A new study from George Washington University casts doubt on the argument that “restrictions on abortion coverage approved in the House version of the health-care bill likely will affect the affordability of the procedure for only a small minority of women.” The study finds that “the treatment exclusions required under the Stupak/Pitts Amendment will have an industry-wide effect, eliminating coverage of medically indicated abortions over time for all women, not only those whose coverage is derived through a health insurance exchange”:

In effect, the size of the new market is large enough so that Stupak/Pitts can be expected to alter the “default” customs and practices that guide the health benefits industry as a whole, leading it to drop coverage in all markets in order to meet the lowest common denominator in both the exchange and expanded Medicaid markets. Furthermore, for the reasons outlined above, because the Stupak Amendment bars the subsidization of plan administration activities in connection with prohibited procedures, it can be expected to chill the development of abortion coverage supplements as well as entirely separate plans to non-subsidized women. .

The Stupak amendment “is intended to reach only a specific part of the market,” but in effect, the provision — which prohibits the government from funding any plan that offers abortion coverage — could “move the entire health benefits industry away from its current inclusive coverage norms and toward a new norm of exclusion,” the report concludes.

Given the size of the market in the Exchange (30 million and growing), the scope of the amendment, and the technical challenges and difficulties that arise from administrating supplemental abortion coverage, insurers will “shift away from current abortion coverage norms“; excluding abortion from coverage will become the new norm.

Ultimately, “companies offering coverage products in the employer-sponsored market” “may elect to simply remove the [abortion] procedures from their products so that they can be sold in all markets.” The Stupak amendment will discourage insurance companies from providing abortion coverage and increase the costs of the procedure:

- Amendment could chill the development of abortion coverage supplements: Since Stupak effectively requires that supplemental abortion coverage “be administered separately from other plans,” the cost of supplemental abortion coverage “could be expected to be far higher than simply the cost” of any other supplemental policies.

- Companies would have to absorb the extra administrative costs of providing supplemental abortion coverage: “Not only would companies have to absorb all costs of administration into the supplemental or separate plan fee, but companies would confront having to expand provider networks to assure access to the full range of medically indicated abortions in the case of women who purchase expanded coverage.”

- Cost of later-term abortions would be particularly expensive: The cost of abortions performed later in pregnancy can already “carry a price tag in the thousands of dollars.” However, since this coverage will now be sold as supplement — excluded from the larger risk pool — “the cost of a supplement or a plan that carries additional coverage could be considerable.”

- No incentive for companies to offer additional coverage for women who move into Exchange: While a migration over time of thousands of smaller employers (who offer abortion coverage) into the Exchange “might encourage health benefit services companies to create supplemental abortion coverage products,” the Stupak amendment discourages their development. Currently, almost no insurers offer supplemental abortion coverage in states that already bar the sale of products that offer abortion coverage. The Stupak amendment is designed “to push the price of supplemental coverage higher by prohibiting the integration of administration costs into a single administrative scheme.”

- What if the abortion procedure is part a broader treatment? Under Stupak, plan administrators can only pay for abortions that threaten the life of the mother. But what if the abortion procedure “is part of broader treatment for a serious health condition?” What if the procedure must be performed to in the course of treating a significant health problem? “In these circumstances, how are plan administrators to distinguish between the abortion procedure and the rest of the treatment? Will the entire cost of a course of treatment (e.g., surgery to repair a damaged pelvis following an automobile accident) be denied if abortion is part of the procedure? Health plan administrators, confronted with the prospect of a legal violation for paying for the excluded abortions, may elect to deny the treatment altogether, claiming that it is all related to the excluded treatment.”

The unintended consequences of Stupak are alarming. Legislators have designed a policy that changes the way abortion is treated by insurers and providers in the broader health care market. The amendment devastates the status quo and could prove a serious obstacle to women.

Lawmakers and some doctor and patient groups are criticizing the “new guidelines from a government task force that recommends against routine mammograms for women under 50.” The U.S. Preventive Services Task Force advises doctors against routinely providing the service to women under 50, but notes that “there may be considerations that support providing the service in an individual patient.”

