Over at the religious debate site Patheos, a writer named Libby Anne has advanced an argument that pro-lifers really ought to be pro-choice, for a host of moral reasons that I won’t deal with today. In the process of making this broader case, she also advances a particularly absurd health policy argument: that President Obama has been a pro-life president. She begins this portion of her argument by quoting another author:
As most observers surely know, the Affordable Care Act (a.k.a. “Obamacare”) requires insurance coverage for birth control, a provision staunchly opposed by most of the same religious conservatives who oppose legalized abortion. If Peipert is correct, however, the ACA may prove the single most effective piece of “pro-life” legislation in the past forty years…
In the Affordable Care Act’s contraception mandate, we have a previously unimaginable opportunity for satisfying compromise on abortion. In accordance with liberal demands, the procedure will remain safe and legal, and reproductive choices will be extended to those who have been unable to afford them in the past. In exchange, conservatives will see abortion rates plummet, achieving a result comparable to that of illegality but without the fierce controversy or government imposition in the lives of individuals.
Libby Anne writes, emphasis hers:
Obamacare stands to cut abortion rates by 75%. And yet, the pro-life movement has been leveraged in opposition to Obamacare, and most especially in opposition to the birth control mandate. They don’t believe women should be guaranteed access to free contraception even though this access is the number one proven best way to decrease the number of abortions. That access would, to use the rhetoric of the pro-life movement, prevent the murders of 900,000 unborn babies every year.
I understand Libby Anne may not spend a great deal of time in this arena, but the claim that “Obamacare stands to cut abortion rates by 75%” is simply false. Even the law's most hardened advocates would not advance such a claim with a straight face. Let’s explain why.
The study on contraception mentioned in passing is this one, from Washington University in St. Louis researcher Dr. Larry Peipert. He found that upon being given free (taxpayer-funded) birth control, abortions sunk dramatically among a population of St. Louis area women:
From 2008 to 2010, annual abortion rates among participants in the Contraceptive Choice Project -- dubbed CHOICE -- ranged from 4.4 abortions per 1,000 women to 7.5 abortions per 1,000. That’s far less than the 19.6 abortions per 1,000 women nationwide reported in 2008, the latest year for which figures are available.
There are numerous methodological critiques of this study. The biggest one, from my perspective, is that the actual figure of abortions from this population was apparently estimated, not tabulated. This is a major issue. The relevant comparison you want is not to women nationwide, but to that same population of women - otherwise, the comparison obviously fails.
Abortion rates differ widely between the states, and Missouri has one of the lowest rates of any state. It ranged, you guessed it, from 5-8 abortions per 1,000 women aged 15-44 as of 2008. From 5-8 to 4.4-7.5 is barely a statistically significant decrease. We could analyze the raw data of the study for a better comparison, but no raw data is supplied in the paper, as Lydia McGrew points out:
At a minimum, the authors should have been made to answer the following questions: Was that a misstatement, or do you really mean to say that you did not collect raw data on abortions among study participants but rather estimated abortion rates in your cohort? If so, why? You were interviewing participants repeatedly throughout the study. Why estimate the data? … Obviously, if the actual abortion rate among the participants was merely estimated, while we are not told how it was estimated, the article's statistical value is highly questionable from the outset.
An even more troublesome issue with this study is that it was focused from the beginning on increasing the level of buy-in for implants and IUDs. There’s a false assumption repeated by many of the journalists that when we discuss contraception, we mean the pill. In reality, for purposes of this study and in many of the others cited about abortion reduction, it’s the more permanent and more expensive implants and IUDs which are being deployed (the pill fails roughly 8% of the time). Peipert required that all participants in the study had to be willing to change their method of contraception, precisely because the stated case for the study was “to promote the use of the most effective contraceptive methods (IUDs and implants).” According to Peipert’s description, they did this through:
Contraceptive counseling included all reversible methods but emphasized the superior effectiveness of LARC methods (IUDs and implants). (p. 1)
All participants were read a brief script informing them of the effectiveness and safety of LARC methods at initial contact and completed an in-depth, evidence-based contraceptive counseling session at enrollment. (p. 2)
In addition, the project provided education to promote the use of the most effective contraceptive methods, IUDS, and implants in an effort to alter population outcomes. (p. 5)
Again, this makes the study less representative of the population as a whole, and more representative of a specific type of population. But let’s assume for the sake of Libby Anne’s argument that none of these problems with the study matter, and that everything it says is rock solid truth. Her claim that “Obamacare stands to cut abortion rates by 75%” would still be completely false.
