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How Stupak's amendment could change the whole insurance market

Brian Beutler has a good post assessing the Stupak amendment's likely impact on the exchanges. "It is safe to say," he concludes, "that the vast majority of, if not all, women in the exchanges will not be allowed to have abortion coverage in their benefits packages."

But the bigger danger is the eventual growth of the exchanges. If health-care reform began with huge exchanges, in which only a small portion of the participants were on subsidies and the Stupak amendment only applied to a fraction of the market, insurers would probably offer mostly policies that included abortion coverage. In reality, almost 90 percent of the population on the exchanges will be subsidized, so there is no real market for insurers to present a policy that covers abortion. That presents a much bigger problem.

The exchanges are not likely to stay small. They will gradually add larger and larger employers. But it won't happen all at once, and so there's no reason to believe that that the insurers will change their offerings all at once. And maybe they never do. After all, very few insurance customers call insurance companies to ask whether their policy covers abortion. Virtually no one calls their HR department to ask that question. There's a real chance that insurers might never switch back over, as they've already got products in the exchange, and they don't want to have to go through the trouble of offering one package to people with subsidies and one package to people without subsidies.

Over time, that could mean that the norm becomes an insurance market that doesn't cover abortion as opposed to an insurance market that does. Stupak's amendment is a limited, though bad, policy in its current form. But it could grow into something much larger. If it sets the standards for the exchanges and the exchanges eventually become the standard for the whole insurance market, then the Stupak amendment could transform coverage for not just poor women, but all women.

By Ezra Klein  |  November 13, 2009; 12:13 PM ET
Categories:  Health Reform  
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Comments

Ezra you might want to take a closer look at this. Under the House Bill all employers have only five years to bring their health insurance plans up to QHBP, Qualified Health Benefit Plan, levels. Meaning that such plans have to offer equivalent coverage, and presumedly include equivalent restrictions to those individual and group plans offered within the Exchange.

I'll have to dig into the bill language but if it is held that Stupak governs ALL QHBPs then equally it would apply to employer provided insurance outside the Exchange after the transition period. Nor is there much room for other forms of group insurance that are not employer based because then you run up against the "Individual Responsibility' requirements that require proof of 'Acceptable Coverage' which once again brings in a requirement of coverage under a QHBP or some form of public insurance (VA, Medicare, Medicaid, Tri-Care).

It really doesn't matter how many people are covered in the Exchange if PLANS offered outside the Exchange have to be QHBP equivalent anyway. Does Stupak in effect ban ALL comprehensive health insurance plans from offering coverage for elective abortions after the 5 year transition?

At first glance it would appear so.

Posted by: BruceWebb | November 13, 2009 12:41 PM | Report abuse

If this does turn into a larger problem over time, couldn't the amendment be repealed with the larger bill in place? My point is that since it's not a large problem at this time and it can be corrected in the future, it make sense just to include the amendment so you can the overall bill passed. Thoughts?

Posted by: twiebe1 | November 13, 2009 12:50 PM | Report abuse

What do you care? You just want a bill to pass. How are they going to remove this amendment later when it's the only reason the bill will pass? You think the republicans will let that thru, if they're not in power any way. Screw every wowman in the country out of their right to choose and hope they don't notice seems to be the dems plan.

Posted by: obrier2 | November 13, 2009 1:05 PM | Report abuse

If it sets the standards for the exchanges and the exchanges eventually become the standard for the whole insurance market, then the Stupak amendment could transform coverage for not just poor women, but all women.


oh please stop with the grandstanding already. Abortions on average run about $300-$600. The only ones who would end up being affected financially are the poor. Any middle class or upper middle class person would be able to afford that and again you don't mention that medicaid (from my understanding) doesn't cover it now anyway. Oh and now neither does the RNC's plan!

Posted by: visionbrkr | November 13, 2009 1:14 PM | Report abuse

To be clear, I do want a bill that helps correct the problems in the health care market. And my thinking is if (once passed) this law does "screw every woman" as you suggest, then your sentiment may be exactly what is required to generate the politic heat required overturn the amendment.

