Health Care Reform , Contraception, & Abortion

Health Care Reform , Contraception, & Abortion

by Pam Green, © 2009, updates 2017

There are so many reasons why meaningful Health Care Reform MUST include rock solid assurance that contraception, sterilization, and abortion coverage is available as part of the basic package of coverage for all subscribers who desire such coverage. Of course these aspects of coverage could be declined by anyone who does not want them or has religious objections to using them. (Likewise women past menopause will probably decline these coverages as well as coverage for pregnancy and child-birth simply because they are no longer at risk.) But the Rabid Religious Right's position that because they don't want these services themselves or consider use of such services to be morally bad, these services should be denied to everyone is an outrageous violation of the American principle of religious freedom.

to those who want to exclude insurance coverage of contraception and abortion because "sex is sinful" or "abortion is sinful" :

I propose to show the absurdity the position of denying treatment to one person based on the religious beliefs of some other person, denying treatment to everyone based on the beliefs of a minority or even a majority, by applying that same position of denial of treatment to conditions caused by other forms of voluntary behavior that one religious group or another considers to be morally "bad behavior".

Please note that all the examples I name are ones involving long continued voluntary behavior that would also be labled as "bad" behavior by some religions and not by other religions (nor by most agnostics and atheists). If we are going to exclude services on the grounds that the condition being treated results from voluntary behavior or from "bad" behavior, then we must also ban all the following :

• Treatment of lung cancer resulting from long term tobacco smoking : considered "bad" morally by Seventh Day Adventists and probably some other religious groups (including Mormons ?). Note however that tobacco smoking had a ritual or religious approval from a number of Native American religions.


• Treatment of liver cirrosis resulting from long term excessive alcohol drinking : all alcohol being considered morally "bad" by Mormons, Muslims, Seventh Day Adventists, and Methodists, plus no doubt some religious groups I am not familiar with. However consumption of wine forms part of religious ritual in almost all genres of Christianity ("this is my blood") and in some rituals of Judaism.


• Treatment of traumatic injuries caused by alcohol intoxication on the part of the injured party. Same reasoning as previous item.


• Treatment of type II diabetes resulting from obesity resulting from chronic over-eating and failure to exercise : remember that Gluttony is one of the Seven Deadly Sins in the generic Christian view, and failure to excercise perhaps qualifys as Sloth, another Deadly Sin.


• Treatment of heart disease, artheriosclerosis , and stroke resulting from high fat diet and failure to excercise : Gluttony and Sloth again. Most of the fats that contribute to heart disease are fats from animal sources, and eating of various animals is morally offensive to some religious groups. Eating of pork is offensive to Orthodox Judaism and to Islam. Eating of beef and veal are offensive to Hinduism. Eating of any meat is offensive to at least some portion of Buddism and (I think) Seventh Day Adventism .


• Treatment of survivors of unsuccessful suicide attempts because suicide is considered a mortal sin by quite a few religions, though considered an honorable or acceptable action by other religions past and present.
• Treatment of any adverse consequences of recreational drug use, as such is considered "bad" by some religions although considered a desirable religious rite by a few Native American sects (peyote and a few other drugs).


• Treatment of injuries incurred while perpetrating or attempting to perpetrate a robbery ("Thou shalt not steal") or violent assault or murder ("Thou shalt not kill"). The only religions that come to mind that encouraged murder were those endorsing human sacrifice such as ancient Aztec or worshipers of Baal and the perhaps still existing cult of Kali.


• And, inevitably, treatment of any form of sexually transmitted disease since of course this (usually) results from sexual activitiy (or less commonly , from blood transfusions or sharing of IV needles by recreational drug users).. Coverage of any kind of contact tracing so as to offer testing and treatment to exposed partners would likewise be excluded. This would greatly exacerbate epidemic spread of these diseases, but at least the morality of those who disparage sex would be satisfied.

Do any of the above examples strike you as absolutely absurd ? Of course they do, because they ARE absurd.

Yes, these ARE all behaviors that our schools and public health advertising system should educate people to refrain from or to do in moderation only for the sake of protecting their own health, just as these systems should promote other aspects of healthy lifestyle. It would be reasonable enough if an insurance scheme offered a substantial premium discount to those subscribers who refrained from these unhealthy lifestyle choices as well as those who refrained from various forms of drug abuse. Likewise it would be rational to offer discounts to those who refrained from having sex without a barrier method designed to protect against various sexually transmitted diseases, though it would be very hard for an insured person to prove this compliance.

