What the Health-Care Debate Says About Abortion

In the end, I predict, their bluff won't be called. Abortion-rights supporters have threatened to take down health reform if the final product includes the restrictive language of the House bill. In the end, the dispute will be resolved, with a few legislative tweaks that fully satisfy neither side. And in the end, although they will have succeeded in removing the offending amendment, pro-choice forces will be worse off than before the debate began.

The hard truth laid bare by the health-care debate—hard, at least, for those of us who support abortion rights—is that a Democratic president, Democratic Senate, and Democratic House do not add up to a pro-choice outcome. A victory on health care for abortion-rights supporters will consist, at best, of maintaining the status quo.

This is, of course, just one act being played out in the larger drama of the Obama administration: for all the fervent hope and soaring expectations, politics remains the art of the possible. To govern is to deal—from climate change to Guantánamo. The health-care debate itself features several similar subplots—the public option, illegal immigrants, even gun rights—and how each is resolved affects the other. Lose a few votes here, gain some there.

Abortion remains the omnipresent irritant of American politics. The country seems to have reached an uneasy equipoise on abortion rights: some, but not too much. Yet the adversaries in both sides remain engaged in trench warfare, with every battle over a few hard-fought yards. Abortion opponents have little hope of overturning Roe v. Wade, but they can try to make access more difficult. Supporters of abortion rights are, for the most part, trying to maintain the ground already won.

Meanwhile, abortion is a handy public-policy hand grenade to be tossed in the middle of any legislative battle by those whose goal is to blow things up. The current fight—over whether the health-care bill does enough to make certain that government money isn't used for abortions—underscores abortion's continuing potency as a political weapon.

It presents a sobering tally of the cost, from the point of view of abortion-rights supporters, of the DINO (Democrats in name only) strategy: winning back the House by backing candidates in red districts with politics scarcely different from the Republicans they replaced. Democrats have picked up 56 seats since 2004, but the number of pro-choice members has risen by 44, not nearly as much. "I wish we were fighting for advances," says Nancy Keenan, president of NARAL Pro-Choice America. "Instead, we're just fighting to defend."

As a measure of how much things have changed, consider that back in 1993, the Clinton health-care plan included abortion as part of the minimum benefits package that insurers would have to offer. Now, the compromise language—the language agreed to by pro-choice groups—explicitly excludes it.

As a measure of how quickly things have changed, consider that candidate Obama said he opposed the Hyde amendment, the longstanding prohibition against using federal Medicaid funds to pay for abortions for poor women, except in cases of rape, incest, or where the life of the mother is endangered. "He believes that the federal government should not use its dollars to intrude on a poor woman's decision whether to carry to term or to terminate her pregnancy," the Obama campaign said in answering a questionnaire. Now, President Obama embraces Hyde as the new normal. "I think that there is a balance to be achieved that is consistent with the Hyde amendment, what existed before we reformed health care," Obama told Fox News, although he says the House language goes too far. "I believe in the basic idea that federal dollars shouldn't pay for abortions, but I also think that we shouldn't restrict women's choices." He told ABC News that he wants to make certain "we are not in some way sneaking in funding for abortions." Sneaking in? This is the candidate that NARAL rushed to endorse during the Democratic primaries?

This political evolution, not surprisingly, mirrors a shift in public opinion. Support for—and opposition to—abortion rights has held fairly steady for decades. Two thirds of Americans say they do not want to see Roe v. Wade overturned; even 40 percent of Republicans believe that establishing a constitutional right to an abortion was "a good thing."

But in 1994 the public was closely divided on the question of whether abortion coverage should be a guaranteed benefit: 49 percent opposed it, while 42 percent said it should be included. Now, the Pew Forum on Religion & Public Life reports, 55 percent oppose coverage by a government plan, and just 28 percent support it. At the same time, the issue of federal funding for abortion coverage doesn't drive opposition to health reform. Only 3 percent cite it as the main reason for their opposition.

How this peripheral issue came to ensnarl the health-care debate offers a case study in the theory and practice of interest-group politics. Democratic leaders urged the abortion-rights crowd to stand down on health care. They were told not to push, this time around, for abortion as part of the minimum benefits package. No jockeying to use the opportunity to lift the Hyde amendment.