I find it unfortunate, but obvious, that there are tradeoffs that will have to be made if anything health care related is going to change for the better. And I'm wondering about the feasibility of defeating the amendment, later. I'll admit that defeating the amendment may require more than one change in power and I can see where this is concerning. But can it be done easier then getting back into the kind political position which is required to pass a health care bill?

Posted by: twiebe1 | November 13, 2009 1:29 PM | Report abuse

And of course the exchanges as CURRENTLY proposed consist largely consist of small businesspeople and individual contractors. Stupak's amendment means that women who choose to leave large employers to build their own enterprises and create their own wealth will face a fairly wrenching choice that their male competitors will not. This strikes me as horribly retrograde gender policy even outside the narrow abortion question.

Posted by: NS12345 | November 13, 2009 1:30 PM | Report abuse

1. Roe v. Wade was not about "choice", it was about the patient/doctor relationship. The decision said that the state cannot summarily override medical decisions made in that relationship.

The Stupak amendment (and indeed the Hyde amendment) effectively says that the state can interpose itself in that type of decision when care is financed by the government. It says that the government has the right to force citizens of lesser means to buy private insurance and that by accepting the subsidies necessary for their compliance, they forefeit the right affirmed by Roe v. Wade.

It is disengenious for people to say that someone who can't afford health care premiums can come up with $300-$500 to pay for an abortion. If they had $300-$500 in savings, they wouldn't qualify for the subsidies in the first place. Only someone unaware of the strigent asset restrictions of Medicaid could make such a statement.


2. I'm still waiting to hear even a modicum of outrage about the gender rating in the exchanges that will reduce the level of coverage available to middle-aged women. There's a clear double-standard operating here.

Posted by: Athena_news | November 13, 2009 1:37 PM | Report abuse

ns12345,


seriously? If someone is going to "strike out on their own" and leave their large employers do you really think that a $300+ abortion is going to stop that? If that would make them pause then maybe they shouldn't be starting their own companies in the first place. Whose to say that their large employer couldn't have subjected outpatient surgical procedures to their deductibles in their network and thus they'd be paying for it all anyway? I state AGAIN the only ones affected by this are the poor. That doesn't necessarily make it right, but don't make it out to be bigger than it really is.

Posted by: visionbrkr | November 13, 2009 1:38 PM | Report abuse

Wouldn't women employees lobby their companies to not go on the exchange? I know I wouldn't choose to work for a company that offered a health insurance plan that would leave me high and dry if a pregnancy goes wrong half way through.

It's not the $300 abortions that matter. It's the ones that are complicated due to health problems that cost $1000+$1000+...

Posted by: ideallydc | November 13, 2009 1:51 PM | Report abuse

But if overtly political decisions can alter health care coverage, cost control has NO hope. Its abortion today, and access to arthroscopic knee surgeries or MRIs tomorrow. The concerning part of the Stupak amendment is that is explicitly a non-medical, non-cost driven coverage question solely driven by politics. When MRIs are restricted to those based on value, opponents will still have data and testimony that it makes sense to cover it. That'll all sound reasonable to the public, and no progress will get made. The fact we're seeing this stuff is happening before legislation on health care reform is even finalized, is the strongest argument against a government-driven vs market-driven approach to health care reform.

Posted by: wisewon | November 13, 2009 1:58 PM | Report abuse

Do you really not see that the fundamental problem is not the Stupak amendment but rather the government's role in determining what will be covered by health insurance?

Posted by: DavidBerkian | November 13, 2009 2:35 PM | Report abuse

I am not opposed to women getting abortions, but I truly cannot believe how many people seem to think there is a right to have someone else pay for an abortion. If you really cannot scrape together $300-500 for an abortion you ought to be making more responsible contraceptive decisions.

Posted by: ab13 | November 13, 2009 2:41 PM | Report abuse

"I am not opposed to women getting abortions, but I truly cannot believe how many people seem to think there is a right to have someone else pay for an abortion. If you really cannot scrape together $300-500 for an abortion you ought to be making more responsible contraceptive decisions.

Posted by: ab13 | November 13, 2009 2:41 PM"

You can say the same thing about almost anything. Abortion is a legal medical procedure. Why shouldn't it be covered just like any other legal medical procedure? Should we prohibit insurance coverage for anything that costs under, say, $1,000? We need to have a coherent and rational explanation for why some procedures are covered and others are not -- and our personal preferences really don't cut it.

