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What Prevents Abortions?

A man on the bus the other day made an interesting remark about abortion. He said:

All these pro-choice people are lucky their mothers were pro-life. Because if they weren’t pro-life, they wouldn’t have had them.

Usually, I either completely tune out or else promptly forget any bus lectures I hear from complete strangers. But this one seemed at least a little bit relevant because it strikes to the heart of a misconception some abortion opponents seem to have about those who favor keeping abortion legal in the United States — namely, the (mistaken) idea that pro-choicers want people to have abortions.

Pro-choicers are a diverse group. Reasons for supporting the availability of legal and safe abortion range from women’s health concerns to privacy to the belief that prohibition is simply not a viable alternative. I have never heard anyone say they are pro-choice because they want people to have abortions just for the sake of having an abortion.

Actually, I’ve heard quite the opposite — people saying that they are pro-choice and want to minimize the number of abortions that take place. This is the idea of ‘safe, legal, and rare.’

With that in mind, one would think that though pro-life activists disagree with the ‘safe’ and ‘legal’ parts, they might be amenable to working with pro-choice groups toward the ‘rare’ part. Unfortunately, this is the exception rather than the rule.

The thing is, the public health and medical communities have a fairly good sense of what policies tend to reduce abortion: access to contraception, and comprehensive sex education, for example. In other words, policies that reduce unintended or unwanted pregnancies in the first place.

A recent study of more than 9,000 women at risk for unintended pregnancies, for instance, found that providing free birth control lowered both the number of unintended pregnancies and abortions. Abortion rates for this group ended up being less than half that of regional and national rates. Teenage pregnancy within this group was also rarer than the national average (6.3 births per 1,000 teenagers, compared to 34.3 per 1,000 in the nation as a whole).

The Guttmacher Institute also noted contraception’s role in preventing unintended pregnancies in a 2011 testimony to the Committee on Preventive Services for Women. They explain that as unmarried women at risk of unintended pregnancies increased their contraceptive use, their abortion rates fell from 50 abortions per 1,000 women in 1981 to 34 in 2000.

Additionally, they cite studies that show reductions in teenage pregnancy thanks to increased contraception use. Notably:

One study found that from 1991 to 2003, contraceptive use improved among sexually active U.S. high school students… these adolescents’ risk of pregnancy declined 21% over the 12 years. Another study found that increased contraceptive use was responsible for 77% of the sharp decline in pregnancy among 15–17-year-olds between 1995 and 2002 (decreased sexual activity was responsible for the other 23%); and increased contraceptive use was responsible for all of the decline in pregnancy among 18–19-year-olds.

There is also strong evidence that comprehensive sex education (as opposed to abstinence-only) helps prevent unintended pregnancies. Studies show that abstinence-only education can actually be counterproductive, leading to higher rates of teen pregnancy. One review of federally-funded abstinence-only programs found that most of the most commonly used abstinence-only curricula contained “false, misleading, or distorted information about reproductive health.”

Disturbingly, a Centers for Disease Control and Prevention report notes that the most common reason women who had unintended pregnancies after not using contraception gave for their failure to use contraception was that they did not think they could get pregnant. It bears repeating: a plurality of this group (about 36 percent) actually responded that they did not think it could happen to them when asked why they had not used contraception. Perhaps better education on the subject could have prevented at least some of this confusion.

Yet many pro-life groups reject the recommendations of the public health and medical communities and instead claim exactly the opposite, maintaining (in the face of all evidence) that contraception and comprehensive sex education cause higher levels of abortion.

Take this so-called “Fact Sheet” put out by the United States Conference of Catholic Bishops (USCCB), for instance (and, full disclosure, I’m Catholic). It claims, among other things, that contraceptives fail to prevent pregnancy, and cites this statistic as evidence:

Forty-eight percent of women with unintended pregnancies and 54% of women seeking abortions were using contraception in the month they became pregnant.

At first glance, that seems fairly alarming. Is contraception really that ineffective? Well, no, as it turns out. And I’ll get to that in just a moment. First, though, I need to deal with something the USCCB excised from the reports it cites for these statistics.

This sheet leaves out an important disclaimer that its sources (which you can read here and here) include: even though the women may have been using contraceptives that month, they were likely using them inconsistently.

Another Guttmacher report shows the breakdown of the 48 percent of women who had been using contraceptives the month they got pregnant. As it turns out, most of those women had been using contraceptives inconsistently. The chart below (taken from the Guttmacher report, which you can find here.) shows the breakdown.

"The two-thirds of U.S. women at risk of unintended pregnancy who practice contraception consistently and correctly account for only 5% of unintended pregnancies." (Guttmacher Institute)

So, the two-thirds of women at risk of unintended pregnancies who consistently use contraceptives make up only 5 percent of unintended pregnancies. In contrast, though only 16 percent of such women do not use contraceptives, they account for a full 52 percent of unintended pregnancies.

For women seeking abortions, here’s the key part that was left out of USCCB’s  “Fact Sheet:”

Among those women, 76% of pill users and 49% of condom users report having used their method inconsistently, while 13% of pill users and 14% of condom users report correct use.