Abortion-rights supporters agreed, largely because they had to: the votes for what they wanted weren't there. Not only that, they acceded, reluctantly, to compromise language explicitly excluding abortion from the required benefits package as the price of getting the measure out of committee. Now, they'll be lucky if that language—which pro-life supporters denounce as insufficient to prevent federal funds from being used for abortion—survives.

Well-behaved women rarely make history, the bumper sticker instructs, and for many feminist leaders the lesson of the House vote was clear: no more Ms. Nice Person. Colorado Democrat Rep. Diana DeGette, the leader of the pro-choice caucus, says she has collected more than 40 signatures for a letter threatening to sink health reform if the final version includes the offending amendment by Michigan Democrat Bart Stupak, which would prohibit any insurer in the exchange from covering abortions if any of its policyholders receive federal subsidies. "In the end, I think we'll fix it," she told me. "But if it's not fixed, in the end we would vote no … We don't want to kill health-care reform. We think it's a massive expansion of health care for women. But you can't have a devil's bargain of reducing their access to abortion at the same time. That's a devil's bargain nobody should have to make." Except what happens if the devil has the votes?

Years of imperfect parenting have taught me the dangers of making threats you're not willing to enforce. Carrying out this threat, if it comes to that, would be a terrible idea.

Women in general—and lower-income women especially—stand to gain far more from health reform than they would lose from not having abortion coverage. Most poor women, for better or worse, already have to pay for abortion out-of-pocket. If women participating in the exchanges have to pay for the procedure as well—well, many of them will have previously been without any insurance whatsoever. The average cost of a first-trimester abortion is $400. And most abortions aren't paid for by insurance now.

There is an element of sky-is-falling-ism at work here as well. Yes, it would be outrageous to tell women that they cannot purchase coverage that includes abortion with their own money, the practical effect of the Stupak amendment. And there is a legitimate fear that the impact will become greater over time, if more Americans get insurance through the exchange or if insurers start to tailor their other coverage to comply with federal rules.

But "the greatest threat to women's fundamental right to abortion since it was recognized under the Constitution," as the National Organization for Women claims? Hardly. And excuse me if I take this hyperbole with a bowl of salt: these are the folks who held signs outside the 1990 confirmation hearings for Justice David Souter proclaiming STOP SOUTER OR WOMEN WILL DIE.

You don't have to be pro-choice to be afflicted with this legislative myopia. Indeed, the Catholic bishops, who were instrumental in getting the Stupak amendment adopted, say another health-care priority is expanding coverage for the needy. Yet they, too, are willing to take down the bill over the abortion issue—even though the likely effect of passing health care would be to reduce the number of abortions. As Rachel Laser of Third Way, a centrist think tank, points out, more low-income women would have access to contraception and medical care for themselves and their children. Not only that, the language the bishops have decreed unacceptable would make it easier for those who oppose abortion to avoid buying insurance that violates their beliefs.

From the pro-choice side, the optimistic take on the implications of the fight is that it has energized a complacent constituency. "This topic has woken a sleeping giant among women in this country—and, particularly, young women," says Cecile Richards, president of the Planned Parenthood Federation of America. Cosmopolitan magazine put a link to Planned Parenthood's petition against the Stupak amendment on its Web site.

Fine, but I worry that the current battle has also unavoidably opened up a dangerous new front in the abortion wars over private coverage. Expect future arguments about whether employer-sponsored plans—plans that are, after all, subsidized by tax dollars because health-insurance benefits are tax-free—should include abortion, as a large majority currently do.

Already, the Republican National Committee has ordered its abortion coverage rewritten to exclude abortion. I'd like to see Michael Steele explain that to the distraught staffer who has just discovered that she is carrying a fetus incapable of surviving outside the womb.

And consider this chilling latest from Fox News/Opinion Dynamics: 51 percent of those polled said private insurance should not include abortion coverage. Just 37 percent said it should. A CNN/Opinion Research poll produced a similar conclusion: 51 percent opposed to using private insurance for abortion coverage, 45 percent in favor.

There was no way to avoid an abortion fight in health care. The pro-choice side had no good options, only less bad ones. The worst one of all would be to take a step that punishes women in the name of protecting their rights.