This article was first published by The American Prospect.

In September 1993, as Hillary Clinton lobbied Congress to pass her
health-reform bill, she plainly addressed the looming controversy over
reproductive care. "It will include pregnancy-related services, and
that will include abortion, as insurance policies currently do," she
told the Senate Finance Committee. Conservatives were incensed. But as
the history books record, it was industry pressure and legislative
malaise that killed Hillarycare, not debate over women’s rights.

On the campaign trail, Barack Obama did not shy away from the issue
of abortion, pledging, "On this fundamental issue, I will not yield."
In the context of health reform, though, the president and his staff
have been reluctant to directly address reproductive rights. In a March
interview with the Christian Broadcasting Network’s David Brody, the
White House’s chief domestic policy adviser, Melody Barnes — who once
sat on the board of Planned Parenthood — claimed she had never spoken
to the president about whether abortion services should be covered
under a universal health-care system. "We haven’t proposed a specific
benefits package or a particular health-care proposal, so we’re going
to be engaging with Congress to have this conversation," she said. When
Office of Management and Budget Director Peter Orszag was asked by Fox
News in July whether the public insurance plan should cover abortion,
he was vague. "I’m not prepared to rule it out," he said. The president
finally addressed the issue himself in a July 21 interview with Katie
Couric, in which he bucked reproductive rights groups by saying he
would consider deferring to the "tradition" of "not financing abortions
as part of government-funded health care."

Perhaps in response to the failure of the Clintons’ highly detailed
plan, Obama’s strategy has been to leave the nuts and bolts of health
reform up to the legislative branch, saying only that the resulting
bill must fulfill three goals: lower costs, provide Americans with more
health choices, and assure quality. That lack of detail has shoved
Congress deep into the weeds. Predictably, the president’s vagueness
hasn’t prevented anti-choicers from seizing upon the possible inclusion
of reproductive-health services as a vehicle to activate their base
against reform. "A vote for this legislation, as drafted, is a vote for
tax-subsidized abortion on demand," wrote Douglas Johnson, the National
Right to Life Committee legislative director, in a letter to Congress.
That message penetrated. At a July 14 press conference, Rep. Joe Pitts,
a Republican from Pennsylvania, claimed health reform undermined
Americans’ "right to life. Let’s make it explicit that no American
should be forced to finance abortions." As the health-care debate
reached a fever pitch in the weeks before Congress’ summer recess, Fox
News featured daily segments on the threat of "subsidized abortion."

Meanwhile, Obama declared in his July 18 radio address that he would
not sign any reform bill that did not include a public health-insurance
program. A public plan is central to progressives’ goals of lowering
costs by giving private insurers real, high-quality competition. A
government-funded insurance option might, eventually, serve as the
shell for a single-payer health-care system similar to those of Western
Europe. But if Congress acquiesces to abortion opponents and passes a
public plan that does not provide reproductive-health services
comparable to what Americans can purchase in the private market or
obtain through their employer, it will be a weaker plan with a smaller
constituency. After all, the typical woman spends five years of her
life pregnant, or trying to become so, but a full 30 years avoiding
pregnancy. Without good reproductive-health coverage and strong buy-in
from women — who use more health care than men — it is difficult to
see how a public plan would gain strength over time.

Contrary to conservative hand-wringing, reproductive rights have
been under constant assault in the health-reform debate. At stake is
not only whether a potential public plan covers contraception or
abortion but also whether existing private health insurers, 87 percent
of which currently offer some abortion access, will be able to continue
to do so once they are operating within the new health-insurance
exchanges. The exchanges will house both public and private plans after
reform and will be regulated by the federal government.

This increased government intervention in the health sector both
excites and terrifies advocates for better reproductive care. The
potential upside is that through a public plan, an expansion of
Medicaid, and more competition among private insurers, many more women
will be able to afford good reproductive health care. But the potential
downside is stark: A politicization of which reproductive-health
services insurers can cover, meaning that under anti-choice
administrations, abortion and even contraceptive limitations or bans
could become the norm.

For millions of American women, insurance-subsidized abortion is already off limits. After Roe v. Wade
legalized abortion in 1973, one of the religious right’s first
successes in limiting access to the procedure was the passage of the
Hyde Amendment. Since 1976, Hyde has banned Medicaid — the federal
health-insurance program for poor women and children — from paying for
abortions, except in the most extreme cases when a woman’s physical
health or life is in danger. Medicaid covers 7 million American women
of reproductive age, or 12 percent of women in that cohort. Federal
employees, members of the U.S. military, Peace Corps volunteers, and
prisoners are also barred from using their government health coverage
to access abortion.

