abortion


The Pro-Life Legal Case Against the Individual Mandate

The Bioethics Defense Fund has file an amicus brief in the the Eleventh Circuit Obamacare case, arguing that the imposition of the individual mandate has the effect of forcing some Americans to pay, against their wishes, premiums out of their own pockets for abortion provision for others. This requirement, the brief argues, exceeds the boundaries of permissable obligations imposed by government, and is thus unconstitutional. A press release appears here, and the whole brief, well worth reading, is here.

posted by James C. Capretta | 1:30 pm
Tags: Bioethics Defense Fund, Obamacare, abortion
File As: Health Care

Pro-Lifers and “Repeal and Replace”

Federal subsidization of insurance coverage for abortion services was among the most contentious issues in the healthcare debate. Pro-life groups stood firm in their opposition to such funding, to the point of opposing the entire legislative package unless it was fully and definitely removed from the bill. Moreover, they worked tirelessly as the legislation was under consideration to advance language that would have made it absolutely clear that direct federal funding of elective abortions would not be a part of the reformed system.

In the end, those efforts came up short because the pro-lifers’ supposed congressional allies on the Democratic side abandoned them when it mattered most. The result is that the new law does provide taxpayer funding of elective abortions, for the first time in many years.

But passage of the new law did not end the debate, on abortion coverage or health care more generally. As was evident in the 2010 midterm election, a plurality of Americans remains strongly opposed to the bill that passed. Scores of the new law’s most ardent supporters were swept out of office by the voters. Now, a strong movement is building to repeal what was passed and replace it with a reform program more consistent with American values. The push for “repeal and replace” will almost certainly be among the most prominent themes of the new Republican House come January.

However, Richard Stith, a pro-life law professor at Valparaiso University, is urging his fellow pro-lifers to stay off the “repeal and replace” bandwagon. In an article for First Things online, he has suggested that a more promising approach for pro-lifers is amending the new law with clear pro-life language.

His logic goes something like this. In the healthcare marketplace of today (before the new law’s provisions take effect), private insurance, including plans organized by employers, more often than not covers elective abortions. Under the new law, the government will start running a larger share of the insurance marketplace in 2014, and subsidize it explicitly with tax dollars. That means more Americans who are now in today’s private insurance market will get their coverage in the future through a system organized by the government. Because taxpayer money will be involved, pro-lifers sought to extend the prohibition against funding of elective abortions—a prohibition that now applies to other tax-financed health care like Medicaid—to the new government-managed marketplace too. Had they not been defeated in that effort, they would have successfully removed elective abortions from insurance coverage for millions of people who are in plans that pay for such abortions today. So, Stith argues, the solution here is not to revert to the anti-life status quo of today’s private insurance market, but to extend the pro-life protections which apply to taxpayer-funded health care to the entire government-managed marketplace that will emerge in 2014.

Stith has a point. It’s true that many Americans are unknowingly subsidizing elective abortions through their private health insurance premiums today. They often have no choice in the matter, as their employers are making the decisions about what’s covered and what’s not in employment-based plans. Stith’s perspective is certainly a legitimate position for a pro-lifer to take, given where things stand.

But is it the only legitimate position for pro-lifers? The answer is most definitely “no.”

The issue of how a healthcare system addresses abortion provision is of course of paramount concern. Indeed, it is a necessary condition of an acceptable program that it not force Americans to subsidize the elective abortions of others. That is a non-negotiable first principle that pro-lifers have rightly made their top priority.

But for many Americans, including many pro-lifers, that is a necessary but not sufficient criterion for determining the acceptability of a reform program. There’s much, much more to consider. For many pro-lifers, even if the new healthcare law were amended to include the Hyde Amendment (against funding abortion) and Weldon Amendment (conscience protections), the amended law would still be so flawed, because of what it would do to the American economy as well as American health care, that the only remedy is its full repeal and replacement with economically sound reform that is also pro-life. Of course, pro-lifers are under no obligation to share this point of view.It is not a precondition for pro-life sentiments.But neither are pro-lifers under any obligation to accept at face value the supposed benefits of the new law when reason tells them otherwise.

The basic premise of the new healthcare law is that the federal government has the capacity to allocate resources in the health sector to promote equity and efficiency. There is abundant evidence that demonstrates this to be a very dubious assumption. Instead of promoting quality and efficient health care, the government pursues budget cutting with arbitrary, across-the-board payment-rate reductions for those providing medical services. There’s no effort to distinguish based on how well or badly they treat their patients. Everyone gets cut at the same rate, and the predictable result is that willing suppliers of services leave the marketplace. The only way to then reconcile supply and demand is with queues and waiting lists, which are commonplace in Canada and the United Kingdom. Putting the government in the cost-control driver’s seat is a recipe for a long-term decline in the quality of American medicine.

