This is a tricky topic, and I’ve seen so many confusing and misleading statements on it. Much of it comes from not thinking carefully enough about how health insurance works. Let me try to describe the coverage of abortion in five hypothetical systems, all mirroring real world examples. Let us assume that the legal status of abortion is the same in each country. And let us assume that all countries have universal coverage.
(1) Single provider. This is a case where the government runs the healthcare system. It runs the hospitals and it pays the staff. The closest real world example would be the UK National Health System. In this country, you can get an abortion either through the public system without paying, or you can pay for it at a private clinic. As far as I know, this is how it works in the UK. In a single-provider model, one can make the case that the government is cooperating directly in each and every abortion. And taxpayer funds are used directly to fund abortion. This is probably the most extreme case. And yet – are the UK bishops campaigning to shut down the NHS?
(2) Single payer. This is a case where healthcare providers are private, but insurance is managed by the government. Let’s assume that it is funded by a special social security contribution. Both revenue and expenses are treated as part of the government budget. Here, if a person has an abortion, the government’s involvement is one step removed. The person pays for the insurance through her own contributions, and the government entity pays for the procedure. This is problematic, but not as bad as (1). How does the Church in Canada and France deal with this?
(3) Unsubsidized private insurance with a public option. In this case, everybody must purchase insurance from a list of private insurers, or a public option (either through employers or on an exchange). For this thought experiment, the nature of the public option is very important. Let’s assume (because it is in accord with recent proposals) that it is a “weak” public option – just like its private competitors, it must negotiate with providers directly. It cannot use government muscle, and it cannot set single payer-style reimbursement rates (in the US context, this means it cannot use Medicare rates). It is also not subsidized by taxpayers, and is fully supported by premiums. How is this treated in an accounting sense? Best practice would suggest it be not be included in the budget, or treated as part of government at all (because it is run on a commercial basis). So if the public option pays for abortion, it is not the same thing as a single payer system paying for abortion. It does not come from the budget, or from the general revenue pool. It’s basically like a private insurer that is managed by the government. Now again, this could be problematic, but not as bad as (2).
(4) Unsubsidized private insurance without a public option. In this case, everybody must purchase insurance from a list of private insurers (either through employers or on an exchange). These private insurers cover abortion. For reasons that I cannot understand, very few people point to the moral implications of this. The US insurance market is presently dominated by a small number of large companies. Most of them cover abortion somewhere. So even if your individual plan does not, you are contributing funds to a company that in all likelihood is paying for somebody’s abortion. In a recent “gotcha” moment, Time’s Amy Sullivan shows that Focus on the Family’s insurance comes from a company that pays for abortion. I see little distinction between paying a dedicated tax to a single payer fund, paying a premium to a public option, or paying a premium to a private insurer. I would say this is at least as problematic as (3), but not at all on the pro-life radar.
(5) Subsidized insurance. One of the main components of the reform is not the public option, but the subsidies to allow people fulfil the individual mandate and get health insurance. Various bills suggest various subsidy levels, some more generous than others. Since you’ll get the subsidy whether or not you choose the public option, let’s set this distinction aside. In this case, the taxpayer is giving a subsidy to a person to purchase an insurance plan that may cover abortion. Yes, there is an issue here, but let’s think about it. Again, it’s the issue of fungibility. Already, the government provides funds to Planned Parenthood, on the understanding that this money does not fund abortion – but isn’t it fungible? Already, Medicare makes payments to hospitals that provide abortion – but isn’t it fungible? Already, the federal government allows states to fund abortions through Medicaid, even if there’s no federal money – but isn’t it fungible? Note also a standard Republican health reform proposal – tax credits – also involves using taxpayer money to subsidize private insurance that covers abortion. Where was the pro-life industry on that one? And we can really push this even further. What is the government provides unemployment benefits and the person uses that money to pay for an abortion? What if tax cuts are used to fund abortion? Clearly, a problem, but a whole murky grey area.
My point here is that there is a whole lot of confusion on this issue. In systems where the moral link between the taxpayer and abortion is more clearcut, the Church does not seem to spend any energy fighting the health insurance system. In the US, the main issue seems to be the fungibility of money and the direct subsidization of abortion. But why is this not also an issue with private insurance?
Don’t get me wrong. I would like the proximity of the healthcare system and the incidence of abortion to be as remote as possible. I fully support the efforts of Bart Stupak, and I hope he succeeds. But how can this be a deal breaker? This is what I have trouble understanding. The late Cardinal Dulles once argued that:
“[a] vote [for an appropriations bill that includes some provisions for funding abortions] might arguably be licit if the funding for abortion were only incidental and could not be removed from a bill that was otherwise very desirable.”
To me, this sums up the current situation perfectly. I have yet to see a compelling moral case over why the treatment of abortion ought to be a dealbreaker, given the remoteness, the consistency with treatment of private insurance, and the experience of other countries.
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