A Woman’s Guide to Proposed Health Care Reform

This article is part of Double X's ongoing coverage of health insurance woes. Read Sarah Wildman's story about being denied coverage for her maternity care [2], readers' tales of health insurance woes [3], Diane McWhorter's troubles with condescending doctors [4], and Linda Hirshman's take on whether Sarah Palin could kill health care reform [5].

In Europe and Canada, governments subsidize everyone’s health care, and insurance covers controversial procedures like abortion and sex changes. At the end of the day, Western Civilization continues to trudge along just fine, thank you very much.

But this is America. Congress broke for summer recess with four out of five pieces of health reform legislation completed and passed out of committee—but with the crucial Senate Finance Committee continuing to dally. And according White House health policy czar Nancy-Ann DeParle, at the top of the list of disagreements among that committee’s bipartisan Gang of Six is abortion. Should health reform legislation refer to the procedure at all, and if so, by protecting access or denying it?

There are other issues at stake as well in the health reform debate specific to women. Here then, is your DoubleX guide to the potential benefits and pratfalls of the various proposals for the health care overhaul.

Abortion Access: During a July 23 webcast intended to mobilize anti-abortion activists against the health care overhaul, Focus on the Family founder James Dobson said [6], “The health care bill being advanced by Congress is the abortion advocates' dream come true.” A coalition of religious right organizations launched the website Stop The Abortion Mandate [7], which claims health reform would force all private insurers to cover abortions, and that doctors would lose their jobs if they refused to perform the procedure. After reform, “insurance companies will have to ensure there are abortionists readily accessible in every region,” the site threatens.

The truth is far more nuanced. The health reform bills in front of Congress do not include lists of medical procedures that insurance companies must cover. None of the legislation even mentions the word “abortion.” If reform passes, an independent council of medical experts, led by the surgeon general, will advise Health and Human Services Secretary Kathleen Sebelius on what basic services private and public insurance plans must cover. The much-feared “abortion on-demand” is unlikely to make the cut. Not only is the issue politically combustible, but most existing private plans cover abortion only in cases of risks to the mother’s health or severe developmental disabilities in the fetus.

What’s more, President Obama has already said he supports a “robust conscience clause” [8] protecting the rights of doctors and nurses to refuse to offer abortions or sterilization, as long as they are willing to refer patients to providers who do offer those procedures.

Reproductive rights advocates are actually playing defense in the health reform battle. Right away, they agreed not to pressure Congress or the White House to overturn the Hyde Amendment as part of reform. This is the law that, since 1976, has prevented Medicaid from funding abortion. Additional bans against abortion coverage for federal employees, women in the military, Peace Corps volunteers, and female prisoners will also be left untouched by the health legislation emerging in the House and Senate.

Still, pro-lifers see a new age of “publicly-funded abortion,” because health reform would provide government subsidies to help poor and middle-class women purchase insurance, and some private plans do offer abortion coverage in some cases. That’s why abortion opponents want to see explicit language written into the bill that would prevent women who receive subsidies from accessing insurance-funded abortion. How likely is this to happen? Max Baucus, the Senate Democrat who chairs the Finance Committee and is leading the down-to-the-wire negotiations, hasn’t ruled it out. And President Obama has signaled he, too, is open to abortion restrictions. In a July 21 interview with Katie Couric, the president said he would consider deferring to the “tradition” of “not financing abortions as part of government-funded health care.”

Contraceptives: The same groups that seek to use health reform to curtail abortion rights have also stepped up their efforts to limit access to hormonal birth control. Here, religious conservatives are encountering more roadblocks. All the existing reform plans mention family planning coverage, which, historically, has been one of Medicaid’s success stories. According to the National Campaign to Prevent Teen and Unplanned Pregnancy, for every $1 the federal government spends providing birth control to poor women through Medicaid and Title X, it saves $4.02. After all, contraceptives are exponentially cheaper than pregnancy and childbirth.

The legislation goes a step further than current policy, allowing states, for the first time, to use federal dollars to provide birth control assistance to women who don’t qualify for Medicaid, but who are still too poor to afford their prescriptions. Currently, if states want to provide such aid, they must go through a cumbersome waiver process, and only half the states have done so.

Maternity Care: If the White House and Congress really want to “bend the cost curve” of American health care so that it doesn’t bankrupt us, maternity care would be a good place to start. For women, childbirth is the number one cause of hospitalization, and Caesarean sections are the most common surgery. In part because of our staggering C-section rate—almost a third of all births now use the procedure—the United States is paying far more for childbirth than are other developed nations. We also spend more because women routinely give birth in the hospital attended to by a doctor, while in other Western nations, pregnancies without complications typically end at a birthing center staffed by registered nurses and midwives.

But the powerful professional associations that represent American doctors, like the American Medical Association, are reluctant to encourage alternatives to hospital births. The health reform bills in front of Congress do little to change existing policies that discourage the use of midwives and birthing centers by making them more costly or even impossible to insure—even though research shows they are just as safe for mothers and babies [9], and result in lower C-section rates.

On the upside for expectant mothers: If reform passes, the medical council that determines a minimum benefits package will almost certainly include prenatal care and childbirth as required services.

Young Women: The post-college set has, potentially, the most to gain from health reform. If any of these bills pass, all Americans age 26 and under would be eligible for coverage under their parents’ plans. This especially affects young women, who use more medical care than young men because they need to go for regular gynecological check-ups and fill their contraceptive prescriptions.

Gender Rating: All the health reform proposals would prevent “gender rating”—the insurance companies’ practice of charging women (who go to the doctor more frequently than men, when they’re older as well as younger) higher premiums.

Access: Where will your insurance come from if and when one of the reform bills pass? If you qualify for employer-based coverage, that will continue to be your most viable—or, perhaps, only—method of attaining insurance. If you are unemployed, self-employed, or you work part-time, you will be able to choose a coverage plan from within a "health insurance exchange," which you can think of as a menu of options, or a regulated marketplace. One item on that menu will likely be a public plan managed by the government, much like Medicare. The others will be private plans that meet the minimum coverage requirements mandated by the HHS secretary.

All the health reform bills expand Medicaid coverage for the very poor, and offer subsidies to help low-income and some middle-class people afford insurance coverage via the exchanges. The House and Senate HELP committee versions of reform are more generous, offering the subsidies to people earning as much as $43,320 a year or families of four earning $88,200. The Senate Finance Committee is likely to cut those numbers down to $32,490 for an individual and $54,930 for a family.

If your income exceeds those limits, you could be expected to pay as much as 15 percent of your salary in health care costs, if you buy it yourself. That’s a hefty bill: A woman earning $50,000 would be on the hook for $7,500, or about the same amount she’d pay currently for a private policy, if no reform bill passed at all. That makes the part of health reform that requires you to have insurance seem a tad unfair. (All four of the Congressional bills would require you to pay a fine equal to 2.5 percent of your income if you don’t qualify for government help and remain uninsured.)

Last note: Even if health reform sails through Congress and onto President Obama’s desk, none of these new programs is likely to be available until 2013. By then, of course, Congress will have had dozens more chances to tinker with the plan. And you’ll have had dozens of more chances to pay for skyrocketing health care costs.