THE TREATMENT DECEMBER 23, 2009
Harold Pollack is a professor at the University of Chicago School of Social Service Administration and Special Correspondent for The Treatment.
The House and Senate bills both contain measures that restrict health insurance coverage for abortions. When you consider that the vast majority of private policies currently cover these services, this is a genuine step backwards for women's right to choose, in both practical and symbolic terms. Feminists are rightly livid, doubly so because they realize that these provisions are unlikely to be greatly softened given the delicate political compromises required to pass a health reform bill.
One question deserves more careful thought than it has received: How much will these measures actually prevent women from securing access to abortions? This is an empirical question. We don't precisely know the answer. It's depressingly unsurprising that most people's responses to this question are highly correlated with their political and moral views.
Moderates and conservatives note that the average cost of an abortion in America is less than $400. A woman determined to have one can hit the ATM, write a check, run up her credit card, borrow from a relative or a friend, or hit the local payday loan store. Poor people pay surprising amounts for cell phones and cable TV. They can be surprisingly resourceful in paying for abortions, too.
On the whole, the empirical record seems to favor this perspective. Via email, the distinguished health economist Theodore Joyce summarized the views of most empirical economists who have studied this question:
I don't see it being very important at a population level. It is a $400-$500 procedure for 90 percent of terminations that occurs less than once per woman per reproductive lifetime. … Prices can [go higher] for late terminations in hospitals when indicated for fetal anomalies. Teens and poor women recognize pregnancies later and end up needing more second trimester abortion. … They will be hurt.
Phillip Levine of Wellesley College, one of the nation's leading experts on the economics of abortion, summarizes the available evidence in a useful little volume, Sex and Consequences: Abortion, public policy, and the economics of fertility. Many studies have examined changes in abortions and births induced by changes in state and federal abortion policies. Federal policies, notably the Hyde Amendment, greatly changed abortion policy in some states, and left policies unchanged in others.
Summarizing the available evidence, Levine concludes that restrictions on Medicaid funding reduced the number of abortions by 3 to 5 percent. That's a pretty small effect, although the effects are somewhat more impressive when one restricts one's attention to low-income women most strongly affected by these policies. There is little evidence that abortion restrictions actually increase the overall number of unwanted pregnancies carried to term. When low-income women face a more restricted environment, they respond by finding alternate strategies to finance abortions. They may also be more likely to aggressively practice contraception.
Levine cites this evidence in a recent New York Times op-ed, titled "False Alarm on Abortion." He notes that 12 percent of American women age 15-44 are covered by public insurance programs that are already barred from using federal funds to cover abortions. Another 20 percent of this same age-group is uninsured.
Of course for these women, $400 is a nontrivial amount of money. That's two months of cash welfare payments for a family of three in several states with the most punitive abortion laws. Then there is the secrecy and the stigma. It's one thing to ask Mom for $400 to cover the rent or asthma medication. It's quite another to borrow funds for an abortion. Many women don't want their friends, parents, relatives, or partners to know that they are pregnant. When women are reluctant to borrow the money or to produce a tell-tale credit card bill, restricting abortion coverage can have a real impact on both the number of abortions and (though this is more complicated) on the number of unwanted pregnancies brought to term.
As Theodore Joyce suggested, poor women are also more likely to be ambivalent about their pregnancies, to discover them later, and to lack regular access to health services. Poor women are more likely to rely upon a patchwork of safety-net abortion providers. This patchwork is often frayed, not least because pro-life forces have mounted a ferocious, at-times legally and morally dubious war of attrition against abortion providers. For these reasons and others, they are much more likely to have later abortions that are more costly and complex, and more wrenching in every other way, too. These issues are left unaddressed in health reform.
Thirty years ago, North Carolina created a special fund to finance abortions for indigent women. Funding was inadequate for five of the years it was in operation. So state monies were sporadically made available and shut off during this period. Such on-again, off-again financing patterns are catnip to economists, because they provide a "natural experiment" to estimate the impact of transient funding gaps on abortions and births. Phillip Cook and colleagues examined this experience, paying special attention to young low-income African-American women affected by these policies. During periods in which no funding was available, three in every ten pregnancies to low-income African-American women age 18-30 that would otherwise have been aborted were carried to term.
This work by Cook and colleagues is not the final word. Maybe North Carolina women implicitly counted on this fund, only to find out that there was no money at the moment they expected to find help. Permanent and clear policies tend to elicit a larger and more consistent response among women. When the ground rules are stable, Planned Parenthood and medical providers can also devise clearer strategies to respond.
Economics is an imprecise science. We learned during welfare reform that plausible "natural experiments" can be quite misleading in predicting the impact of large social policies. Still, the preponderance of the evidence suggests that health reform will not markedly worsen practical access to abortion services. Women with private insurance are most at-risk of losing their abortion coverage. These women have much lower abortion rates and typically have incomes far above the poverty line. Most, presumably, can scrape up that $400. Not that every abortion-related economic issue is so readily pushed aside. Older woman with medical complications and IVF sometimes receive hospital-based abortions that can be quite costly. These issues, too, are left unaddressed in health reform.
Indeed, health reform would help low-income women by helping them obtain health insurance, including improved access to contraceptive services. According to one study by Levine and Melissa Kearney, expanding Medicaid eligibility to near-poor women produced a 15 percent decline in births among young women made newly eligible for family planning coverage. That's a large number of prevented unintended pregnancies. For this reason and others, Levine believes that health reform is worth passing.
I do too, but I remain alarmed. Had the Times a richer sense of irony, Levine's essay might better have been titled "Wrong Alarm." The alarm is false because the bottom third of the American income distribution already lacks access to abortion coverage. The Stupak amendment or the Senate's less severe compromises don't make the situation all that much worse, but they probably harden and codify this lack of federal coverage as the political consensus for years to come.
Theodore Joyce expressed my own frustration well. Noting the new Oklahoma law that requires all women to answer 30 personal questions before they can have an abortion, and a new Missouri law (temporarily enjoined) that would effectively harasses abortion providers by requiring them to meet standards of ambulatory surgical centers, he notes:
I am saddened that anti-abortion forces have so much influence. I appreciate the anger by Planned Parenthood at hurdles providers and women must go through to terminate a pregnancy. … [T]he amendment is just another swipe at women and women's reproductive rights in which abortion is treated differently from many similar surgical procedures.
I have written before about people I respect who hold pro-life views, and the need for mutually respectful dialogue on these issues. I have less respect for people who use economic pressure to restrict abortions among low-income women, when more privileged Americans would not for a moment tolerate such restrictions applied to people like themselves. Indeed measures to restrict middle-class women's access to abortion coverage may be the greatest political boon to feminism in many years.
I hope so. Millions of pregnant women—some frightened or in difficult personal circumstances—beg, borrow, or scrape together the funds required to terminate an unwanted pregnancy without public aid. The policies that force them to do so may prevent some unwanted pregnancies and deter some abortions. Econometric analysis does not capture the accompanying human costs, but they are real.