Most of the health damaging behaviors listed in my absurd examples are VOLUNTARY behaviors that generally have to be done MANY times, continued over a long period, in order to be likely to cause damage to one's health. Pregnancy is different in that regard. An unwanted pregnancy or a wanted one that has become a disaster (seriously impaired fetus or serious risk to maternal health) requires only ONE single act and , for the woman, NOT always a voluntary act, as rape and sexual abuse of girls and women is all too common.

As to the religious objections to these behaviors, only some religions consider sex to be "bad" and then only in some circumstances. Most religions give minimal or generous approval to sex in some other contexts, mosly in the marital procreational context. Some religions seem to celebrate sexuality and its pleasures to an extent that might impress even a bonobo. Hinduism may be one of these, certainly to judge from their religious art.

Need we add that all too often the very religious leaders who publically preach the immorality of a given type of sexual behavior are later found to be secretly indulging in that very type of behavior or one generally considered even less morally acceptable. The examples exist in every religious sect.

If sexual abstinence is so wonderful, how about Senators, Representatives, and Governors, and Presidents practicing this virtue instead of hypocritically preaching it while behaving quite otherwise. Ditto to all the religious leaders who secretly molest or seduce members of their congregations.

(Update note : our current (2017) POTUS has been living in adultery according to the Catholic view (which does not recognize divorce) during his past couple of marriages. Others might regard his conduct as bigamous, polygynous.)

Finally if we are going to exclude contraception and abortion on the grounds that some religions consider sex for purposes of pleasure or emotional bonding rather than for purposes of reproduction to be "bad", then absolutely we MUST also ban every form of treatment for "E.D." for that very same reason. (Note : an impotent man can still reproduce either by stored frozen semen or by a fresh ejaculate obtained by electro-probe stimulation, as is used for dairy bulls -- not fun, but gets the job done.)

I have not cited other forms of medical treatment that violate the religious beliefs of various religions that would apply to conditions not caused by "bad" behavior, but rather treatments that in themselves violate the rules of that particular religion regardless of the nature or cause of the underlying illness or injury. However these too exist and thus would be eligible for exclusion from coverage based on religious minority views. To give only two examples :

• Blood transfusions for whatever reason are considered religiously unacceptable by Jehovah's Witnesses. This is based on a biblical injunction against "eating blood". That sounds to me like it probably was intended to prohibit either human sacrifice or canibalism, both of which have a widespread occurance in human history and both of which are generally disapproved today, even by total atheists. Or maybe this was an injunction against the Christian communion practice of "this is my blood" ??? It's hard to imagine that whoever put this particular injunction into the Bible really was thinking about blood transfusions, since that procedure was still many centuries in the future. Jehovah's Witnesses do allow use of blood substitutes derived from bovine hemoglobin. I do know that some Vet Schools have had clients refuse blood transfusions for their pets on the grounds of religious belief.


• Just about all medical treatments for any reason whatsoever are rejected for religious belief reasons by Christian Scientists, whose belief is that prayer is the only acceptable treatment. This view if applied to everyone would exclude all medical treatment from insurance, eliminate Medicare, and end public funding of medical schools. Fortunately the Christian Scientists don't try to impose their views on anyone except their own children, and the courts have strongly curtailed parental rights to refuse medical treatment for a severely ill or injured child.

(Update 2017 : the Hobby Lobby decision by the Supreme Court a few years ago may imply that an employer who is a Christian Scientist could refuse on religious grounds to provide employees with any health insurance that covers any medical treatmeent but merely covers treatment by prayer, probably prayer with the pastor hired by the employer.)

to those who don't want "their" tax money spent on abortion :

As to the arguements from the Rabid Religious Right that they shouldn't have "their" tax money spent on something they find morally repugnant, ie on abortion (or on prevention of the need for abortion by tax funded contraception subsidy), let's try applying that to other tax expenditures for purposes that one religion or another considers deeply morally repugnant.

