women of reproductive age are covered by Medicaid (Boonstra, 2007), which represents 12.8% of all beneficiaries. At the same time, an estimated 1.2 million abortions are performed each year in the U.S. By approximately 2% of women between the ages of 15 and 44 (Robertson, 2010). These numbers suggest that of the 60 million women between the ages of 15 and 44 in the U.S., those covered by Medicaid would represent close to 12% of this demographic. These calculations would predict that close to 140,000 abortions each year are obtained by women who have Medicaid coverage; however, only a small proportion of these abortions would have qualified for Medicaid coverage under the Hyde Amendment. The actual number of such abortions is unknown.

The number of abortions qualifying for Medicare coverage is expected to increase dramatically in 2014 when all low-income Americans under the age of 65 become eligible under the Patient Protection and Affordable Care Act of 2010 (ACA) (Klees, Wolfe, and Curtis, 2012; Natoli, Cheh, and Verghese, 2011). The ACA is predicted to increase Medicaid eligibility by 20 million, in addition to the 54.7 million already enrolled. Of these, about 2.56 million women would be of reproductive age, representing 51,200 abortions annually.

The ACA includes language that prevents federal sanctions against providers who choose not to provide abortions, abortion-related services, or abortion referrals (CMS, 2010). This 'right of conscious' provision is consistent with a number of state laws that have been enacted that provide legal protection for medical professionals who feel a moral or religious obligation to not participate in, or provide assistance to patients seeking, abortions (Beal and Cappiello, 2008). A 2007 survey revealed that nearly 25% of U.S. physicians feel no professional obligation to even refer patients to other physicians, let alone provide advice or services (Baker, 2009).

Robert Baker (2009), one time chair of the American Society for Bioethics and Humanities, argued for a more nuanced and middle-of-the-road approach in situations when the moral and religious beliefs of medical professionals interferes with a patient's ability to obtain legally-protected care. According to Baker, health care organizations should make room for clinicians who believe abortions violate their mores, while still protecting the patient's right to receive these services. One solution would be to implement contingency plans to handle morally challenging requests made by patients, thereby meeting the sacrosanct goal of moral neutrality in the medical profession. Such an approach would satisfy most ethics principles, including range, nonmaleficence, justice, and faithfulness, while providing a mechanism for professionals to perform their duties without fear of losing their job or license.

Issue Statement

The results of the survey reviewed by Baker (2009) suggest that between 20 and 25% of physicians are morally opposed to abortions or providing patients with any assistance in obtaining an abortion. This finding seems to indicate that a significant number of clinicians are frequently confronted by patients making requests that they find morally objectionable. As former Assistant Secretary for Health Garcia stated "… health providers shouldn't have to check their conscience at the hospital door & #8230;" (cited by Baker, 2009, p. ii). No one, probably not even the most adamant pro-choice advocates, considers abortion morally equivalent to contraception. Therefore, it is time to end the practice of using abortion as a method of birth control, while at the same time protecting access to contraceptives.

Stakeholders

One of the primary stakeholders are the clinicians who morally object to providing abortion services, but fear job loss and license revocation if they perform their duties in accordance with their beliefs. Another primary stakeholder is the women seeking abortions for a variety of reasons, under the protection of the Fourteenth Amendment as interpreted by the U.S. Supreme Court in Roe v. Wade (1973). The final primary stakeholder would be the unborn fetuses, whose legal rights mature incrementally during gestation and are protected by state governments. The other stakeholders include American taxpayers, who feel their civil rights are being violated when forced by the threat of sanctions to fund abortions. Medical licensing boards and administrators for health care providers would also be interested in the outcome, but primarily from a policy change perspective.

Policy Goals and Objectives

While 'right of conscious' provisions will provide legal protections for providers who choose not to engage in abortions or assist patients in obtaining abortions, the ACA provision that provides this protection does not supersede federal and state laws (CMS, 2010). The implementation of conscientious objector contingencies by healthcare providers mentioned by Baker (2009) seems viable, but also prone to the same dangers faced by clinicians that 'right of conscious' provisions are designed to solve. In other words, medical professionals who are morally and religiously opposed to assisting in abortions may still face informal sanctions.