Further, the new law is based on deceptive budgetary and economic assumptions that mask the true costs of what was passed. The official cost projections are alarming enough—$1 trillion in spending over the next decade, financed by $500 billion in Medicare cuts (mainly in the form of lower payments for services) and another $700 billion in tax hikes. But the reality will be far worse than that. The centerpiece of the new law is a very generous new subsidy program for health insurance, available to families with incomes between 133 and 400 percent of the federal poverty line. Census data shows there are 111 million people in that income range, but official estimates assume only 20 million or so will get the new subsidies. The assumption is that many millions of otherwise qualified people will stay in job-based coverage, and thus lose out on thousands of dollars in federal support. That’s never happened before with an entitlement program, and not likely to happen this time. One way or another, the vast majority of those eligible for financial support will end up getting it, and the cost of the new law will soar, by another $1 trillion over ten years according to one estimate.

There are many other important reasons to have deep reservations about the new law. It will discourage hiring by employers, especially among low-wage workers, because employers will get penalized with fines if those workers end up in government-subsidized insurance. It creates new penalties for marriage, by handing out more subsidies to unmarried couples than to married ones with similar incomes. And it hands over to the government vast new power to insert itself into medical decisions.

Proponents of the new law will argue that its main achievement is covering about 30 million people with insurance who do not have it today. The truth is that many of those people who would gain coverage would do so only because they were forced to sign up or else pay a new fine to the federal government. Many of them are younger and far healthier than the average American, which is why they hadn’t signed up previously. The number of very sick Americans who would gain new coverage under the proposal is far, far less than 30 million.

There are much better ways to address the genuine needs of the uninsured than what was passed. The fundamental problem in American health care is insufficient productivity by the health sector. The solution is not top-down micromanagement from Washington, D.C., but a functioning marketplace in which the government provides oversight but consumers and patients direct the allocation of resources. That can be done by converting today’s federal support for insurance into support that the beneficiaries themselves direct and control. Indeed, a crucial reform would be to give all American households a fixed tax credit—about $6,000 per family—that must be used for the purchase of an insurance plan. This would take the place of today’s tax preference for job-based plans and would guarantee insurance coverage to the entire U.S. population. It would do so in a way that then engendered the kind of dynamic response in the marketplace that could transform American medicine for the better. And it could be an absolutely pro-life step by inclusion of a clear prohibition against coverage of elective abortions in any plan purchased by the credit.

No one suggests that all pro-lifers must adhere to this kind of thinking and support “repeal and replace.” But, at the same time, it should not be expected that all pro-lifers will be satisfied with adding a Hyde-like amendment to what has already been passed. Pro-lifers in Congress would certainly support that step. But there’s a genuine debate still underway in this country about the best way to fix American health care, and many pro-lifers believe firmly that a sensible “repeal and replace” program is the most prudent and principled course.

[Cross-posted at The Public Discourse]

posted by James C. Capretta | 4:19 pm
Tags: Obamacare, abortion, Richard Stith
File As: Health Care

Ben Nelson caves on taxpayer funding of abortion

From a new piece my colleague Yuval Levin and I have over on the Weekly Standard website:

Now that Senator Nelson has announced his intention to vote to end debate on the Reid bill, it's worth looking at whether his actions match his words....

The new Reid language that Senator Nelson now finds acceptable would allow federal subsidies to flow to plans that cover elective abortions in the insurance exchanges. Senate Democrats try to create the impression that only the enrollees' premiums will pay for the abortion coverage. But it's an artificial bookkeeping exercise. Taxpayer funding would support the same insurance policies that pay for abortions. Senator Nelson is touting the fact that states can enact laws which prohibit elective abortions in the exchanges (the so-called "opt out"), but that was already permissible under the previous Reid language. And in any event a state can't protect its taxpayers from financing abortions beyond its borders. Senator Nelson's "compromise" leaves Nebraska's voters entirely vulnerable to paying for California's and New York's abortions.

posted by James C. Capretta | 6:45 pm
Tags: Ben Nelson, Harry Reid, abortion, Yuval Levin
File As: Health Care

For Nelson, It Shouldn’t Be a Close Call

Nebraska Senator Ben Nelson announced yesterday in an interview with a home-state radio station that new language regarding abortion coverage in subsidized insurance plans was not acceptable to him, dealing yet another blow to Senate Majority Leader Harry Reid’s mad-dash rush to pass a bill before Christmas.