Posted by: simpleton1 | November 13, 2009 2:48 PM | Report abuse

"You can say the same thing about almost anything. Abortion is a legal medical procedure. Why shouldn't it be covered just like any other legal medical procedure?"

Because the majority of cases are mostly avoidable. Proper use of contraceptives would prevent most of the unwanted pregnancies. It is not an insurable risk.

Posted by: ab13 | November 13, 2009 2:56 PM | Report abuse

ab13

There are a lot of medical conditions that are avoidable. Never let your kids face, arms, legs and back be exposed to the sun and chances are good they will never get skin cancer. Maintain a life-style where you studiously avoid all carcinogens and you will have less chances of getting at least some kinds of cancer. Avoid all alcohol or other central nervous system depressants, and never drive when you are sick, or tired, or distracted and your chances of being involved in an injury accident are much reduced. If you avoid all sports that involve either contact, speed or height your changes of bone breaks and ligament damage would be greatly reduced.

And it is not just injuries. Never go into the woods and your chances of getting Lyme disease go to zero. Never go to a restaurant and your chances of getting Hepatitis B are much reduced. Don't eat beef or leafy vegetables and your risk for E-Coli drops from very small to microscopic. Where do you stop with the logic of 'avoidable'?

Why blame women who get careless and not skiers? Since many ski accidents are avoidable shouldn't we just throw them a couple of splints and a crutch and tell them to "deal with it"?

Why is having a few too many swigs on the flask at the top of the ski slope and subsequently running into a tree "an insurable risk" while having a few too many drinks at a party and ending up having unprotected sex not?

You are attempting to impose a particular moral view under some logical veneer. Sorry the misdirection is not working.

Posted by: BruceWebb | November 13, 2009 3:31 PM | Report abuse

But if overtly political decisions can alter health care coverage, cost control has NO hope.
Posted by: wisewon | November 13, 2009 1:58 PM | Report abuse


I agree and the doc-fix "kick the can down the road issue" is further proof. How long before government requires infertility to be covered for the poor souls who can't have children. Oh wait, we're already there in my liberal state. No wonder we're going bankrupt and everyone is fleeing New Jersey.

Posted by: visionbrkr | November 13, 2009 3:32 PM | Report abuse

BruceWebb: "You are attempting to impose a particular moral view under some logical veneer."

No, I am not trying to impose a moral view about abortion. I am trying to impose a view that your actions have consequences, and people ought to be prepared to deal with those consequences and not expect others to do it for them. All of the things you mention that are also avoidable also have a highly variable, often catastrophic cost, a cost high enough that adequate protection from them requires insurance coverage. An elective abortion costs roughly $300-500 dollars. If someone chooses to be sexually active without taking adequate contraceptive measures, they ought to be prepared to deal with those relatively minor costs, rather than expecting someone else to pay for it for them.

Some of those examples you gave are also good examples of adverse selection and how it negatively impacts insurance premiums. People who act irresponsibly when skiing shouldn't be able to take advantage of lower than necessary insurance premiums, but it's a very difficult if not impossible thing to prevent. That doesn't mean we shouldn't try to avoid paying for other uninsurable risks with insurance. Two wrongs don't make a right.

I've yet to see anyone make a coherent case for why anyone besides the most impoverished women ought to have someone else pay for their abortion.

Posted by: ab13 | November 13, 2009 4:36 PM | Report abuse

The majority of women don't have abortion in their coverage right now. Federal plans forbid it, Medicaid forbids it, 54% of the private market doesn't cover it and many don't even have health insurance.

The question is about the future. And much of that is unknown. This is all we know: Stupak-Pitts applies the Hyde Amendment framework to the expansion of federal health programs. Pro-choicers, who have always hated the Hyde Amendment, thought special protections would be provided.
The future? It's possible that private plans will never offer a plan covering abortion. It's possible that they do, as they already offer multiple plans. It's possible that employers pay for additional abortion coverage. It's possible that affordable health care, responsible society and changing cultural attitudes eliminate abortion.
Anything is possible in the future. We shouldn't be dictated by the fears and demands of the abortion provider lobby alone.

