NEW YORK – Millions of American women will face tough choices about abortion coverage if restrictions in the House health care bill become law, both sides in the abortion debate agree.

Divisions over abortion are a major obstacle in President Barack Obama's push for health care overhaul, with both sides arguing over how to apply current law that bars taxpayer dollars for abortions in a totally new landscape. Under pressure from the Catholic Church and abortion foes, the House added tough restrictions to its version of a health care bill.

The measure would prohibit the proposed new government-run insurance plan from covering abortions except in cases of rape, incest or to save a mother's life, and bars any health plan receiving federal subsidies in a new insurance marketplace from offering abortion coverage. If women wanted to purchase abortion coverage through such plans, they'd have to buy it separately, as a so-called rider on their policy.

"It forces insurance companies and women to navigate a series of chutes and ladders to get abortion coverage at the end of the day," said Donna Crane, policy director for NARAL Pro-Choice America.

The amendment's proponents says its goal is simply to ensure that a long-standing ban on using federal dollars for elective abortions is extended to coverage plans arising from new health care legislation.

Rep. Bart Stupak, D-Mich., an abortion foe, insisted the amendment is not a dramatic change in current law, offered to negotiate if his critics could convince him otherwise, and said it leaves ample alternatives for women to obtain coverage if they use their own money and are willing to buy a separate, add-on plan.

"If you really still want this coverage, you can have it," he said. "The only difference is that more people will have to make that decision that they didn't confront before. ... More people are going to have to choose, 'Is this a benefit I want?'"

Crane and other abortion-rights advocates say the amendment would make it harder — in some cases perhaps impossible — for millions of women to have health insurance that covers abortion. They depict it as one of the gravest assaults ever on American women's reproductive rights.

Two large groups of women would not be affected by the amendment: low-income women already ineligible for abortion coverage because they rely on federal Medicaid funds for health care, and women who have abortion coverage through the private plans of their own or their husbands' large employers. Most Americans currently have employer-sponsored coverage.

That leaves a significant number of other women likely to be affected — women who would be prime candidates for joining the new federally subsidized plans, but in the process might have to forgo abortion coverage they had previously under a private plan. These would include self-employed women who must buy their own coverage, divorced women who formerly were insured through their husbands' employers, and women who work in small businesses whose owners decide to seek more affordable coverage through the new exchange.

"This is a middle-class abortion ban that would impact millions of middle-class women," added Cecile Richards, president of the Planned Parenthood Federation of America. "It's saying to them, 'You can't get full coverage that meets your needs.'"

Abortion-rights activists say the option of buying additional coverage for abortion — a so-called rider — is a false promise. They cite the examples of Oklahoma and North Dakota, where riders have had negligible use even though allowed under state laws that otherwise ban insurance coverage of elective abortions.

"Abortion coverage should be part of the regular package," Crane said. "Women don't expect unplanned pregnancies and don't expect their wanted pregnancies to go wrong. ... They don't anticipate needing abortion coverage so they wouldn't buy a rider."

Kristin Binns of WellPoint, Inc., which oversees health plans serving 35 million Americans, said it's impossible for the insurance industry at this stage to estimate how much such riders would cost and the extent to which they might be offered.

"We don't have a clue," she said.

Douglas Johnson, the National Right to Life Committee's legislative director, said it's difficult to forecast the restrictions' practical impact, but he agreed that some women now covered for abortions would face restrictions if they wanted to switch to potentially cheaper coverage in the new insurance marketplace, known as an exchange.

"There's a choice they are offered by the government — this gift, this great subsidy — and this plan is not going to cover everything, as a matter of public policy," he said. "If there's a market (for add-on abortion riders), if there are people who think it's that important, it will be offered."

The Congressional Budget Office estimates that 21 million people would purchase individual coverage through the exchange, under the House plan. That would amount to about 7 percent of Americans under the age of 65. Of those, about 18 million would have government subsidies and thus would have to be in plans that don't cover abortions.

"Beyond that, it's an open question for individual insurance companies — how much of their business is in the exchange or outside it," said Adam Sonfield of the Guttmacher Institute, which studies reproductive-rights issues.

Stupak says one reason his amendment's impact would be limited is because only a small fraction of abortions — 13 percent by Guttmacher Institute estimates — are paid for directly by private insurance. The vast majority are paid for in cash, even by women with abortion coverage who do so out of privacy concerns.

However, Dr. Willie Parker, an abortion provider in Washington, D.C., noted that insurance coverage could be vital for women with health problems who need hospital abortions costing many thousands of dollars, compared to roughly $400 to $800 for a first-trimester abortion in a clinic.

"The cash option was a challenge for many women even in more reasonable economic times," Parker said. "I see that becoming worse as people have to make hard decisions because abortion is not considered part of health care."

Obama says he wants to strike a balance on the issue, but whether such middle ground can be found remains unclear.



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