• The most obvious of these is war and military spending, which takes a huge chunk of every taxpayer's taxes. The Amish and the Quakers consider war and any participation in the military to be profoundly morally repugnant (as in "Thou shalt not kill"), yet they have to pay taxes to support these governmental activities. And if Quakers and Amish were to be excused from paying that portion of their taxes, you'd better believe that suddenly a lot of people would have an epiphany and join one or the other of these very respectable and long-established religions. (I wouldn't mind using a horse and buggy for transportation, indeed I used to drive my horse Sunny into town, but I really look terrible in black, so I guess I'll join the Quakers rather than the Amish.)


• A lot of taxpayer money is spent on capital punishment for some admittedly very nasty criminals. But there are some very sincere people who believe on religious grounds ("Thou shalt not kill" again) that it is profoundly wrong to deliberately take the life of even the most depraved person. They get excused (indeed are excluded) from sitting on juries in potentially capital cases, but they don't get excused from a penny of taxes used for executions.


• Maybe we should exempt some portion of taxes going to FEMA for those who regard floods , fires, and earthquakes to be "Acts of God" ? Perhaps those same people should be excused from being taxed to support their local Fire Department and local Flood Control district ? If so, their homes and other real estate should be allowed to burn or flood away and should not receive an Disaster Aid payments. .


• Of course there are already many who clamor to be excused from paying for public schools unless they can control the curriculum to conform to their own religious views. Or they want other taxpayers to pay for vouchers so they can send their children to church run private schools that do teach according to their particular religious mythology. (or pathology)
  (Note: there is probably a much much better arguement for partial school tax relief for those who have no children and thus are not directly using the school system. Of course we all tend to benefit from having other peoples' children educated to become productive members of society rather than remain illiterate and innumerate, but parents burden and benefit from the schools more than do non-parents. Still you know very well that there will never be any kind of non-parent school tax relief.)


• Surely Hindus should ask to be excused from taxes going to support Dairy Farm subsidies since dairy farming involves the killing of most male calves, thus killing a sacred beast. Perhaps Orthodox Jews and Muslims could be excused from any taxes that go to subsidize pig farming, since the eating of pork is a religious abomination.


• Those whose religion (lited above) forbids tobacco should ask to be excused from being taxed to subsidize tobacco growing.

There are probably no end of absurd arguements that could be made for exemption from one tax or another on the grounds of religion. The arguement regarding war taxes and capital punishment are not absurd, but we all know that there will never be tax relief for anyone on these grounds. Even the Amish, who are excused from participating in public education beyond grade school (See Yoder v Wisconsin, surely one of the Supreme Court's less well reasoned opinions.) and from participating in Social Security and are recognized as excused from actual military draft as Conscientious Objectors, are NOT excused from paying those portions of their taxes that fund the military and war. Likewise the Quakers are recognized as Consientous Objectors but are NOT excused from paying taxes to support the military and war.

At the moment it is not at all clear whether or how much tax money will be required for Health Care Reform. Probably a good bet that some tax money will be required one way or another.

Update 2017 : of course quite a lot of tax money has been required under ObamaCare, but one would have to balance that against savings from costs of uninsured persons using the ER as their primary care and costs of long term care for chronic illnesses that could have been cured or made less severe if treated at an early stage or a preventative care stage. Doing this math would be hard to do.

Concerning the "conscience exemption" for MDs and pharmacists :

The so-called "consience exemption" that allows a pharmacist to refuse to fill a legally prescribed doctor's prescription for contraception or for Plan B emergency contraception or that allows the pharmacist to refuse to fill a request for an over the counter contraceptive or Plan B (which is legally a non-prescription item in some states) and which allows an MD to refuse to provide information on contraception or abortion or to refuse to perform same , without immediately turning the patient over to some other MD willing to provide the requested or needed services, is utterly abhorrent as it simply means that the pharmacist or MD is allowed to elevate his own "conscience" or beliefs above those of the patient. Is not the patient a person of rights equal to those of the pharmacist or MD ? Is not the role of the pharmacist or MD one of service to the needs and wishes of the patient whose health and body are at stake ? The doctor's role to the patient is analogus to the car repairman's role to the car owner.