During a July 14 interview on MSNBC, Sen. Chuck Grassley, the
ranking Republican on the Senate Finance Committee, contended that when
it comes to abortion and health reform, "what we’re trying to do is
maintain current policy." Yet because any potential public health plan
would be funded by the federal government, what anti-choicers would
really like to ensure is that Hyde would also apply to any new public
insurance programs.

That isn’t likely to sit well with the public. Though past polls
have shown Americans are resistant to the concept of "taxpayer-funded
abortions," the public seems to see health reform under a different
light. According to a poll by the Mellman Group on behalf of the
National Women’s Law Center, 71 percent of Americans support coverage
for reproductive health, including contraception, under a public plan.
Sixty-six percent support coverage for abortion in a public plan.

None of the health-reform proposals being considered by Congress
explicitly threaten Hyde or the other existing federal bans on abortion
funding. In fact, reproductive-health-care advocates reluctantly admit
that the repeal of Hyde, although a long-term priority, is not on their
current agenda. After all, some Democrats, including Vice President Joe
Biden, have a history of support for the ban. "Hyde is discriminatory
against poor women, and we’d like to see it overturned," says Adam
Sonfield, a senior policy associate at the Guttmacher Institute. "But
it does not seem to be a political priority right now."

To protect against disruptions in American women’s access to
reproductive medicine, advocacy groups are recommending that an
independent council of medical experts — not a political appointee —
define which services will be covered by insurance plans participating
in the exchanges. Such a commission would likely argue for the
inclusion of abortion and contraceptive services. Though politically
volatile, family planning is rather uncontroversial in the insurance
industry and among public-health experts. For every $1 spent on public
family-planning services, the government saves $4.02. The public sector
alone saves $4.3 billion in medical costs each year thanks to the
family-planning coverage the federal government already provides poor
women through Medicaid and Title X. That’s because birth control and
abortion are simply much less costly than pregnancy.

The final health-reform bill will likely establish a council of
experts to advise the health and human services secretary on what
benefits should be covered. But in both the House and Senate proposals,
the council’s power is limited; it is still the HHS secretary who makes
the final call. This means that under anti-choice administrations,
abortion and contraceptive access could be threatened within the
health-insurance exchanges. "The potential there is that many, many
women could lose the coverage they presently have," said NARAL
Pro-Choice America President Nancy Keenan in July, as hundreds of
Senate amendments were being filed on health reform, many of them
seeking to prevent abortion coverage.

Another risk is that even if abortion services are covered, health
clinics that provide abortion — such as the Planned Parenthood network
— could be barred from participating in the exchange, meaning they
would not be able to offer insured services to patients in either
public or private plans. An amendment to the Senate Health, Education,
Labor, and Pensions (HELP) bill from Barbara Mikulski, a Democrat from
Maryland, would protect the status of clinics, but it attracted
opposition even from some Democrats, such as Sen. Bob Casey of
Pennsylvania, who identifies as pro-life.

For many congressional Republicans — and some of the 19 moderate
House Democrats who joined their cause — fanning the flames of the
abortion debate is, at least in part, a tactic for delaying reform. To
be fair, some family planning opponents do support the broader goal of
universal health care — the Catholic Church chief among them. But
according to Marilyn Keefe, director of reproductive-health programs at
the National Partnership for Women and Families, "The pressure [on
reproductive rights] largely comes from people who don’t support the
larger health-reform effort."

Advocates were able to ensure that both the House tri-committee
bill and the Senate HELP bill made it through committee without any
amendments limiting access to reproductive care. But as Tina Tchen,
director of the White House Office of Public Engagement, told a July 15
Planned Parenthood conference — perhaps in an effort to tamp down
expectations — "That was not easy. It was not easy in committee. It
won’t be easy to hold on the House floor. It won’t be easy to hold on
the Senate floor."

Women’s organizations find themselves in the strange position of
playing defense, even as a pro-choice president sits in the White House
and both houses of Congress have pro-choice majorities. "Depending on
some of the things that are being proposed, we could be worse off"
after health reform than before it, Planned Parenthood President Cecile
Richards said at the conference. "That is untenable. Those are some of
the tough conversations we’re having, frankly, with the White House and
Congress. We can’t be worse off."