Gaming out Stupak

Even if the damned thing becomes law, why won’t insurance companies offer retroactive abortion-coverage riders? Termination is cheaper than carrying to term.

It appears that the Senate version of the health-care bill won’t include the Stupak Amendment. But assume for a moment that Pelosi decides the votes aren’t there in the House to pass a Stupak-less bill. How bad is that?

As I try to game the situation out, it seems to me that the answer is “Maybe not bad at all.”

Imagine that you’re running a health insurance company that offers individual policies through the exchanges. (Recall that group policies aren’t covered by Stupak.) You’re not allowed to cover abortion under your regular plan, but you’re allowed to offer a supplementary policy – a “rider” – to cover abortion services.

At first blush, this seems stupid; since no one plans to need an abortion, very few people will buy the rider.

But what happens when some of the women you insure get pregnant and wants to terminate? Since perinatal care plus delivery would probably cost you $2500, while a first-trimester abortion costs about $200, you’d be happy to provide the abortion coverage gratis if you thought that otherwise even as many as one in twelve of those women would choose to carry to term. You can’t provide it gratis; that’s what Stupak provides. But you could provide it cheap, even to someone who’s already pregnant. Charge $50 for the abortion-coverage rider, effective immediately.

Now I don’t know that the companies would do this, but it seems to me that doing it would be very much in their best interests. That makes the idea of threatening to scuttle the whole bill if Stupak stays in even more far-fetched than it would otherwise be.

Whether Stupak passes or not, the pro-choice forces ought to make a concerted move to challenge the Hyde Amendment status quo. Restoring Medicaid coverage may be a bridge too far, but it seems to me that getting rid of the ban on abortion coverage for women in the armed services and the female family members of those in uniform ought to be a fairly easy sell, with the Secretary of Defense and the service secretaries testifying that the current policy is bad for recruitment and morale and the brass hats testifying that it’s bad for readiness.

Author: Mark Kleiman

Professor of Public Policy at the NYU Marron Institute for Urban Management and editor of the Journal of Drug Policy Analysis. Teaches about the methods of policy analysis about drug abuse control and crime control policy, working out the implications of two principles: that swift and certain sanctions don't have to be severe to be effective, and that well-designed threats usually don't have to be carried out. Books: Drugs and Drug Policy: What Everyone Needs to Know (with Jonathan Caulkins and Angela Hawken) When Brute Force Fails: How to Have Less Crime and Less Punishment (Princeton, 2009; named one of the "books of the year" by The Economist Against Excess: Drug Policy for Results (Basic, 1993) Marijuana: Costs of Abuse, Costs of Control (Greenwood, 1989) UCLA Homepage Curriculum Vitae Contact: Markarkleiman-at-gmail.com

32 thoughts on “Gaming out Stupak”

  1. "…but it seems to me that getting rid of the ban on abortion coverage for women in the armed services and the female family members of those in uniform ought to be a fairly easy sell, with the Secretary of Defense and the service secretaries testifying that the current policy is bad for recruitment and morale and the brass hats testifying that it’s bad for readiness."

    Frankly, Mark, after 8 years of the Bush administration, you should know better than to assume that 'readiness' would matter one farthing to the average GOP politician.

    Military pork, yes – actually defending the country is another thing.

  2. Also, Mark, with this the Democratic leadership is basically telling much of the liberals to shove it, that they have to not get what they want, while the GOP is rewarded for playing obstructionism. If they decide to not play ball, there's nobody who has a right to complain.

  3. Nice to see Mark's got the military's factual assessment all ready to go. That's the way social science works in the Reality-Based Community!

    But Mark's imagination isn't so good when it comes to what would be good for an insurance company to do, and sees just a static relationship between costs of pregnancy and costs of delivery, as if the numbers aren't affected by the costs.

    And Mark's proposal, in essence, is that insurance companies should pay women to abort.

    Yet Mark wonders why I shudder at the thought of him having control over our health care system.

  4. I think that the point that Mark was making is that most insurance companies would rather make profits for themselves than moral decisions for others.

  5. "Mark’s proposal, in essence, is that insurance companies should pay women to abort. "

    … if charging someone fifty bucks is the same as paying them.

  6. The strategic political analysis that Prof. Kleiman offers on this blog is on the level of a twelve year old playing monopoly with himself — "I give you Baltic Ave., and I get a monopoly on Boardwalk and Park Place."

    If the Catholic bishops go into open opposition, automatic loss for health care reform. You might have noticed that the house vote was 220-215. There may be a few votes to pull out in emergency, but how many?

