All along, the argument over abortion coverage has missed the mark, in my view. It has been all about how abortion is paid for, when what most people would like to see are fewer abortions.
No one has addressed the question of whether reforming the health care system would make a difference in the number of abortions performed in this country–until now. Writing in the New England Journal of Medicine, Patrick Whelan takes a look at Massachusetts as a test case. Its experience is instructive because the expansion of coverage envisioned in this bill is similar in many respects to what Massachusetts put into place in 2006.
Whelan writes: “The recent experience in Massachusetts suggests that universal health care coverage has been associated with a decrease in the number of abortions performed, despite public and private funding of abortion that is substantially more liberal than the provisions of the federal legislation currently under consideration by Congress.”
Here’s what else he found:
The relevant part of the Massachusetts program is Commonwealth Care, which provides subsidized insurance to the self-employed, small businesses, and unemployed individuals with incomes below 300% of the federal poverty level. This quasi-public agency began coordinating care through five private participating health plans effective January 1, 2007. I sought to determine whether this increased availability of care has led to an increase in the number of abortions performed in Massachusetts.
The number of abortions in Massachusetts in 2006, the year before the new law was implemented, was 24,245, including 4024 among teenagers. I obtained data from the Massachusetts Department of Public Health for each of the two subsequent years. Some 158,000 people were enrolled in Commonwealth Care plans during the first year. The Urban Institute estimated that between the fall of 2006 and the fall of 2008, the proportion of adults with incomes below 300% of the poverty line who were uninsured fell from 24% to 8%; 63% of all newly insured adults were in either Commonwealth Care or the state Medicaid program.
In 2007, the first year of Commonwealth Care, the number of abortions fell to 24,128, and in 2008, it fell to 23,883 — a decline of 1.5% from the 2006 level (see graph). The number of abortions among teenagers in 2008 fell to 3726, a 7.4% decline from 2006. These decreases occurred during a period of rising birth rates, from 55.6 per 1000 women 15 to 44 years of age to 56.9 per 1000 in 2006 and 57.2 per 1000 in 2007 (the latest year for which data are available from the Massachusetts Department of Public Health), and an increase in overall population (in 2008, the Massachusetts population surpassed 6.5 million for the first time, and it was nearly 6.6 million in 2009, according to the Census Bureau). The abortion rate thus declined from 3.8 per 1000 population in 2006 to 3.6 per 1000 in 2008. Overall, since 2000, the number of abortions in Massachusetts has dropped by 12% (from 27,180 to 23,883) and by nearly 36% since 1991.2 The Massachusetts abortion rate has similarly dropped by a third, from 30 per 1000 women 15 to 44 years of age in 1991 to about 20 per 1000 in 2005, with most of the decrease occurring during the late 1990s.3
Is this definitive proof that health reform could actually reduce the number of abortions? Does government funding encourage women to decide to have the procedure? Whelan himself concedes that other factors are more important.:
There has been some controversy about whether the availability of state Medicaid funding for abortion increases abortion rates. One study showed a statistically insignificant effect of Medicaid funding on the abortion rate, which (if the association was not simply due to chance) was about 95% less determinative than the most significant factor: employment of the male sexual partner, which substantially decreases the likelihood that a woman will seek an abortion.
But he also adds that Massachusetts’ experience suggests that providing coverage of abortion will not, in and of itself, increase the number of them:
Massachusetts is one of 17 states that provide full coverage for abortion under the state Medicaid program (MassHealth) for the poorest residents, and abortion is a covered service under all the Commonwealth Care plans that cover the next tier of income earners. Yet in this midsized, ethnically diverse state, full insurance coverage of abortion services for all lower-income residents did not result in an increase in the number of abortions performed.I believe it is reasonable to conclude that the possibility of some federal subsidization of overall care, for a fraction of the additional 31 million people who would be covered, would not mean a significant or even a likely increase in the number of abortions performed nationally.