Let’s consider for a moment how the contraception mandate actually works. It is a requirement that all insurers pay for all FDA-approved contraception methods for all women with the ability to reproduce (including minors - yes, the federal government just made it easier for your 15-year-old to get sterilized without your knowledge) without requiring a co-pay. Here’s the actual text of the requirement, enforced under the Department of Health and Human Services’ authority to determine what benefits are “essential” for all plans to cover:
According to the final interim rules provided by the United States Department of Health and Human Services (HHS), “the HRSA Guidelines require coverage, without cost sharing, for all Food and Drug Administration (FDA) approved contraceptive methods, sterilization procedures, and patient education and counseling for all women with reproductive capacity.”
This language, derived from the Institute of Medicine (IOM) recommendations for preventative services, ensures all minors with “reproductive capacity” are included under the contraceptive mandate’s coverage. To abide by these rules, employers who provide insurance to their employees must provide coverage for any female dependents to receive contraception, sterilization, and abortifacients such as the “morning after” pill without a co-pay.
This requirement only applies to those employers, however, who currently offer insurance coverage. Under Obamacare, only employers with 50 or more full time employees (or part time equivalents) are required to offer coverage or risk paying a fine. So while the contraception mandate is certainly a headache for larger employers, and has resulted in a number of lawsuits from religious and academic institutions who don’t want to have to drop coverage, it’s not a requirement that will impact any significant number of small businesses and employers, who generally don’t offer coverage of prescriptions or any insurance coverage at all. In other words, most women who work for employers impacted by the contraception requirement already have access to the contraceptives Libby Anne is talking about – it just doesn’t allow insurers to charge a co-pay for it.
What Libby Anne completely ignores is that the majority of abortions are sought by women who are the least likely to have employer-based insurance – namely, the poor. While the vast majority of insurance plans prior to the contraception mandate already covered abortion and contraception services (with co-pays), according to the Guttmacher Institute, only 13 percent of abortions are charged to insurers. These employer-covered women aren’t the ones who are seeking more abortions. While abortion rates are trending down overall, they are increasing among the poorest Americans – 42% of all abortions were from American women below the federal poverty line in 2008.
For these women, the likeliest to seek out and obtain abortions, Obama’s contraception mandate for employers will make no difference whatsoever.
What will make a difference for them is the dramatic eligibility expansion of Medicaid – the most sizable difference in Obamacare's coverage, adding as many as 25 million Americans up to 133% of the federal poverty level to the system by 2020 if fully implemented – which will likely only increase the number of abortions. Americans are generally unaware of the fact that the Hyde Amendment applies only to federal funds, not to state funds, and states that currently fund abortions under their Medicaid programs for virtually any health related reason include: Alaska, Arizona, California, Connecticut, Hawaii, Illinois, Maryland, Massachusetts, Minnesota, Montana, New Jersey, New Mexico, New York, Oregon, Vermont, Washington, and West Virginia. If you pay taxes in these states, your tax dollars are used for this purpose. Under the Medicaid expansion to 138% of the federal poverty level, millions more women will be eligible for these subsidies.
Consider just two states. All by themselves, California and New York spend tens of millions of taxpayer dollars every year funding non-rape/incest/life of the mother abortions – New York remains the abortion capital of America, per capita. There were 133,000 publicly funded abortions in just those two states in 2010, representing roughly 10 percent of total abortions in the country. Taxpayers in those respective states paid for all of those. And this funding makes a difference, as Guttmacher notes: “Approximately one-fourth of women who would have Medicaid-funded abortions instead give birth when this funding is unavailable.” That's why pro-life governors are fighting to defund Planned Parenthood.
In sum, Libby Anne’s claim that “Obamacare stands to cut abortion rates by 75%” is completely fraudulent. Obama’s contraception mandate is unlikely to result in any significant increase in access to contraceptives among those women likeliest to have abortions, and for those same women, his Medicaid expansion will result in an increase in access to taxpayer subsidies for abortions. One can debate the morality of either policy, but to suggest either of these steps is “pro-life” is absurd.