    Prof. Kleiman has posited that the greed of health insurance companies should propel them to offer abortion coverage even without subsidy due to the differential cost of a live birth. In that case, why should they charge at all? Why don't they offer pregnant women $1000 to have an abortion? After all, no one plans on having one and won't buy separate coverage. (Of course, no one plans on having a major health crisis, but most people have health insurance).

    The reason they won't do that is most people recognize that abortion is a barbaric practice that has entrenched itself in our society, but can't yet figure out how to extract ourselves from it and preserve the economic and social status quo.

  7. Has anybody done an analysis of how and why a first-trimester abortion has gone from $250 to $200 over 25 years, while every other thing even remotely connected to medicine has been going through a zillion percent annual inflation?

  8. The other thing to do is offer it without any pre-existing condition requirement. So, you could buy the coverage for Mark's $50 even when you are already pregnant. Will still save the insurance companies money, so it is in their interest.

  9. Suzii- I think the decline in price might be that women are having fewer abortions, both due to better access to family planning, as well as the emergence of the "morning-after" pill.

    But I'd also like to ask Mark: WHAT?

    I just don't get this blog post.

  10. The analysis is not up to his usual level. Of course it is in the economic interest of the insurance company for their customers to not have children. They can encourage that by offering family planning material or free birth control. If the only two choices for the insurance company were to pay for the abortion or incur the cost of prenatal care plus labor and delivery plus perinatal care then there is no question that the insurance companies should pay women to have abortions. But if the $200-250 is keeping the women from getting the abortion then I have no idea who this woman is. The cost/benefit analysis for the insurance company has to be at the margin. If they sell a $50 rider and take a $150 hit for each policy then that is a good deal for them if it is the deciding factor in somewhere between %3-5 of the women. I just don't think that amount of money makes that much of a difference for even 1 out of 30 women. If it did then the anti-abortion crowd would be waving $250 vouchers at women entering those Planned Parenthood clinics in order to get them to cancel their appointments.

  11. Ok,first of all, any members who voted for the bill thinking the Stupak amendment was going to be in the final product were idiots. Or, more likely, figured that their constituents were sufficiently stupid that the amendment would be effective political cover. (Of course, the average politician has good reason for figuring their constituents are morons: They got elected, didn't they?)

    That said, the reasoning does suffer. You're basically analyzing this as though an abortion were a sterilization procedure. But, do abortions really reduce the number of pregnancies a health insurance company ends up paying for, or do they just shift them to a later date? (And possibly introduce complications for that later delivery.) If it's "shift", then abortions really don't save insurance companies much money, and paying for them isn't such a great deal.

  12. Hoisted from comments at LGM: In the states that require health insurers to offer abortion coverage as a rider, separate from their regular plans, there is no evidence that any insurers actually do so. So there must be some other factor that Mark's analysis is missing, that makes it not in the insurers' best interest.

  13. elliottg says:

    "The analysis is not up to his usual level. Of course it is in the economic interest of the insurance company for their customers to not have children. They can encourage that by offering family planning material or free birth control."

    ISTR that there's actually a problem with many insurance copmanies not including birth control in their benefits, even though they do cover things like V1agra and C1al1s. Methinks that the situation is not a clear-cut as Mark seems to think. And this is beside the obvious point that any insurance company might decline to offer abortion coverage because they'd rather not get grief from right-wingers.

  14. Along the lines of Edsez comment – doesn't the legislation get rid of the 'no pre-existing condition' requirement, so that if it is offered, one can buy it after the fact?

  15. It's interesting to me that almost everyone on this thread is male, or at least uses a male name (the exceptions are Suzii and possibly Horseball). If there were more women commenting, we wouldn't have ideas like Brett's listed here, that abortion may lead to complications in a later pregnancy.

    First, abortion is safer than going through a complete pregnancy. One example is ceasarians, which we do a lot of in this country. They often led to complications in subsequent labor & deliveries. If you have an abortion, you're not going to have a ceasarian.

    Two, why does Brett assume most abortions are followed by wanted pregnancies? IIRC, a fair number of abortions are obtained by women who feel their families are complete. To me, this just shows how entrenched the right-wing meme that abortions are all sought by loose young women is.

  16. Ohio Mom, I think you concede Brett's points when you elide the difference between "most" and "a fair number". Both can be right, which is a real problem for you, not Brett.

  17. Mark, the abortions that we should be concerned about here are not the $250-$400 first trimester elective abortions. What gives me nightmares – literally – about the Stupak amendment is the second and early third trimester abortions that women have because of major fetal malformation or terminal illness, where the diagnosis begins at the 20 week ultrasound. These are extremely expensive procedures — $18,000k and up — and under Stupak they would not be covered by a woman's health insurance if she was on a plan purchased through the exchanges OR if she was >400% of the FPL and receiving government subsidies. It's not profitable for the insurance companies to rider these conditions even if they could get 100% of their pregnant members into the pool, especially considering that their preferred provider networks and network discounts aren't very useful in dealing with these surgeries since they usually involve an ethics committee and/or a trip to an out of state (and ergo out of network) specialty provider.

