Abortion Rates and Universal Health Care
N Engl J Med 2010; 362:e45April 1, 2010DOI: 10.1056/NEJMp1002985
Among the most nettlesome obstacles in the yearlong debate over increasing the accessibility and affordability of health insurance has been the question of what effect health care reform legislation would have on the incidence of abortion. 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. Parties on both sides of the national debate on this issue, including the U.S. Conference of Catholic Bishops, reached an informal consensus early last year that reform should maintain as nearly as possible the status quo, which mostly keeps the federal government out of the abortion business.
Current law restricts federal payments for abortion to instances of sexual assault, incest, or jeopardy to the life of the mother. The centerpiece of abortion-funding restrictions, which governs federal Medicaid and other expenditures by the Department of Health and Human Services, is a budget appropriation rider called the Hyde Amendment, which has been approved by Congress annually since 1976. Substantial disagreement has emerged on how the spirit of the Hyde Amendment should be applied to the novel situation created by extending health coverage to more than 30 million additional people, some of whom will require a degree of public subsidization. Offering federal subsidies to private insurance plans will enable millions of lower-income women to obtain health insurance coverage, but the conundrum for legislators has been how to provide this care without federally subsidizing abortions or, conversely, restricting access to abortion for women who subscribe to these plans.
Underlying the opposition to federal subsidization of private plans that provide abortion is the belief that such subsidies would remove financial disincentives for women to have abortions and would result in a significant increase in the abortion rate in the United States. For example, in a video released last summer that featured 16 religious leaders speaking out against health care reform, Dr. Richard Land, an official of the Southern Baptist Convention, said, “If we fail, abortion will dramatically increase.” Representative Trent Franks (R-AZ) said in a nationally televised interview that “this health care plan will be the largest expansion of abortion in the United States since Roe vs. Wade, only this time it'll be paid for by taxpayer dollars, and people don't see that as health care.”
The effect of expanded health insurance coverage on the abortion rate is difficult to predict. I undertook a study of the effect that coverage-expansion efforts in Massachusetts had on that state's abortion rate as one means of predicting the possible effect at the national level. In 2006, Massachusetts enacted legislation entitled “An Act Providing Access to Affordable, Quality, Accountable Health Care.” At the time, according to the Census Bureau, more than 10% of Massachusetts residents had no health insurance. Before the new law was enacted, Massachusetts ranked ninth among the states in the number of uninsured nonelderly adults (86% were insured in 2004–2005). But implementation of the legislation resulted in a rate of coverage of 94% among nonelderly adults in 2008 — the highest rate in any state.1
The national health care reform legislation that was recently passed by the Senate has been modeled, in many respects, on the Massachusetts reform law; both lack the “public option” that was included in the House bill, which was the focus of the Stupak–Pitts Amendment prohibiting federal subsidies for health plans that would pay for abortion. Therefore, I hypothesized that the early experience in Massachusetts might serve as a good model in which to examine whether a substantial expansion in health care coverage might result in an increased number of abortions.
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 graphPercentage Changes in the Nonelderly Insured Population in Massachusetts and the Number of Abortions Performed after Implementation of the State's Universal Health Care Law (2006–2008).). 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
The significant decrease in the abortion rate during the 1990s moderated somewhat between 2000 and 2008. But the vital statistics in Massachusetts indicate that this overall downward trend continued during the first 2 years after the implementation of the law that expanded health insurance coverage to virtually all residents. As of February 2010, more than 439,000 additional people were covered by health insurance, according to the Massachusetts Division of Health Care Finance and Policy, yet the most recent data indicate that the number of abortions in Massachusetts simultaneously reached its lowest level since at least the 1970s.
Complex social phenomena such as abortion rates are subject to a variety of political and social factors that are difficult to gauge. It is unclear, for instance, why there was an increase nationally in the abortion rate during the latest year (2006) for which statistics are available — a 3.2% increase over 2005.4 These data may indicate that there was a further national slowing in the decline of abortion rates during the Bush administration and could explain the somewhat slower decline in the more recent Massachusetts data.
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.5
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.
Disclosure forms provided by the author are available with the full text of this article at NEJM.org.
This article (10.1056/NEJMp1002985) was published on March 17, 2010, at NEJM.org.
From the Departments of Medicine and Pediatrics, Massachusetts General Hospital and Harvard Medical School, Boston.
Commonwealth Fund state scorecard on health system performance. Boston: Massachusetts Health Care Quality and Cost Council, 2009. (Accessed March 16, 2010, at http://www.mass.gov/Ihqcc/docs/meetings/Massachusetts_combined_tables_v2.pdf.)
Abortion surveillance — United States, 1991. MMWR CDC Surveill Summ 1995;44(2):25-53. [Erratum, MMWR Morb Mortal Wkly Rep 1995;44:479.]
State facts about abortion: Massachusetts. New York: Guttmacher Institute, January 2008. (Accessed March 16, 2010, at http://www.guttmacher.org/pubs/sfaa/massachusetts.html.)
Abortion surveillance — United States, 2006. MMWR Surveill Summ 2009;58(8);1-35.
Wright J. Reducing abortion in America: the effect of socioeconomic factors. Washington, DC: Catholics in Alliance for the Common Good, November 2008. (Accessed March 16, 2010, at http://www.catholicsinalliance.org/files/CACG_Final.pdf.)
- Citing Articles (2)
Wendy V. Norman. (2012) Induced abortion in Canada 1974–2005: trends over the first generation with legal access. Contraception 85:2, 185-191
Danielle Bessett, Katey Gorski, Deepani Jinadasa, Marcy Ostrow, Megan J. Peterson. (2011) Out of Time and Out of Pocket: Experiences of Women Seeking State-Subsidized Insurance for Abortion Care in Massachusetts. Women's Health Issues 21:3, S21-S25