Of the many contentious issues in the health care reform battle, abortion provisions ignite some of the hottest sparks. Carole Joffe, professor at the Bixby Center for Global Reproductive Health at the University of California, San Francisco, has followed the abortion debates for years. Whatever health care reform finally emerges, Joffe believes that access to an abortion in the United States will remain a complicated matter and that abortion services will not be normalized into the health care system any time soon. In her latest book, "Dispatches from the Abortion Wars: The Costs of Fanaticism to Doctors, Patients, and the Rest of Us," Joffe explores the impediments to abortion care.
By Carole Joffe
As the health reform bill nears a pivotal vote in the House, abortion remains at the center of this long running drama. Will Rep. Bart Stupak (D-Mich.) find enough anti-abortion allies to derail the measure because the Senate bill allegedly does not contain as strong anti-abortion language as the congressman was able to insert in the original House measure?
The health reform process wasn't supposed to go this way.
Recognizing the explosive nature of the abortion issue, President Obama and abortion rights Democrats continually said, "This is a health care bill, not an abortion bill." Early in the process, Rep. Lois Capps (D-Calif.), a staunch supporter of abortion rights, put forward an amendment that stipulated that any health care bill should be "abortion neutral" -- neither increasing or decreasing the coverage Americans now get from private insurance plans, and not challenging the longstanding Hyde amendment which states that no federal funds can be used for abortion, except under very limited circumstances.
This amendment did not satisfy pro-life forces, and the last few months have seen a battle between different camps within that movement as to whose restrictions on abortion go farther -- Stupak's, which demands that women wanting abortion coverage purchase a separate rider? Or Nebraska's Democratic Senator Ben Nelson's, which permits abortion coverage if a woman writes two separate checks to her insurance company?
It is anyone's guess, what will happen. The bill may be defeated by opponents of abortion. It may squeak through. House Democrats who support abortion are dismayed by the abortion provisions but are not willing to let the entire bill fall.
One thing is clear, however: damage has already been done to future insurance coverage of abortion. An analysis by a leading health policy scholar concludes that many insurance plans—which now mostly do cover abortion—will cease to do so, because of the cumbersome requirements involved in both the Senate and House bills.
With an eye toward being attractive to as many markets as possible, some of these companies will drop abortion coverage, even if health reform does not pass at this point.
But the probable impact of health care reform politics on the insurance market is only one of a host of factors that make abortion care in the United States a remarkably complicated affair in many locations
As I was researching a book on the contemporary abortion wars, the words, from a Woody Guthrie ballad about the Great Depression, "Some will rob you with a six gun, some with a fountain pen," frequently ran through my mind. Nothing of course is worse than the violence that periodically strikes the world of abortion provision (eight members of this community have been murdered since 1993, most recently, Dr. George Tiller of Kansas in May 2009).
But such incidents, thankfully, happen only occasionally. Yet every day those who perform abortions and those women who seek them have to deal with a host of cumbersome laws and regulations that make abortion care seem like running an endless obstacle course.
That abortion was not going to be easily normalized into the American health care system as a routine part of women's reproductive health (as it is in many European countries) became clear almost immediately after the Roe v Wade decision in 1973. A politically powerful Right to Life movement emerged in response to this decision, and one of its first and most significant legislative victories was the passage of the Hyde amendment.
State legislatures eventually began to pass numerous laws attempting to regulate abortion provisions in various ways (over 800 such laws were introduced in 2009 alone). Among these: waiting periods of 24 or 48 hours, parental consent and notification measures, onerous reporting requirements (a recently passed Oklahoma law demands providers fill out a 37-item questionnaire on each patient), and most egregious, in my view, mandated informed consent requirements in 23 states which involve blatant mistruths about the alleged health risks of abortion, such as breast cancer, mental illness and future infertility.
How has this massive regulation of abortion affected women seeking the procedure? Here's what we know. Regarding the Hyde amendment, a recent report from the Guttmacher Institute concluded that "approximately one-fourth of women who would obtain a Medicaid-funded abortion if given the option are instead forced to carry their pregnancy to term...".
We also know that the number of abortion providing facilities in the United States fell from a high of 2,908 in 1982 to a low of 1,787 in 2005 (the most recent year for which data is available). We can reasonably assume that this dramatic drop is due in great part to the difficulties many clinics had in conforming to the numerous regulations mentioned above.
We know that the numbers of abortion performed in the United States have also seen a dramatic decline, from a high of 1.6 million in 1990 to 1.2 in 2005. What we don't know is how much of this decline to attribute to improved contraceptive use, to changing cultural attitudes about abortion, or to the difficulties faced by the most vulnerable women in actually getting to a facility and affording the procedure.
Similarly, we can only speculate about how many women are kept from seeking the abortion they want because of legitimate fears of being "outed" by protesters who show up at clinics with video cameras or unfounded, but still terrifying, fears because of the misinformation they may have received from anti-abortion propaganda, including the information that providers in some states are legally bound to give.
That abortion care continues to take place in such a highly polarized environment as the contemporary United States is a testament both to women's determination to control their fertility, and to providers' willingness to endure conditions found no where else in health care.