  18. Elliotg: "But if the $200-250 is keeping the women from getting the abortion then I have no idea who this woman is." Keep in mind that some pregnant teenagers end up giving birth in the restroom at the prom or (insert anecdote here) which should outline the range of actual human responses to an unplanned pregnancy. Keep this sort of scared teenager in mind: someone who is indecisive enough about half a dozen things (Admit to self that test wasn't wrong? Tell parents? Travel to distant clinic without parents finding out? Try home remedy you read on the Internet?) that, yes, the positive action of scraping up $200 may be a barrier. Also, it goes without saying: the poor don't necessarily have savings, not even $200 under the mattress, not even $2000 worth of pawnable heirlooms. Times are tough.

    Is that bad outlier-anecdote reasoning? Yes, it probably is. Who cares? I don't want me, you, Mark, or least of all Mr. Stupak to have some sort of rational-social-planner approach to what decisions women make about their health. I want to butt out. Health decisions should be made as autonomously as possible. Putting abortion into everyone's standard bare-bones insurance package is (or was) doing a perfectly good job of maintaining that autonomy.

  19. If it were true that the controversy surrounding Stupak amendment is not about the practicalities of access to abortion. According to the Guttmacher Institute, the highest abortion rates – by far – are among black women. http://www.guttmacher.org/pubs/journals/3422602.h… And the rates are highest among black women within 100-200% of the poverty line. Thus, the biggest economic consequences will be to black women.

    From what I can tell I don't see the Congressional Black Caucus leading the opposition to the Stupak Amendment. Rather, it appears to be most vociferous among the affluent white women who self-identify as feminists and their menfolk. So, I don't think the real issue is whether a woman who wants to have an abortion can get her hands on $200 or $250, but whether abortion will continue to be the subject of moral contest. The pro-life politicians can be satisfied that they have done so.

  20. Seconding Belleweather's comment.

    A "positive" amnio is tragic enough without being told that your termination will be cash up front. Would the regulations allow the insurance company to pay for the lab work, anesthesiologist, PACU, etc? What about if the procedure was done by induction of labor with misoprostol (which is still a couple of days of hospitalization) rather than by D & E? What if the fetus is already demonstrably deceased (so the patient only pays cash for the KCl injection)?

  21. If insurance companies wanted to, they could find a way to offer riders are the (probably net negative) expected cost of providing service. But there's another really nasty gotcha to the legislation, which is that it also potentially requires insurance companies and doctors to make a decision about when a pregnant woman's life is in danger. In addition to the obvious nonzero death rate during "normal" pregnancy and delivery, there are plenty of pregnancy-related medical conditions that pose an elevated risk of death without rising to the level of "terminate the pregnancy or die" — or at least not until death is a fairly plausible outcome even if the pregnancy is terminated. Ectopic pregnancies, fetal death, fetal malformations incompatible with independent life, or incompatible with normal delivery, pre-eclampsia in all its variations…

    Stupak would result in a complete mess in this area. Doctors, patients and insurance companies would all have to balance the risk of getting hauled up in front of some wingnut prosecutor against the risk of avoiding necessary care. And the result would inevitably be more dead women, more widowers, more orphans. Which is apparently fine with the congressman.

  22. "And the result would inevitably be more dead women, more widowers, more orphans. Which is apparently fine with the congressman."

    Well, yes, that's what "pro-life" means. Here is a current posting from Tristero on Digby's Hullabaloo:

    From Think Progress:

    "Stupak is an attempt by the pro-life movement to use health reform as a vessel to ration access to reproductive health services."

    No.

    Stupak is an attempt by the pro-coathanger movement to use health reform as a vessel to ration access to reproductive health services.

    As long as we provide the foes of women's reproductive rights the opportunity to cast themselves as being "for life," and do so voluntarily, we will continue to lose ground on a fundamentally moral issue in which we, supporters of unrestricted health care for women, hold the high ground.

    Do you think "pro-coathanger" is needlessly confrontational, even if true? Ok, Digby's formulation, "coerced birth," is a more than reasonable substitute. Or if you insist, "anti abortion rights" is fine.

    But an important note about that last one: the issue is one of rights, not whether we think a specific set of procedures agrees with our abstract moral code. We can't leave the word "rights" out of the phrase without rhetorically handing the opposition – which is headed by people that genuinely hate women, especially poor women – a powerful concession.

