Health care legislation before the U.S. Congress would allow a new government-sponsored insurance plan to cover abortions, a decision that would affect millions of women and recast federal policy on the divisive issue.
Federal funds for abortions are now restricted to cases involving rape, incest or danger to the health of the mother. Abortion opponents say those restrictions should carry over to any health insurance sold through a new marketplace envisioned under the legislation, an exchange where people would choose private coverage or the public plan.
Abortion rights supporters say that would have the effect of denying coverage for abortion to millions of women who now have it through workplace insurance and are expected to join the exchange.
Advocates on both sides are preparing for a renewed battle over abortion, which could jeopardize political support for President Barack Obama's health care initiative aimed at covering nearly 50 million uninsured and restraining medical costs.
"We want to see people who have no health insurance get it, but this is a sticking point," said Richard Doerflinger, associate director of pro-life activities for the U.S. Conference of Catholic Bishops. "We don't want health care reform to be the vehicle for mandating abortion."
Donna Crane, policy director for NARAL Pro-Choice America, said abortion opponents "want an abortion ban in private insurance, and that's not neutrality at all — that's a radical departure from current law. They want something far more extreme than where I think the American public is."
A compromise approved by a House committee last week attempted to balance questions of federal funding, personal choice and the conscience rights of clinicians. It would allow the public plan to cover abortion but without using federal funds, only dollars from beneficiary premiums. Likewise, private plans in the new insurance exchange could opt to cover abortion, but no federal subsidies would be used to pay for the procedure.
"It's a sham," said Douglas Johnson, legislative director for National Right to Life. "It's a bookkeeping scheme. The plan pays for abortion, and the government subsidizes the plan."
Representative Lois Capps, a governing Democrat from California and author of the compromise, said she was trying to craft a solution that would accommodate both sides. Her amendment also would allow plans that covered no abortions whatsoever — not even in cases of rape, incest or to save the life of the mother — to be offered through the insurance exchange.
"With all due respect, not everyone adheres to what the Catholic bishops believe," said Capps, who supports abortion rights. "Our country allows for both sides, and our health plan should reflect that as well."
For years, abortion rights supporters and abortion opponents have waged the equivalent of trench warfare over restrictions on federal funding. Abortion opponents have largely prevailed, instituting restrictions that bar federal funding for abortion, except in cases of rape and incest or if the mother's life would be endangered.
A law called the Hyde amendment applies the restrictions to Medicaid, forcing states that cover abortion for low-income women to do so with their own money. Separate laws apply the restrictions to the federal employee health plan and military and other programs.
But the health overhaul would create a stream of federal funding not covered by the restrictions.
The new federal funds would take the form of subsidies for low- and middle-income people buying coverage through the health insurance exchange. Subsidies would be available for people to buy the public plan or private coverage. Making things more complicated, the federal subsidies would be mixed in with contributions from individuals and employers. Eventually, most Americans could end up getting their coverage through the exchange.
The Democratic health care legislation as originally introduced in the House and Senate did not mention abortion. That rang alarm bells for abortion opponents.
Since abortion is a legal medical procedure, experts on both sides say not mentioning it would allow health care plans in the new insurance exchange to provide unrestricted coverage.
It would mirror the private insurance market, where abortion coverage is widely available. A Guttmacher Institute study found that 87 percent of typical employer plans covered abortion in 2002, while a Kaiser Family Foundation survey in 2003 found that 46 percent of workers in employer plans had coverage for abortions. The studies asked different questions, which might help explain the disparity in the results.
In the Senate, the plan passed by the health committee is still largely silent on the abortion issue. Staff aides confirmed that the public plan — and private insurance offered in the exchange — would be allowed to cover abortion, without funding restrictions.
Under both the House and Senate approaches, the decision to offer abortion coverage in the public plan would be made by the health and human services secretary.
Abortion opponents are seeking a prohibition against using any federal subsidies to pay for abortions or for any part of any costs of a health plan that offers abortion. Such a proposal was rejected by the House Energy and Commerce Committee, the same panel that approved Capps' amendment.
But abortion opponents say they can't accept a public plan that would cover abortion. And they say private plans in the insurance exchange should offer abortion coverage separately, as an option.