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By David G. Taylor September 1, 2011

Insurance companies required to cover preventive care

In assessing whether President Obama fulfilled this promise, we need to look several elements of reproductive health: improving overall health care coverage for women, birth control coverage and abortion services. Obama has made substantial gains in two and compromised in the other.

When we last updated this promise, Congress was on the verge of passing President Barack Obama"s signature health care legislation, the Patient Protection and Affordable Care Act, into law. One of the bill"s most formidable obstacles in securing passage was a group of anti-abortion House Democrats, led by Rep. Bart Stupak, D-Mich.

Rep. Stupak and Rep. Joseph Pitts, R-Penn., crafted the Stupak-Pitts Amendment that prohibited federal funds from paying for abortions in the health insurance exchanges set up by the legislation. This action was to insure the new bill would uphold the Hyde Amendment, a legislative provision first instituted in 1976 that bans the use of federal funds in paying for most abortion procedures through Medicaid. The Stupak-Pitts amendment passed the House of Representatives but was not included in the Senate"s version of the bill.

Stupak and his coalition threatened to vote against the Senate version if it did not contain similar abortion funding restrictions. As a compromise, Obama issued Executive Order 13535, in which the president assured abortion critics that no federal money would go toward funding abortions in the new health exchanges. In other words, President Obama"s executive order was a promise that he would continue to enforce the Hyde Amendment's provisions.

The final law did, however, contain an amendment championed by Sen. Ben Nelson, D-Neb., another Democrat. This amendment requires that insurance companies in the exchange that provide abortion coverage must collect two separate payments from each person who purchases the plan. One portion of this payment goes toward general health concerns while the other goes toward a fund specifically for abortion services. The abortion fund, however, must be paid exclusively by the buyer.    

Groups that support abortion rights weren't thrilled with that, but they were pleased the bill did not contain Stupak's amendment.

"(W)e regret that a pro-choice president of a pro-choice nation was forced to sign an Executive Order that further codifies the proposed anti-choice language in the health care reform bill, originally proposed by Senator Ben Nelson of Nebraska," said Cecile Richards, President of Planned Parenthood in a press release about he health care bill"s passage. "What the president"s executive order did not do is include the complete and total ban on private health insurance coverage for abortion that Congressman Bart Stupak (D–MI) had insisted upon. So while we regret that this proposed Executive Order has given the imprimatur of the president to Senator Nelson"s language, it is critically important to note that it does not include the Stupak abortion ban."

A provision in the health care law grants Secretary of Health and Human Services (HHS) Kathleen Sebelius the power to implement regulations when it comes to women"s preventive care. On August 1, 2011 Sebelius announced a new HHS regulation, which stipulated that health insurance companies, starting a year from that date, will be required to fully cover birth control pills without requiring a co-payment. HHS argues that, because of co-payment costs, women"s preventive services are underused. The HHS guidelines, based on recommendations by the Institute of Medicine, also apply to tests for the human papillomavirus (HPV), screenings for gestational diabetes and some counseling services. These guidelines apply to all insurance companies, not only those in the insurance health exchanges.

It is unclear whether emergency contraceptives, commonly known as the "morning-after pill", will be covered. The guidelines state that health insurance companies must cover contraceptives "as prescribed." Many emergency contraceptives can be bought over the counter and may be ineligible.

A Kaiser Family Foundation poll found that two-thirds of Americans agreed with the HHS decision. The mandate, nevertheless, attracted criticism from conservative lawmakers and pundits and religious groups.

"Pregnancy is not a disease, and fertility is not a pathological condition to be suppressed by any means technically possible," said the United States Conference of Catholic Bishops in a statement.

"What the president"s just said, is now all of us have to pay that co-pay for other people"s birth control and for other people"s morning-after pills," said Rep. Michele Bachmann, R-Minn., a candidate for the Republican presidential nomination.

Anticipating such objections, the HHS allows religious institutions to choose whether insurance offered to their employees includes these changes.

We asked Planned Parenthood for its thoughts on where Obama stood in terms of delivering on his promise. "President Obama has been a champion for women"s health. From passing historic legislation that will expand health care access to millions more women to ensuring that women have access to vital preventive health care with no co-pays or additional costs, the Obama administration has stood strong for women"s health and made a significant difference in the lives of women," said Planned Parenthood spokesperson Tait Sye in a statement to PolitiFact.

President Barack Obama stated that he would make women"s reproductive health care a centerpiece of his reform legislation. Although "at the heart" is nebulous phrase, we find that the health care legislation, and particularly the new HHS guidelines, shows the importance that the administration places on women"s health. We rate this as a Promise Kept.

Our Sources

Department of Health and Human Services press release, August 1, 2011.

Women"s Preventive Services: Required Health Plan Coverage Guidelines.

Interview with Planned Parenthood spokesperson Tait Sye.

CBS News, "Feds" free birth control rule drawing fire," August 1, 2011.

Rep. Michele Bachmann campaign stop in Iowa, August 7, 2011.

Kaiser Health Tracking Poll -- August 11, 2011.

