Abortion & Healthcare Reform: A Matter of Conscience?

2020.05.25 Conscience._MironovConscience, Miranov, 2015

Abortion is a stumbling block to healthcare reform.  Fear that a government-financed system would trample over individuals’ convictions about abortion is one of the most impassioned objections to reform.

Is there a way to honor strong values for and against abortion within a reformed system?

This post will explore conscientious objection as a compromise that would allow citizens to embrace healthcare reform without sacrificing their deeply-held principles about abortion. In so doing, this post attempts to follow the code of the Civility Project and the pragmatism of Yuval Levin in pursuit of reconciliation of this toughest of political disagreements.

Most Americans Avoid Extremes, but the Extremes Are Intense

Citizens express a wide range of opinions about abortion and its legality. On this controversial topic, like on many issues in contemporary American political discourse, a significant majority gravitate away from either extreme. A Marist Poll survey in June 2019 made that point:

“… The debate is dominated by the extreme positions on both sides,” said Barbara Carvalho, director of the Marist Poll, which conducted the survey. “People do see the issue as very complicated, very complex. Their positions don’t fall along one side or the other. … The debate is about the extremes, and that’s not where the public is.”

In that poll, for example, only 21% of pro-life Republicans opposed late-term abortions under any circumstance, even to save the life of the woman.  Similarly, only 27% of pro-choice Democrats favored unrestricted across-the-board abortions on demand up until fetal viability. Much larger majorities of those polled endorsed more moderate and nuanced views.

By the same token, anti-abortion sentiment is quite intense among a significant minority. A poll in July 2019 by Public Religion Research Institute (PRRI) found that fully 27 percent of respondents base their votes entirely on the single issue of abortion.  That same poll found that up to half of citizens oppose public funding of abortion, depending on wording of the question.

This means that healthcare reform cannot proceed, as a practical matter of politics, without addressing anti-abortion sentiment among this significant minority of citizens. Indeed, opponents to single-payer healthcare cite government-sponsored abortion as a key reason against reform, as discussed in a previous post.

Current Status of Abortion Coverage

What is the current status of insurance coverage for abortions?

The Roe v. Wade decision by the U.S. Supreme Court in 1973 formally legalized women’s rights to abortions. But by no means did this decision put to rest widespread anti-abortion indignation nor vigorous efforts to limit those rights or overturn them altogether. Nor did the Supreme Court settle other related conflictual interests among women, medical professionals, taxpayers, and insurers (including employer sponsors).

Regards federal payments, for example, since 1977 every year Congress has added the Hyde Amendment to its annual budget, forbidding use of federal funds for abortion except to save the woman’s life, or, since 1993, in cases of rape or incest. Regards the conscience rights of hospitals and doctors to refuse performance of abortions, the 1973 Church Amendment has blocked Medicare and Medicaid from overriding their refusals.

At the state level, no federal law requires either coverage or exclusion of payments for abortions. As a result, every state has different provisions, both for state funding of abortions and for regulating commercial insurance coverage, according to a recent review.

Increasingly, these uneasy accommodations on abortion have been devolving into turmoil and acrimony.

Abortion Coverage Under Single Payer

What if every patient, every doctor, the entire healthcare finance system – and every taxpayer – was swept into a one-size-fits-all single-payer system? What if everyone’s taxes paid for abortions, whether they morally objected or not? Or alternatively, what if the single system prohibited any and all payment for abortion?

It is easy to see that these irreconcilable extremes could lead to a political stalemate over healthcare reform, especially to the extent that the government becomes the dominant – or exclusive – source of payment for healthcare.

Conscientious Objection

Let’s look at conscientious objection, and how this concept might be applied to the abortion conundrum.

In the United States, conscientious objection to military service has been allowed since the nation’s founding, according to a well-referenced Wikipedia entry.

But allowing pacifists to opt out of combat imposed other duties on them. Namely, under the draft they were required to perform alternative service, such as non-combat medic service.  And they still needed to pay taxes, even though taxes support war.

The situation is more complicated with abortion, since this involves not only an individual woman, but also health professionals, a healthcare facility, and a payer, be it a private insurer, an employer’s benefits program, or a tax-supported public plan.

Accordingly, under a hypothetical single-payer system, here is a range of policy choices that might be considered to accommodate the interests of all the stakeholders, including those taxpayers with a conscientious objection to abortions.

  • Allow beneficiaries to opt out of abortion service for themselves, with corresponding (rather small) discount from premium (or personal tax obligation); this presumably would apply only to women of childbearing age. This amounts to including abortion within the definition of obligatory “essential benefits,” but with permission to decline coverage based on conscientious objection.
  • Allow an optional “rider” for abortion services. This would be the converse of the first option for women of childbearing age. Abortion would not be included in the definition of “essential benefits,” but rather would be offered as optional coverage. The additional premium (paid as a tax) could be calculated using a progressive formula, so that low-income women would not be disadvantaged. However, opponents of abortion might consider this formula to be an indirect federal subsidy.
  • Allow taxpayers to opt in to paying for abortions. This option roughly parallels the current Hyde amendment. But it would set up an optional dedicated federal fund for abortions.  Taxes paid by those who opted to support abortion funding would be segregated from other healthcare funding streams and kept separate from the taxes paid by conscientious objectors who did not opt in.
  • Allow taxpayers to opt out of public funding of any abortion. This would reverse the current Hyde-amendment default of no federal tax for funding abortion. The onus would be on conscientious objectors to affirmatively withhold their taxes from abortion funding.  The reduction in their personal tax would be calculated as the annual cost of abortions nationwide divided by the total number of taxpayers. Taxes for those taxpayers who did not opt out would need to be increased by a corresponding amount.
  • Allow taxpayers to opt for “alternative payment” as a substitute for contributing to the cost of abortion services. For example, alternative payments could instead be applied in an equal amount to a child welfare fund, which could support foster care as well as other social and educational services. This approach would overcome arguments from either side over the “default” unfairly favoring the other.

Each of these options has a slightly different impact on tax payments, and thus could be subject to policy debate. But each honors the freedom of conscience of women and taxpayers, and avoids “establishing” one moral-religious position over another.

How would persons opting out qualify as a conscientious objector? The most straightforward way would be to allow taxpayers to sign a simple attestation without setting any higher bar, such as exists for conscientious objection to military service.


Persons debating healthcare reform can be reassured that the issue of abortion coverage need not be a “deal breaker,” contrary to the claims of some opponents of reform. Fixing U.S. Healthcare blog proposes that any of the conscientious objection approaches presented here could assuage the moral sensibilities of all citizens. This type of solution would honor freedom of conscience while still acknowledging duties to the common good, in this case a costworthy healthcare system. In so doing, it would respect the Founders’ vision of a robust social contract in a tolerant, equitable, pluralistic society. Perhaps there could be other morally and politically acceptable approaches, as well.

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Image Credit

Title:  The Conscience, 2015

By:  Andrey Mironov

URL: https://commons.wikimedia.org/wiki/File:Conscience._Mironov.jpg

License:  This file is licensed under the Creative Commons Attribution-Share Alike 4.0 International license.

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