If ever you thought this country's Constitution protects rich and poor alike, think again. The U.S. Senate seems bent on reserving its promises only for paying customers. How else to explain the Senate's move to forbid managed-care health plans from performing Medicaid-funded abortions for poor women? The vote betrays not only the Medicaid program's health-enhancing purpose, but also the Constitution's promise of equality for all.
There is nothing particularly novel in this latest antiabortion venture. Congress has prohibited federal funding of most abortions for two decades, and many states have slapped similar bans on their own Medicaid funds. (Minnesota has funded Medicaid abortions since late 1995, when the state Supreme Court declared its 17-year ban unconstitutional.) But the rise of the managed-care industry - and its increasing use to cover Medicaid recipients - has spurred a new worry that poor women may be getting away with abortions after all.
Why the worry? Because managed-care plans charge a flat fee for a basic package of health services - from antibiotics to appendectomies to abortions. The fretful senators have no quarrel with that system as long as Medicaid patients using it are asking for care of which they approve - bunion removal, say, or a spot of chemotherapy. What troubles them is the possibility that some poor woman whose health care is paid partly by federal money might take matters into her own hands and have an abortion. And they worry as well that managed-care plans - ever-eager for profit - will save money by badgering pregnant women away from costly childbirth and into cheaper abortions.
The health plans could save more money still by smothering patients outright, but never mind that. The worries plaguing abortion foes call for less drastic measures. All that's necessary is a declaration by Congress that federal Medicaid dollars may not be commingled with state money to purchase managed-care packages that include abortion coverage. The Senate approved that language by voice vote last week; the House is expected to follow suit soon. Exceptions would be made for pregnancies caused by rape or incest or that endanger a woman's life.
The quick result of this measure will be an accounting nightmare for states like Minnesota that now underwrite abortions with their own funds. The long-term upshot will be a reinforced wall between poor women and their bodies - and between poor women and their wealthier counterparts.
This is just the kind of barrier the Medicaid program was meant to topple. Its mission is to assure that America's needy can make meaningful medical choices - just as Americans with money have long done. It's a goal well-served by the managed-care movement, which seeks to treat patients according to need rather than income. Indeed, it could be argued that this wall-shattering philosophy finds inspiration in that ultimate guarantor of equality and privacy: the Bill of Rights, which the U.S. Supreme Court has said grants all people control over their own lives.
Many lawmakers laugh off the idea that even poor women have a right to abortion. They consider abortion somehow akin to cosmetic surgery: If women think they're entitled to it, the reasoning goes, they should pay for it themselves. But that argument overlooks the very real anguish an unwanted pregnancy can inflict. Abortion can be a firebreak against that anguish - marking the line between opportunity and despair, madness and sanity, sickness and health, family disintegration and peace.
Its life-determining importance is one reason the U.S. Supreme Court ruled in 1973 that the abortion decision is crucially personal and thus worthy of constitutional protection. But for too many penniless women in too many states, this right to choose will likely remain theoretical. They'll be free to decide whether to have a wart removed, but not whether to have a child. They will remain a world apart from their more affluent sisters, who can count on the Constitution's promises - because they can pay for them.