For the average female population, mammograms cause more harm than good:

The harms resulting from screening for breast cancer include psychological harms, unnecessary imaging tests and biopsies in women without cancer, and inconvenience due to false-positive screening results. Furthermore, one must also consider the harms associated with treatment of cancer that would not become clinically apparent during a woman’s lifetime (overdiagnosis), as well as the harms of unnecessary earlier treatment of breast cancer that would have become clinically apparent but would not have shortened a woman’s life. Radiation exposure (from radiologic tests), although a minor concern, is also a consideration.

The debate underscores the complexity surrounding public health care management and raises new challenges for comparative effectiveness research. More immediately, the new guidelines create a political dilemma: clinical trials suggest that mammograms don’t work very well for younger women with thicker breast tissue. The test yields more false positives, anxiety, and over treatment (that itself can lead to more serious health problems) than saved lives. It also drives up health care costs.

Undoubtedly for some women, the mammogram is a life saver, and lawmakers fear that insurance companies will seize the new guidelines to deny coverage for mammograms for younger women. But the Prevention Services Task force had a choice. It could have issued a recommendation that would have 1) hurt the majority of the under 50 population, 2) helped a small number of women, but 3) added to skyrocketing health care costs. Or it could have issued a recommendation that would have 1) benefited the majority of the under 50 population, 2) didn’t create more waste in the system and 3) harmed a small percentage of women. Only in the world of political rhetoric can one test everyone and improve all health outcomes.

At the end of the day, health care providers need to follow scientific protocols. The system can’t accommodate a situation in which doctors order CAT scans for simple headaches or complicated surgeries for problems that can be solved with a regimen of medication. Policy makers must balance risk and benefit because a free-market approach creates the kind of health care costs that price millions out of the health insurance market. It produces a situation where 46 million Americans are uninsured, 45,000 die every single year because they don’t have health insurance, while the nation spends 16% of it’s GDP on health care and $800 billion/year on health procedures that actually worsen health outcomes.

In a situation with no good answers, scientific research should inform the best answer.

Conservatives dismiss the importance of extending health insurance coverage to the 46 million uninsured by arguing that every American already has access to health care in the nation’s emergency rooms. “We hear a lot of people talk about the 46 million plus who don’t have access, well that’s hogwash,” Rep. Paul Broun (R-GA) told a caller on CSPAN’s Washington Journal in April, “Everybody has access, the problem is everybody doesn’t have insurance”:

- Sen. Jim DeMint (R-SC): “Well, no one is going to go without health care, because everyone can just show up at the hospital, but that’s just not the most efficient way to do it.” [Huffington Post, 11/04/2009]

- Rep. Steve King (R-IA): “All Americans have health care. Every single one. And 85 percent of us are insured….you would throw out the liberty of America. Throw out the baby with the bath water of the best health insurance industry in the world, the best health care delivery system in the world. Destroyed by a desire to create a dependency society to steal our freedom.” [CSPAN, 10/07/2008]

- Rep. Virginia Foxx (R-NC): “There are no Americans who don’t have healthcare. Everybody in this country has access to healthcare.” [Talk Radio News Service, 7/24/2009]

But a new study published in Archives of Surgery has found that not all Americans are treated equally. Uninsured Americans “with traumatic injuries, such as car crashes, falls and gunshot wounds, were almost twice as likely to die in the hospital as similarly injured patients with health insurance,” the study concluded.

Researchers have long argued that uninsured adults face a higher risk of mortality than insured adults, are less likely to seek needed medical care, and are more likely to develop serious chronic conditions. This Harvard team of researchers hypothesized that “given the pervasive evidence of disparities in screening, hospital admission, treatment, and outcomes due to insurance status, a disparity in outcomes in trauma patients (in-hospital death) among the uninsured may exist, despite preventive regulations (such as the Emergency Medical Treatment and Active Labor Act).” They were right:

The report does not definitively explain why the variations “in mortality would exist in a system where equivalent care is not only expected but mandated by law,” but concluded that access to care not the same as having health care insurance.

The uninsured patients may experience treatment delay, different care than insured patients (“uninsured trauma patients were less likely to be admitted to the hospital and received fewer services during their admission compared with insured trauma patients”), and possess “a lower rate of health literacy and may have less aptitude in communication with physicians and other treating team members.”