Americans are accustomed to thinking about the “social safety net,” the network of financial support and services, both public and private, that helps individuals and families deal with periods of poverty or job loss. We are less accustomed to thinking about a “conscience safety net,” the network of policies and institutions that allows people to deal with deep differences in values and moral outlook.
Nowhere is that conscience safety net more important, and more frayed, than in health-care decision-making and financing. Today people disagree on a profound range of ethically grounded decisions about practices, from abortion to in vitro fertilization to assisted suicide, that go to the heart of what citizens believe properly constitutes health care. Combine these deepening differences with a tendency to bureaucratize and centralize health-care financing and administration, and profound clashes are sure to follow.
While we closely follow disputes that result in lawsuits, like the Hobby Lobby and Little Sisters of the Poor litigation over mandatory contraceptive coverage or California’s mandate that even churches include elective abortion in their insurance plans, we tend to pay far less attention to the structural and economic changes in health care that actively, but quietly, erode the conscience safety net. But these disputes may actually be where the rubber meets the road.
Consider the recently announcement from UnitedHealthcare (UH), the nation’s largest health insurer, that it will leave the Obamacare exchange system for 2017 in at least 26 of the 34 states in which it has participated. This means UH would be off the exchanges for sign-ups as early as this fall. UH officials attribute the departure to the company’s sustained financial losses in these marketplaces, which rely on premium tax subsidies to enroll millions of customers whose health histories had reduced their insurability under prior law.
Obamacare Has Allowed for the Conscience Safety Net
The Obamacare exchanges offer a patchwork of components in the conscience safety net. Each recognizes in its own way the legitimacy of citizen objections to using their tax dollars, or their own funds, to pay into an insurance plan that treats elective abortion as ethically acceptable. The underlying law, the Affordable Care Act, permitted states, in their reduced role of regulating health insurance plans, to exclude from their exchanges all plans that cover elective abortion. Twenty-five states have taken advantage of this ACA provision and operate exchanges with no plans that cover elective abortion. The rest allow plans that cover elective abortion.
Then there are the insurance options managed directly by the federal Office of Personnel Management (OPM). These multi-state plans (MSPs) are private-sector plans that must meet a timetable ACA established (a timetable many insurance companies doubted could be met), offered by private insurers like UnitedHealthcare and Aetna in multiple states and eventually reaching all 50 states if they are to remain qualified as MSPs.
The conscience factor for MSPs followed from the fact that the ACA required each private company offering an MSP to provide at least one plan option that excluded elective abortion coverage. This was particularly important because the ACA requires a monthly abortion payment for any plan that covers elective abortions, with the proceeds segregated into an account specifically to pay for those abortions.
On paper, having MSPs sounds like a reasonable way to ensure that at least one subsidized insurance option in each state exchange offers individuals and families coverage without abortion. But, as we have explained before, it is nearly impossible for average citizens to discern whether their plans cover elective abortion before enrolling, much less the import of that fact—that they are paying a hidden abortion surcharge.
Atop the secrecy, the MSPs have not developed smoothly. The ACA describes what an MSP must do to exist on the exchanges and derive the benefit of OPM promotion, but no company is obliged to offer an MSP in the first place. Nor can any company afford to conduct a segment of its operations in a market where it is taking heavy losses. Thus, while Obamacare required the administration to ensure an MSP without abortion coverage was on every exchange by 2017, some insurers have expressed doubt it would meet this deadline.
A Lack of Insurance Plans That Don’t Sponsor Abortions
The failure to implement MSPs or recruit other non-abortion plans has meant that in several states pro-life citizens had no choice. They would be fined if they didn’t purchase a plan, but the only available plans required them to pay a surcharge used to cover others’ elective abortions. Through 2014, all exchange plans in five states covered elective abortion. Three Alliance Defending Freedom lawsuits in Connecticut, Rhode Island, and Vermont challenged this compulsion of pro-life citizens to pay for others’ abortions or be fined by the government.
In response to a lawsuit by the Bracy family in Connecticut, the exchange and federal government added new plans that did not cover elective abortions or require this mandatory abortion fee. Rhode Island’s exchange likewise added new plans the year after the ADF lawsuit. Vermont added no pro-life plan but exempted the objecting individual from the mandate because of his pro-life conscience.
UH’s exit is not just a sign of the economic problems facing Obamacare; it may also expose more Americans to the “choice” to pay for elective abortions or be fined. The first conscience impact of UH’s departure may be felt in Massachusetts, where UH has been the only option among the 10 available in the Bay State that does not cover elective abortion. Massachusetts would join Vermont and Hawaii (at least) as states where citizens must either pay into the abortion pool or go without exchange coverage and pay a federal fine.
The conscience safety net will be frayed elsewhere, also. Although UH plans do not uniformly exclude abortion coverage (a factor that might make some plan purchasers object to the company), in many states they have been one more option for customers to avoid paying for something they regard as antithetical to the canons of medical ethics. In Connecticut, for example, UH has been offering seven plans that exclude elective abortion, meaning its departure could wipe out 58 percent of the state’s pro-life options next year. In Colorado, UH has been offering more than 10 percent of the exchange’s abortion-free plans.
UH’s business decision is part of a trend. In the Obamacare era, the health-care industry continues to centralize and concentrate. These largely government-imposed economic obstacles will also leave fewer options for those who want health-care choices that align with their values. With fewer options and less responsive markets, the conscience safety net is likely to continue to deteriorate, and the drive for a massive single-payer system will accelerate. The ability of customers to “vote with their feet” will decline, and so will their ability to vote with their convictions.