Thinking About Who Pays

So, I have been aware today of the case before the Supreme Court of the owners of the Hobby Lobby retail chain resisting a provision of the Affordable Care Act intended to insure access for women to all forms of birth control by requiring that employers either include that in company-sponsored health insurance plans or pay a penalty that would allow then allow women to pursue in the insurance exchanges health insurance plans that would cover birth control. There have been many reports about it; and regular readers will know that I listened to the report this morning on NPR.

 

I wasn’t paying too much attention, largely because I wasn’t hearing much new. After all, this has been a topic of discussion for a while. Then I heard this:

　

"The Hobby Lobby corporation and its owners counter that the simple answer to these arguments is to have the government pay for contraception.

The government replies that is no answer. Otherwise, the government would end up paying for everything. A decision is expected by summer."

　

I found myself wondering something more profound in this idea that if the government wanted to mandate health care, the government should pay for it – something I doubt the Greens or their attorneys thought about when they made that statement (if they made it as reported). That is, if this applies to birth control then it should also apply to therapeutic abortion.

　

First, let me take on directly what I mean by "therapeutic abortion." There are cases (and perhaps not so rare) when terminating a pregnancy is medically appropriate. Think, for example, of the woman a few years ago in Phoenix. She was diagnosed with pulmonary hypertension in the eleventh week of pregnancy. While the case was reported because it was complicated for religious reasons (she was a patient in a Roman Catholic hospital), under court decisions and state laws terminating the pregnancy was appropriate because it was literally to save the life of the mother. In fact even the hospital saw it that way, and terminated the pregnancy. The controversy and news coverage came because of the reaction after the fact of the local Roman Catholic bishop, not because the woman didn’t get the care.

 

So, I’m not talking about "abortion on demand." I do think that terminating a pregnancy ought to be a decision a women makes with her doctor; that there ought to be a supportive family and community for that woman; and that the procedure needs to be available and safe. But, for this post I’m only talking about situations that are clearly medically indicated. The one I cited above was rare and rather spectacular. More common are situations like loss of amniotic fluid mid-pregnancy that doom the fetus and put the woman at severe risk. Sure, these aren’t common, but they do happen. And women die. According to the Centers for Disease Control, in 2009 the rate of pregnancy-related deaths was almost 18 per 100,000 live births. That comes to about 650 women each year; and while that may not sound like many over all, say that to the families of those 650 women.

So, by the logic stated above, the government ought to pay for therapeutic abortions. Of course, that brings us up against the other perspective: those who say "no government money" for abortion, including Medicaid dollars. And then, of course, there’s this problem with the logic: those who would refuse to support birth control in the insurance plans offered by the companies they own would then be supporting birth control in the tax-supported insurance plans and/or direct purchases – because to say "let the government support it" is to say, "let all the taxpayers support it – including us."

My guess is that the Greens’ attorneys have a much more sophisticated way of stating that idea that the news report may not do justice. However, the principle as stated caught my attention. It has possible consequences that seem directly contrary to the results the Greens want to see. Call it another of those unforeseen, but perhaps predictable, medical outcomes.