Of course, it’s crucial that Senator Nelson stick to his guns on abortion. He has always been a self-described pro-life Democrat, and attracted votes accordingly in his election campaigns. So far, he shows every indication of sticking to his guns and insisting on language that is at least as stringent as that offered by Representative Bart Stupak and passed in the House last month. This is no time to go wobbly, or to listen to those who are transparently trying to divide the Senator from his pro-life supporters. If abortion language offered by Senator Reid doesn’t meet the test of the Catholic bishops — and it doesn’t — Senator Nelson owes it to those pro-life voters who have stood with him over many years to stand with them at this critical time.

But, just as importantly, Senator Nelson made it clear in the same radio interview that his concerns with the Reid bill go well beyond protecting taxpayers from financing elective abortions — as they should. Senator Nelson considers himself to be a fiscal conservative too. The Reid bill provides a ready opportunity to prove that he actually is.

Even before a new health-care entitlement program is stood up, the nation’s budgetary outlook is very grim, and has been made more so by the policies of the Obama administration. CBO projects that the Obama 2010 budget plan will drive federal debt up from $5.8 trillion at the end of 2008 to more than $17 trillion by 2019. And it will only get worse from there. Federal spending on Social Security, Medicare, and Medicaid is expected to increase from 11.1% of GDP this year to 17.1% in 2030, a jump in spending of 6% of GDP in just two decades. To put that in perspective, that’s like adding another Social Security program to the federal budget without any new revenue to pay for it.

The Obama administration and its allies in the Senate keep arguing that the Reid bill will begin to fix the entitlement problem. It won’t. It will make the nation’s entitlement problem much worse.

If passed, here’s what’s certain. Medicaid will be expanded to at least another 15 million people. This is the same Medicaid program that is entirely unreformed in the Reid bill and has been growing, on a per capita basis, nearly 2 percentage points faster than per capita GDP growth for three decades. In addition, Senator Reid’s proposal would create a new health entitlement by subsidizing the premiums for households with incomes between 100 and 400 percent of the federal poverty line. In all, CBO says these “coverage expansion” provisions (including tax credits for small businesses) will cost nearly $200 billion by 2019, and that cost will grow 8 percent annually every year thereafter.

And that’s a lowball estimate. The new insurance premium subsidy program is available only to households getting their insurance through the new “exchanges,” not employees who have no choice but to take the plan offered at work. But, as Gene Steuerle of the Urban Institute and I have pointed out elsewhere (see here and here), this kind of two-tiered system of subsidies creates large disparities in the treatment of households with identical financial resources. As matters stand, CBO says only 18 million people would get the premium subsidies in 2015, even though, in 2008, there were already 127 million people under the age of 65 living in households that would be eligible for subsidization. If enacted, it would only be a matter of time before tens of millions of additional people ended up in the subsidy program.

And what does the Reid bill do to slow the pace of rising costs? The President’s Council of Economic Advisers touts the slowdown in Medicare and Medicaid costs, as scored by CBO. But these spending reductions don’t come from more efficient health-care delivery. The savings are from arbitrary, across-the-board payment-rate cuts for hospitals, nursing homes, home health agencies, and others. These cuts do nothing to improve the efficiency of medical practice. Indeed, in the past, they have led to cost-shifting, and Congress has shown no stomach to sustain such cuts in the face of warnings of reduced access to care, such as was provided by the Medicare program’s chief actuary last week.

The administration also believes the new Medicare commission will work wonders. But, as the Concord Coalition has noted, the commission’s mandate is incredibly limited. It can’t propose any changes to hospital or physician reimbursement arrangements. It can’t restructure the Medicare entitlement. And its targets after 2019 wouldn’t save anything. That means, for a few years, the commission might get to cut home health and other ancillary service payment rates. That’s it. Medicare won’t look any different as a result. Never has so much been made about so little. Moreover, the commission itself represents an incredible admission of failure. At the beginning of the year, the Obama administration was promising to come forward with new whiz-bang ideas to painlessly root out inefficient health care without harming quality. They never did. Now they are saying a new independent commission will do it for them. Don’t hold your breath.

Senator Nelson is clearly uncomfortable with the bill as written. Any fiscal conservative would be. It’s not a close call. As the senator said yesterday, the country would be far better off with a more scaled-back bill. He’s right about that. And it’s in his power to deliver just such a bill. Pushing the discussions into 2010 would not end the health-care debate. It would only make it more likely the Senate voted in the end for something the public — and Nebraskans — would find acceptable.

posted by James C. Capretta | 5:28 pm
Tags: Ben Nelson, Medicare, abortion, Harry Reid, Senate bill
File As: Health Care