    Words matter. And the rightwing would never, ever, make the mistake of calling us anything milder than "pro-abortion," despite the fact that is not our position, nor what this is about. It is about rights, rights to healthcare without restrictions for about half the people in this country.

    Think Progress does great work; I'm not raking them specifically over the coals. The rhetorical problem I'm pointing out is so commonplace as to be nearly invisible. My hope is that decent people will focus on how very important it is, always, to resist casting cultural debates in the loaded rhetoric of the right. "Pro-life" is one of their most egregious formulations. And one of the worst.

  23. I support Stupak or something like it. Public health care should be about life saving treatments. If you want an abortion, pay for it yourself.

    I don't expect HCR to provide me with subsidized laser eye surgery either.

    The tough cases of medical need or fetal abnormalities of course should be subsidized, but not the 99% "oops I'm preggers" abortions.

    Also, public money going to abortion will kill Democrats in loyal Catholic rust belt type districts, not just in the South where nominal democrats vote against their party half the time.

    My mother was an Obama donor and volunteer and straight ticket Dem voter. Yet she tells me about how her priest tells her to basically vote Republican because of abortion. She rationalizes with "live and let live" but can't do this is public money is going to subsidize abortion-covering plans.

  24. I do not have the slightest moral objection to abortion myself, but seeing Dems live up to the GOP parody of being "pro-abortion" is disconcerting.

    The US budget is in extreme structural imbalance and we are underfunding things like science research and education. To have any public money go to elective abortions is a horrible idea I oppose on budget grounds.

    Pushing extreme feminism, where "freedom of choice" is converted to "abortion is so good that the public needs to pay for abortions for those who can't afford them" will lose House dems 30 seats in Congress.

    On freedom of choice 60% of the public is with us, on "abortion is like subways and middle schools, something so great it must be subsidized" maybe 20% of the public is there (not me either). Which is why the *vast majority* of Dems outside of ultra-safe gerrymandered districts voted for Stupak.

    Also I enjoy seeing NARAL/Emily's List bitch and moan over Stupak. I also enjoy seeing Rust Belt dems prevail over the coastal elite dems who are running the country and party so badly, for instance strongly pushing the bank bailouts while letting the auto industry go bankrupt.

    They are the Dem version of Club for Growth, repeatedly pushing weak primary challengers who bleed the leading Dems of funds in the primary. A perfect example of this is happening in the Ohio senate primary, where Rob Portman is racking up cash for the general while Jennifer Brunner is launch a divisive kamakazi primary against the more electable Lee Fisher, who otherwise would be competitive on fundraising with Portman.

  25. If men were the reproductive vessel, we'd not even be discussing limiting abortion service. It is my suspicion that such service would include grief therapy and an overnight hospital stay. On this subject I find the American tendency to barbarism pathetic.

  26. "If men were the reproductive vessel, we’d not even be discussing limiting abortion service."

    Oh, BS. Has it missed your attention somehow that the pro-life movement is composed mostly of women? And I could say with no less justice that the main thing causing so many men to be pro-choice is the thought that the availability of abortion makes women more willing to put out, and less likely to go to court demanding child support.

  27. I do not know that the pro-life movement is composed mostly of women. Your source?

    It would astound me to see women attempt, or even think to attempt, to deny men their choice in health care – all laughter and dismay at erection-on-demand pills aside.

    I suspect your pointing out the innately expensive self-interest of men (woman's abortion as opposed to wearing a condom). This aspect of male free choice is adding to the cost of health care for all of us, and shifting a disproportionate burden of responsibility onto women.

  28. "Oh, BS. Has it missed your attention somehow that the pro-life movement is composed mostly of women?"

    Like those bastions of feminism and women's rights the Holy See, and other clergy of desert-originated religions?

  29. Of course insurance companies should pay women to abort _if the women want to abort_, just as they should pay to have tapeworms and other parasites removed. I'm not a woman, but a fetus I don't want is a parasite to me. It lives in my body and saps my well-being for its own selfish needs. A fetus I do want is another matter entirely. That's why I'm pro-choice.

    As for the $50 abortion rider, I'd price it at $1!

  30. I've never understood the pro-choice movement's attempts to demonize the anti-choice movement with "illegal abortions mean more dead women." For the anti-choicers, that's a feature, not a bug. To religious and social conservatives, sex outside of marriage, especially for a woman, is a serious moral transgression, and serious moral transgressions should not go unpunished. If you dare have sex outside of marriage, you get pregnant. If you dare try to abort the fetus, you die. Actions have consequences. Problem solved.

    Needless to say, I'm not an anti-choice asshat.

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