Behind the Family-Planning Flap

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Early Wednesday evening, the House of Representatives passed President Obama's $819 billion plan to stimulate the struggling U.S. economy. But while the package that passed in a 244-188 nearly party-line vote (and didn't garner a single Republican vote) included a bevy of tax cuts and spending programs, one particular item that has been the subject of much debate this week was notably missing.

A relatively small provision to expand state access to family-planning services under Medicaid was seized on late last week by House Republicans as one of their chief reasons for opposing the stimulus bill. Democrats, they charged, wanted to use taxpayer money that was supposed to create jobs to instead "fund the abortion industry" and pass out contraceptives. The Republicans were caught off guard when Obama called their bluff and asked congressional Democrats to remove the provision — and fell back to complaining about the bill's cost and the insufficient size of tax cuts. But then it was liberals' turn to be up in arms over Obama's "betrayal," with some bloggers and pundits accusing the President of "throwing low-income women under the bus" in a pointless effort to woo Republicans who ultimately weren't going to vote for the package anyway. (See pictures of Obama's Inauguration.)

As is so often the case whenever abortion or birth control is the topic, the debate has generated much heat and very little light. With that in mind, let's try to separate fact from fiction on the family-planning flap:

What would the Medicaid provision have done?

Before Obama took office, a group of health organizations including the March of Dimes sent memos to his transition aides asking for a change in federal policy to alter a Bush-era Medicaid policy. Current law does not allow women of childbearing age (15-44) to become eligible for Medicaid coverage until after they become pregnant or they have children who are enrolled in Temporary Assistance for Needy Families (TANF). States that want to expand their Medicaid coverage to allow low-income women to access family-planning services must first obtain a federal waiver.

The provision originally included in the stimulus package would have eliminated the waiver requirement, allowing states to directly access Medicaid funds for family-planning services that do not involve abortion.

Would the provision have required states to cover emergency contraception or abortions?

No. The policy of the Centers for Medicare and Medicaid Services is that abortion "may not be claimed as a family-planning service" under any circumstances. Since 1976, the Hyde Amendment has barred the use of federal funds to pay for abortions. Individual states can use their own funds to pay for "medically necessary" abortions for Medicaid recipients, and at least 17 states currently do so. (See the Year in Health, from A to Z.)

Wasn't the stimulus package about creating jobs and jump-starting the economy? Why was this provision included?

As we've learned this week, the stimulus package included a wide variety of programs, not all of them geared toward job creation or immediate economic benefits. But supporters of the Medicaid provision argue that it would have resulted in lower health-care costs and therefore rightfully belonged in the stimulus package as a cost-cutting measure. Whether or not you agree with that argument, numerous studies have shown that investments in preventative care save money in the long run. The Guttmacher Institute, which advocates for abortion rights, estimates that every dollar of publicly funded family-planning services saves $4 in state and federal dollars. And when the Congressional Budget Office looked at a very similar provision in 2007, it estimated that the federal savings would have totaled $200 million over five years and $400 million over 10.

But how is the money saved? It sounds like you're saying fewer children would be born and so would incur no costs. Isn't that a little morbid?

That's why it's important to explain where the savings come from. When Nancy Pelosi appeared on ABC's This Week and George Stephanopoulos pressed her on this provision, she kept repeating the talking point — "Family-planning services reduce cost. They reduce cost" — without explaining how.

Remember, the provision wouldn't have covered abortion services. The savings come from preventing unwanted pregnancies in the first place through increased access to contraception and better prenatal and postnatal care. According to the March of Dimes, 1 in 5 infants born prematurely has ongoing health problems, and a recent Institute of Medicine report estimated that the economic burden of preterm births (including medical, educational and lost-productivity costs) was at least $26.2 billion in 2005.

So what happens now? Have low-income women been thrown under the bus?

The organizations that pushed for this provision didn't originally ask for it to be included in the stimulus package. They expect the Administration to push for its adoption soon, either in another piece of legislation or as a stand-alone bill. The provision has been introduced in the past three Congresses as the Prevent Prematurity and Improve Child Health Act, sponsored by Democratic Senators Blanche Lincoln of Nebraska and Jeff Bingaman of New Mexico and Republicans Richard Lugar of Indiana and Olympia Snowe of Maine. Senate aides anticipate that the bill will be reintroduced this year.

In the meantime, states can continue to apply for waivers, which are likely to be approved more quickly in the Obama Administration than they were under George W. Bush. Currently 26 states — including eight with Republican governors — have obtained waivers to provide primary care to low-income women before they become pregnant.

That's it? Why did this become such a flash point this week?

There are always those on both the right and the left who are itching for a fight over cultural issues. Conservatives have been claiming since before the election that Obama would be "the most pro-abortion President in history," and they are eager for evidence to back up that charge. After Obama overturned the so-called abortion gag rule late last Friday — which had prohibited foreign nongovernmental family-planning groups from receiving any U.S. funds if they provided abortions or even lobbied for abortion rights in their country — House GOP leader John Boehner shot out a press release titled "President Obama's Executive Order Allowing Taxpayer-Funded Abortions Overseas," even though federal law continues to prohibit the use of U.S. funds for abortions in other countries.

Liberals, meanwhile, are looking to swiftly roll back the policies of what they viewed as an antiwomen Bush Administration. But now they may have to wait a few weeks for that to happen. As one progressive policy analyst noted, inserting the Medicaid provision into the stimulus package "was kind of like bringing up marriage on the third date. You know it's going to come up eventually, so why start a fight at the very beginning, before you've gotten anywhere?"

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