Posted by: cprferry | November 13, 2009 4:36 PM | Report abuse

Also Bruce, analogizing someone getting skin cancer after years upon years of nearly unavoidable exposure to the sun with someone wanting an abortion because they had sex without contraception is not exactly helping your case. A little perspective please.

Posted by: ab13 | November 13, 2009 4:38 PM | Report abuse

Ezra this is a BIG deal NOW! Women currently pay more for health coverage than do men. The "reform" was supposed to change all that. Not so, if women must buy separate coverage for our various health matters. Not to mention that health care in the US should NOT be dictated by the Cathloic Church! We do have separation of church and state!


BAC

Posted by: BAC104 | November 13, 2009 5:18 PM | Report abuse

Because the majority of cases are mostly avoidable. Proper use of contraceptives would prevent most of the unwanted pregnancies. It is not an insurable risk.

Posted by: ab13

Baloney! In a country that has spent millions teaching "abstinence only" education to young women and men it's no wonder there are women faced with unplanned pregnancy! And no contraception is foolproof.

Not to mention that many plans don't cover birth control pills now! It's time the health insurance industry -- and Congress -- stopped screwing women.

Posted by: BAC104 | November 13, 2009 5:29 PM | Report abuse

BAC104,
Why attack abstinence only education, but not the millions of advertisements and cultural attitudes that promote promiscuity and the sexual activity of youths, who wouldn't be prepared to handle those issues regardless of comprehensive sex education and contraception. Look at today's colleges where condoms are readily available, sex ed lectures are provided at orientations and throughout the year, and sex is a continuous topic. Yet pregnancies are common and the spread of STD's continue to rise.
These kids are at the mercy of this hyper-sexualized culture. When it comes to sex education, that's where our focus should really be at.

Posted by: cprferry | November 13, 2009 5:54 PM | Report abuse

"Baloney! In a country that has spent millions teaching "abstinence only" education to young women and men it's no wonder there are women faced with unplanned pregnancy! And no contraception is foolproof."

Oh please. So you think the reason so many people do not use proper contraception is because of the supposed widespread use of "abstinence only"? You can't seriously be that naive.

"Not to mention that many plans don't cover birth control pills now! It's time the health insurance industry -- and Congress -- stopped screwing women."

And why should they? Maybe an insurer could decide to cover the pill because they thought it would reduce potential maternity claims, but there is absolutely nothing about birth control pills that make them something you'd use insurance to pay for. Should insurance pay for condoms? Diaphragms? Satin sheets and rose pedals for the bed?

It's hilarious that in your world not giving someone a handout of free birth control amounts to "screwing" them.

Posted by: ab13 | November 13, 2009 6:05 PM | Report abuse

BAC, if you believe in separation of church and state, you should not want the state not FORCE Catholics and others who abhor abortion to pay for your abortions.

Posted by: AntonioSosa | November 13, 2009 9:53 PM | Report abuse

When leftists say 'separation of church and state' they mean the destruction of the church and dependency on the state

Posted by: cprferry | November 14, 2009 2:35 AM | Report abuse

The Stupak amendment will prevent the exchange from growing. It will give the exchanges a bad image. It will doom health care reform.

Posted by: kazumatan | November 14, 2009 7:57 AM | Report abuse

Great post. I linked to it on my blog at http://newsericks.com/into-the-lions-den/ in which I analogize between the Stupak Amendment and the deer that jumped into the lions' den last week. Read it if you have time and let me know if you like it.

Posted by: RayinDC | November 16, 2009 2:17 AM | Report abuse

If there is such a nationwide demand to ensure abortion access to the poor (Sanger would be proud) then NOW and Planned Parenthood should work with their supporters to set up and administer a nationwide, donor-maintained fund. Problem solved. Why do all liberal solutions to their perceived problems require taxpayer money?

Posted by: msully25 | November 16, 2009 10:51 AM | Report abuse

What is the portion of abortions that are covered by insurance that are the elective $300-$500 kind?

Posted by: ideallydc | November 16, 2009 11:10 AM | Report abuse

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