Now I know someone will interject the Hippocratic Oath regarding "will give no deadly drug" and "nor abortion" at this point.
First of all the Hippocratic School of medicine in its classic Greek era was one of many schools of medicine and , indeed was a minority point of view. The prevailing majority views did not have the deadly drug and abortion countermands.
Now since poisoning was a popular way of getting rid of a political enemy in those days, the "no deadly drug" clause may have been more in view of not enabling a poisoner to murder than in view of not abetting suicide. Suicide was not considered unacceptable in Greek times (nor Roman times); indeed , suicide was considered honorable under some circumstancess..
As to abortion, in Greek times (and Roman Empire times) the child before and after birth was the property of the male head of household . This was as much true for a child of the head of household's wife as for the child of any of his slaves : they were his property. The wife was almost as much property as the slave. In any case the ruling husband had an absolute right AFTER the child's birth to decide whether to rear it or to "expose" it, the latter meaning to leave it on the hillside for predators and scavengers to kill and eat. So any prohibition on the wife aborting the unborn child did NOT rest on any concept of any right of the child to survive, but rather on the property right of the male head of household (husband or slave-owner) and his right to decide whether or not to kill that child. Post-natal infanticide by the father was thus legal and not unusual.
Bet your high school teacher didn't mention any of this when teaching "the Glory that was Greece". Probably didn't mention the upper class Greek romantic ideal of erastes and eromenos either. Damon and Pythias were not just "real good buddies", not just a "bromance" , nor were Achilles and Patrocles, nor were Alexander and Hephastion.

The same absurd examples given above of letting one person impose his personal religious or conscience beliefs on another apply with even greater strength to the pharmacist - patient and doctor - patient relationship.

I guess I can picture a doctor giving a patient who comes in with lung cancer or emphysema or heart disease a bit of a tongue lashing about "why didn't you listen to me any of the hundred times I told you to quit smoking", but I really cannot picture that doctor trying to deny treatment to that patient. Nor can I picture an Orthodox Jewish or Muslim MD refusing to treat a patient for trichinosis.

Now I wouldn't totally object to a doctor who feels so strongly about the "immorality" of providing a certain treatment to a patient to abstain from doing so IF that doctor were required to immediately or with greatest practical speed turn the patient's treatment over to another doctor who was both willing and able to provide that treatment. After all turning the patient over to someone more qualified is exactly what we expect a doctor to do if he feels his own skill or experience in the needed treatment isn't good enough or that another doctor can do it much better. Doctors refer patients to other doctors all the time for this very reason. So I could accept that a doctor who feels great repugnance at a particular treatment would be unlikely to have enough skill and experience at doing that treatment to do it well , nor would the patient feel very secure and trusting about letting that doctor perform reluctantly. Of course "moral repugnance" is not considered a good reason for not being competent in any other type of treatment. The internist will turn a surgical patient over to a surgeon, maybe even a specialist surgeon (eg cardiac surgeon, orthopedic surgeon) because internists normally don't do any surgery except maybe an emergency tracheotomy for a patient who quit breating right in front of the internist. But a general surgeon should have no real excuse for not being competent to do a D & C, which is one form of abortion, and an internist should have no real excuse for not being competent to administer and supervise RU486, the abortion drug for early term abortion. The pharmacist of course has zero excuse for not being competent to fill a prescription for contraceptive pills or for Plan B or to tell a customer where to find the condoms or spermaticidal jelly (or the over the counter Plan B in states where Plan B is OTC ).

Bottom line is that any health care reform should eliminate or severely limit the so-called "conscience exception". The doctor who objects on grounds of conscience to providing contraception or abortion should be required to immediately transfer the patient to a non-objecting doctor competent to perform the services. And the objecting doctor should not be allowed to charge the patient or the patient's insurance for the office visit that led to the refusal. Likewise every pharmacy should be required to have at least one pharmacist on duty at all times the pharmacy is open who is perfectly willing to fill prescriptions for contraception , including Plan B, and to stock and provide all legal OTC contraceptives.

as to the financial impacts of limiting contraception and/or abortion :

I won't go into the full costs to society of limiting or denying contraception and/or abortion, because it should be obvious to anyone who gives it even brief thought that children whose parents cannot or will not raise them or who cannot or will not financially support them become extremely expensive to society. The Welfare expenses for children whose natural parents are not supporting them are enormous. The Child Protective Services expenses for those unwanted children who are neglected or abused are even higher. If parental neglect or abuse fosters later criminal behavior, the resulting Criminal Justice system costs, including prison costs, become astronomical. Even the easy case of the accidental child whose parents would have preferred to prevent conception but who now cheerfully do a good job of rearing is still quite costly in terms of public schooling, a huge state budget item.

I will focus only on the medical costs , and then very briefly.

