Increased Access to Health Care May Decrease Abortions

By Brian Fung

The number of abortions in Massachusetts has decreased despite predictions that health-care reform would have the opposite effect. Can the health insurance expansions part of Obamacare do the same nationally?

Kevin Lamarque/Reuters

President Clinton once famously remarked that abortion should be safe, legal, and rare. The unspoken challenge to him since then has always been, but how do we agree on a path that gets us there? As the controversy over Missouri Rep. Todd Akin continues to burn, it seems we won't have a resolution to our national abortion debate any time soon.

From Massachusetts, though, comes growing evidence that the quest for lower abortion rates may not be at a standstill -- and the key may be better insurance coverage. As the number of insured has gone up in Massachusetts, new state data show a corresponding decline in the number of abortions performed there since 2006.

Massachusetts, of course, is known nationally as the state that launched an ambitious project to insure almost all of its residents -- a proposal that helped give rise to President Obama's own health-care law. Census statistics reveal that in the three years before Governor Mitt Romney enacted the program in 2006, 10.7 percent of state residents lacked health insurance, on average. That three-year average was nearly halved after Romneycare took effect. From 2008 to 2010, Massachusetts boasted the best uninsured rate in the nation: just 5 percent, on average.

Meanwhile, as more people were benefiting from expanded coverage, the abortion rate was quietly coming down. Many states keep detailed records on all the legal abortions they perform, and Massachusetts is no different. According to data from the Department of Public Health and the U.S. Census Bureau, from 2006 to 2008 the annual abortion rate in Massachusetts fell from 3.8 per 1,000 state residents to 3.6 per 1,000. The findings, first reported in 2010 by Harvard rheumatologist Dr. Patrick Whelan, contradicted some forecasts that better coverage would simply drive up the abortion rate rather than bringing it down.

Not only were these predictions proven false in the first couple years of Romneycare -- they grew even more wrong with time. Whelan's study couldn't have predicted this, since it didn't have the data to hand, but the drop in abortion rates has accelerated even more in 2010 and 2011:

And that's just the statewide abortion rate. Drill down to specific demographics, and the improvements are in places even more pronounced. Among pregnant teens, for example, abortions fell by nearly 7.5 percent from 2006 to 2008. By 2011, they were down by more than 21 percent.

Now, for a quick reality check: it's possible that the decline in the abortion rate had nothing to do with Romneycare. In fact, Massachusetts has generally performed fewer abortions every year than the year before it going back to 1991. In the 17 years between then and 2008, Massachusetts' abortion rate fell by more than a third, indicating a long-term trend that may have as much to do with politics or culture as it might with Romney's health-care policy. Distinguishing cause from correlation here is next to impossible without writing a book about it.

That said, scientists think the latest drop in abortion rates is at least partly tied to a couple recent factors. According to Danielle Bessett, a sociologist at the University of Cincinnati who has studied small samples of low-income Massachusetts residents, patients who became eligible for state-subsidized insurance under Romneycare were "delighted" at the prospect of improved access to contraception. People no longer have to rely on condoms alone. Now they can get birth control pills or shots if they prefer. (Of course, conservatives argue that contraception does nothing to reduce abortions; rather than hash out that discussion here, I'll direct you to Conor Friedersdorf.)

Whelan, the Harvard specialist who pointed out the abortion pattern in 2010, thinks that better access to contraception -- and the concomitant decline of abortion -- is the byproduct of broader improvements in public health brought on by Romneycare.

"When women have more stable access to medical care, they're more likely to see doctors, they're more likely to have somebody inquiring about their sexual health," Whelan told me in a phone interview. "The fact that you have somebody who cares about you results in people being healthier, and that includes not getting pregnant if they don't want to be."

Massachusetts is just one state. Luckily, we're soon going to be able to replicate this experiment on a much larger scale, thanks to the Affordable Care Act. If expanded health insurance coverage can put a lid on abortion rates, then states like Texas, New Mexico, and Florida that lead the nation in terms of the rate of uninsured should also see some improvements in their abortion rates as health coverage grows. Keep your eyes peeled.

This article available online at:

http://www.theatlantic.com/health/archive/2012/08/increased-access-to-health-care-may-decrease-abortions/261463/

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