Of the 6.6 million pregnancies that occurred in 2008, 1.2 and 1.1 million resulted in an abortion or miscarriage, respectively (Ventura, Curtin, Abma, and Henshaw, 2012). This represents a decrease from the percentage of pregnancies resulting in abortions historically. In 2001 and 1994, 21% and 24% of all pregnancies resulted in an abortion, respectively (Finer and Henshaw, 2006). By 2008, the percentage had decreased to 18%. Nearly all age groups contributed equally to this decline, but the biggest drop (15%) was in the under 15 age group (Finer and Henshaw, 2006). This decline has been attributed to more teenagers reporting sexual abstinence, the use of contraceptives, and the availability of diverse and effective contraceptives (Ventura, Curtin, Abma, and Henshaw, 2012). These findings suggest that further reducing the use of abortion as a method of birth control is possible given the effectiveness and wide choice of contraceptives available today.

A policy that discourages the use of abortion as a method of birth control and encourages the use of contraceptives is therefore feasible and probably morally acceptable to a large percentage of the U.S. population. A recent Gallup poll found that 89% of all Americans believe that birth control is morally acceptable, including 82% of all Catholics (Newport, 2012; margin of error is ±4%). By comparison, the same survey found that only 38% of Americans feel that abortion is morally acceptable. Public policy should therefore reflect public sentiment regarding the use of abortion as a form of birth control by enacting legislation that ends public funding of abortion and promotes contraceptive use, education, and availability.

Policy Options and Alternatives

Two bills have been introduced into the 113th Congress of the United States that could help provide a framework upon which this policy issue could be implemented. House bills H.R. 61 (2013) and 728 (2013) respectively call for an end to Title X funding of abortion providers through family planning grants and for duties to be imposed on pharmacies to ensure that Federal Drug Administration (FDA)-approved contraceptives are available to the public. The title of H.R. 61 is "Title X Abortion Provider Prohibition Act" and for H.R. 728 it is "To establish certain duties for pharmacies to ensure provision of Food and Drug Administration-approved contraception, and for other purposes." The Senate versions are identical to the House bills.

H.R. 61 (2013) was introduced to the House on January 3, 2013 by Representative Marsha Blackburn (R) of Tennessee. As of today, 89 cosponsors had signed on to support the bill, the vast majority Republicans. The Senate companion bill has 7 cosponsors. H.R. 728 (2013) was introduced to the House on February 14, 2013 by Representative Carolyn Maloney (D) of New York. H.R. 728 was introduced just a few days ago, which may explain why the full text is not yet available; however, the intent seems clear from the title. As of today, the House version of the bill has 20 cosponsors, all Democrats, while the Senate version has 9 cosponsors. Both bills have been introduced to the appropriate committees.

One option would be to allow these bills to go forward without revision, but another option would be to bring these two bills together in an effort to foster compromise. A third option would be to combine both bills and use the result as a seed to grow a major abortion/contraception reform bill with bipartisan support. The relevant evaluative criteria are political feasibility and funding availability.

Evaluation of Option 3: Seed a Major Abortion/Contraception Reform Bill

Criterion 1: Political Feasibility

Pro-H.R. 61 and 728 (2013) seem to capture the primary goals of either side with respect to publicly-funded reproductive health. H.R. 61 reduces public support of elective abortions by ending Title X family planning grants to abortion providers, which is probably one hurdle among many towards complete elimination of public funding for elective abortions. H.R. 728 attempts to ensure that access to contraception is protected in light of the increasing prevalence of 'right of conscious' legislation and official policy at both state and federal levels. Based on a study by the Guttmacher Institute (2012), over nine million women visited a publicly funded family planning service in 2006 for contraceptives and contraceptive counseling. As a result, nearly 2 million unintended pregnancies and 800,000 abortions were estimated to have been avoided. The economic savings, in terms of taxpayer dollars, was estimated to be equivalent to $5.1 billion dollars in 2008. Given these savings and the results of the Gallup survey (2012), the vast majority of Americans would support reducing the country's dependence on abortion as a form of birth control by increasing the availability of contraceptives.

Con -- Combining two bills that were not designed to be combined will probably receive little support from either side of the isle. For example, some bills are introduced merely to state a policy position or a concern about a policy issue (Yano, Tae, Smith, Noah A., and Wilkerson, 2012). The title of H.R. 728 could be interpreted as a warning to Republicans that Democrats may make 'right of conscious' provisions a bigger issue if public's access to contraceptives is further degraded. In addition, the relatively recent passage of the ACA may make any major health reform legislation a low priority for most legislators. Immigration reform, impending sequestration, gun control, and other similar 'hot topic' legislative agendas (Weber, 2013) would likely steal the air from a comparatively low-priority health reform initiative.