Contraception is relatively very cheap, though some forms are cheaper than others. Sterilization is a one time cost that becomes very cheap when amortized over the remainder of the individual's potential reproductive years. The new Essure method for women should be cheaper as well as safer than Fallopian ligation.(see Update note below on Essure.) Vasectomy is a very simple surgery that should be very cheap. IUDs are cheap to insert and cheap to do follow up care. Condoms and contraceptive pills are more expensive. The condom of course does double duty by largely preventing STDs which can be damageing and costly to treat and AIDS which is extremely costly to treat and fatal if untreated.

Update 2017 : more recently it has been learned that Essure is not at all safe, but indeed can have later very harmful effects, some of which are potentially fatal.

Abortion is also relatively cheap or would be if not so greatly repressed and intimidated. It is alot more costly to run a clinic if everyone has to wear bullet proof clothing and the clinic iteslf must have anti-explosive armor.

The prenatal care regime and parturition care for a normal uneventful pregnancy is much more expensive than one time costs for sterilization and much more expensive than costs for quite a few years of contraception. It's also much more expensive than costs of an abortion , especially RU486.

The costs for a complicated or high risk pregnancy and high risk birth or C-section are considerably more expensive than those for an uneventful sequence.

Costs for neo-natal ICU care for premature births and for defective neonatals can become truely awesomely exorbitant. The costs of a few weeks' neonatal ICU could pay for another MD's medical school tuition. Some of the infants who are thus "saved" will have expensive medical problems all their lives or may require custodial care. I'm not considering here the poor quality of life such an infant may suffer, not because I think it is irrelevant, but because the topic for today is cost containment for the health care system, not pity for human suffering that could have been prevented.

Thus in short contraception and abortion rank very high in terms of Value Based Medicine and in terms of Evidence (Efficacy) Based Medicine. They rank higher than ordinary pregnancy and parturition and far far higher than complicated pregnancy, difficult delivery, and neo-natal Intensive Care. Now I am not, of course arguing that every pregnancy should be prevented or aborted, but the fiscal soundness of preventing or aborting unwanted pregnancies rather than compelling their continuation becomes financially irrefutable.

Coverage of contraception, sterilization, and abortion at the request of the patient is an essential and legitimate part of any health care program and must be mandated in any Health Care Reform program.

Update comment 2017 : it would be extremely intereting if a few health insurer would try the following experiment and report the results publically.
Offer every insured person the choice between two policies which are identical except that one plan covers contraception and abortion fully and the other one covers contraception but not abortion. Both plans must fully cover pregnancy care, childbirth care, and all neonatal care (at least for the first 6 months or first year). (A third plan choice might be one that does not cover contraception or abortion.) The choice of which plan would be made by the insured person, NOT by the employer or any other person. For the first five years have the premiums for the two plans be identical, but keep careful outcome records. At the end of 5 years assess total payouts for all health care and assess total payouts for abortion (including consequences of illegal ones) , pregnancy, birth, and neonatal care. After the 5 year analysis, the premiums could be adjusted to reflect any difference in actual payout costs.
I will bet almost anything that the result will be that both total payouts for all care and total payouts for abortion, pregnancy, etc will be much much lower for the plan that covers contraception and abortion than for the plan that does not cover abortion. If those results were circulaed among insurers, I would expect that all of them would discourage sales of "abortion not covered" policies. If employers were informed of the higher premium they'd have to pay for an "abortion not covered" policy, it's likely that almost all would offer employees only the inclusive policy (Alternatively it could be required that the employee to pay the added premium if the employee chose the non-inclusive policy. In that case I am betting that employees would chose the inclusive plan, knowing that , after all, just because a particular treatment was covered does not mean that the patient must choose that treatment)

• You Say that You Dislike Abortion : about all the things that those who say they oppose abortion should be supporting to reduce the need for abortion, ie to reduce unwanted and problem pregnancies. (guaranteed to outrage the Rabid Right and Anti-Choicers everywhere)
• Roe v Wade and the 13th Amendment : a discussion of why Roe did not go far enough and why restrictions on contraception and abortion violate the 13th Amendment which forbids slavery and involuntary servitude. (note : this article may offend some readers.)
• Rob-ye Lobby , a satire on the Supreme Court "Hobby Lobby" decision and its potential implications. An employer whose religion does not allow medical treatment decides to eliminate medical insurance for employees.