Reuters, "U.S. says insurers must fully cover birth control," August 1, 2011.

CNN, "HHS OKs birth control with no co-pay," August 1, 2011.

Wall Street Journal, "Stupak: 15-20 Dems Can"t Back Obama Health Plan," February 24, 2010.

Sen. Ben Nelson, floor remarks, December 24, 2009.

White House, Executive Order 13535, March 21, 2010.

Louis Jacobson
By Louis Jacobson November 10, 2009

Health bill amendment threatens promise to cover abortion

The House passage of a health care reform bill on Nov. 7, 2009, has nearly been overshadowed by an amendment approved by lawmakers the same day. The amendment, which expanded limits on federal funding for abortions, is so unpopular with abortion rights supporters that it could derail the Democrats' plan.

The new controversy prompted the Planned Parenthood Action Fund to highlight a speech President Barack Obama made to the group in July 2007.

In that speech, made while Obama was just a few months into his quest for the Democratic presidential nomination, he said, "In my mind, reproductive care is essential care. It is basic care, so it is at the center and at the heart of the plan that I propose. Essentially what we're doing is, we"re going to set up a public plan that all persons and all women can access if they don"t have health insurance. It will be a plan that will provide all essential services, including reproductive services, as well as mental health services and disease management services, because part of our interest is to make sure that we"re putting more money into preventive care."

We missed this promise when we were assembling our collection of Obama promises, so we are adding it now.

Until recently, it looked as if the House health care bill would live up to Obama's promise, by allowing people who signed up for health coverage under the new health care bill to secure abortion coverage. A provision written by Rep. Lois Capps, D-Calif., that was included in the House bill when it came to the floor last weekend would have explicitly made abortion coverage available in both the public plan and in private plans participating in the new health insurance "exchange" -- a virtual marketplace for the uninsured or people who work for small businesses.

Under the Capps amendment, insurers would not have been required to offer, nor would they have been prohibited from offering, abortion services in order to participate in the exchange. The public plan -- the government-run option -- could include abortion coverage, but the cost of the additional coverage would have to be paid by premiums, not by federal subsidies. In addition, at least one plan in every region would have to offer full abortion coverage, and one would have to exclude it. Any insurance plan participating in the exchange would not be able to discriminate against hospitals or other health care facilities, such as Catholic hospitals, that are unwilling to provide abortions. And the plan would not allow pre-emption of any state laws regarding abortion, such as parental notification laws.

But this language was unacceptable to many antiabortion lawmakers in both parties, and they rallied their forces to propose an alternative. Their amendment, offered on Nov. 7 by Reps. Bart Stupak, D-Mich., and Joe Pitts, R-Pa., passed by a 240-194 vote. It won the support of 64 mostly antiabortion Democrats, who joined virtually all Republicans.

The Stupak-Pitts amendment said people buying coverage on the exchange using federal subsidies for lower- to middle-income Americans would not have abortion coverage except in the case of rape, incest or when the life of the mother is endangered. It also would prohibit abortion coverage for anyone getting coverage on the public option. People buying subsidized private coverage on the exchange could still opt to purchase abortion coverage as a separate rider, as long as they did not pay for it with subsidies. Insurers would be barred from mingling funds from people who use affordability credits to buy coverage with those who do not, and they would have to offer a similar plan on the exchange that does not include abortion.

Abortion-rights groups consider the Stupak-Pitts amendment a severe infringement on rights that have been upheld by the Supreme Court in Roe vs. Wade . While we have rated one Democratic lawmaker's quote about its impact False, based on an overly expansive view of the amendment's restrictions, there is little doubt that the Stupak-Pitts provision would make the measure fall short of Obama's 2007 promise to "provide all essential services, including reproductive services."

The amendment's prohibition on providing abortion coverage to participants in the exchange who receive subsidized coverage or use the public option would clearly break Obama's promise. And while the Stupak-Pitts provision wouldn't establish an outright ban on abortion coverage for subsidized health exchange participants who buy private plans, it would add a significant logistical hurdle by forcing them to obtain a rider to obtain such coverage. Even unsubsidized health exchange participants -- whose ability to secure abortion coverage would not be directly restricted by the law -- might find themselves facing limited coverage choices if insurers take the path of least resistance and simply ignore the market for abortion-inclusive policies on the health exchange.

So, if Obama were to sign a bill with the Stupak-Pitts language, he'd be breaking his promise to make reproductive health care "at the heart" of his program. This could change on a dime, as it did on Nov. 7, and we'll be watching the debate closely to see if this promise merits a change in ruling. But for now, we'll rate this promise Stalled.

Our Sources

Barack Obama, remarks before the Planned Parenthood Action Fund, July 17, 2007

Planned Parenthood Action Fund, alert to members on abortion coverage in the House health care bill, accessed Nov. 10, 2009

Text of Capps amendment to the House health reform bill, accessed Nov. 9, 2009

Text of Stupak-Pitts amendment to the House health reform bill, accessed Nov. 9, 2009

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