Even putting this aside, it really does not make much sense for USCCB to use those statistics the way they did.

The sheet is trying to make the point that contraceptives are not that effective at preventing pregnancy. But to back this up, it uses statistics that only consider the subgroups of women that either have an unintended pregnancy or are seeking an abortion:

Forty-eight percent of women with unintended pregnancies and 54% of women seeking abortions were using contraception in the month they became pregnant. [Emphasis mine.]

It seems odd to use this statistic, which focuses on two specific groups that are already pregnant to back up a broad claim about the efficacy of contraception as a whole. But perhaps even though they are using this in the broader context of contraception efficacy, they are actually trying to make a narrower point that contraception does not effectively prevent abortions (which seems unlikely, because they have a later section dedicated to that, but let’s assume that’s what it is).

Even if this were the actual point, the statistic is still misleading. To keep things simple, I’ll just focus on the unintended pregnancies part. Essentially, the statistic the USCCB sheet used answers this question:

How many women with unintended pregnancies used contraception in the month they got pregnant?

The better question would be:

How many women who used contraception in the month they got pregnant ended up with unintended pregnancies?

It’s a subtle difference, but an important one. The prior one describes a group of women who have unintended pregnancies and asks what portion of them used contraception. The latter one describes a group of women who used contraception and asks what portion of them ended up having unintended pregnancies.

Unfortunately, because I could not find data on the number of women at risk of unintended pregnancy who used contraception and did not unintentionally get pregnant, I cannot answer this latter question. However, given the actual efficacy of contraception, it is likely that the number would be fairly small.

How effective a particular method is varies, but the two most common choices of non-permanent contraception are condoms and the pill. Condoms are 82 percent to 98 percent effective, while the pill is 91 percent to 99 percent effective. The reason these numbers are given in a range is because of the difference between “typical use” (the lower percentage) and “perfect use” (the higher percentage). “Perfect use” refers to the rate when individuals use a method consistently and according to clinical guidelines. “Typical use” is the number you generally get in real-world use, where people do not always use the contraceptive consistently or correctly.

(As a quick aside, this New York Times blog post notes that a large problem is that women often switch contraception methods or temporarily stop using them for any number of reasons, from they just moved to a new city and need to find a new doctor to they switched jobs and now have to navigate a different insurance plan. Educating women on how to handle such potential gaps — no matter how brief — might be prudent.)

So, contraception is not perfect, but it is significantly more effective at preventing unwanted pregnancies than the USCCB presents, especially when educated on how to use it correctly. I bring this up not to single out the USCCB in particular (and I only discussed one specific part of their “Fact Sheet”), but because this example demonstrated what seems to be a common thread among pro-life talking point sheets I’ve seen. Such documents perpetuate false claims that contraception and comprehensive sex education are either ineffective or damaging and offer confusing or incomplete statistics similar to the ones we just examined.

And that is counterproductive when your goal is to prevent abortions.

FURTHER READING

Intended and Unintended Births in the United States: 1982 – 2010,” Mosher, Jones, & Abma. Centers for Disease Control and Prevention, 24 July 2012.

Facts on Unintended Pregnancy in the United States.” Guttmacher Institute, January 2012.

Facts on Induced Abortion in the United States.” Guttmacher Institute, August 2011.

Use of Contraception in the United States: 1982 – 2008,” Mosher & Jones. Centers for Disease Control and Prevention, August 2010.

Study: Free Birth Control Leads to Fewer AbortionsFOX News, 5 October 2012.

How to Make Birth Control Effective,” Danielle Braff. Chicago Tribune, 1 April 2010.

Contraception: Types of Birth Control.” Centers for Disease Control and Prevention, 10 September 2012.

Birth Control: In-Depth Report.” New York Times.

Contraceptive Use in the United States.” Guttmacher Institute.

Testimony of Guttmacher Institute.” Committee on Preventive Services for Women, 12 January 2011.

Are You In The Know: Contraception.” Guttmacher Institute.

Switching Contraceptives Effectively,” Jane Brody. The New York Times, 17 September 2012.

Debunking the Right’s Contraception Myths,” Irin Carmon. Slate, 21 February 2012.

Preventing Unintended Pregnancies by Providing No-Cost Contraception,” Peipert, Madden, Allsworth, & Secura. Obstetrics & Gynecology (Vol. 120, Issue 6), December 2012.

Facts on American Teens’ Sources of Information About Sex.” Guttmacher Institute, February 2012.

Surprise! The Abortion Rate Just Hit an All-Time Low,” Sarah Kliff. Washington Post Wonkblog, 23 November 2012.

Some Abstinence Programs Mislead Teens, Report Says,” Ceci Connelly. Washington Post, 2 December 2004.

Why We Keep Accidentally Getting Pregnant,” Lindsay Abrams. The Atlantic, 26 July 2012.

Understanding ‘Abstinence:’ Implications for Individuals, Programs and Policies,” Cynthia Dallard. Guttmacher Institute, December 2003.

Abstinence-Only and Comprehensive Sex Education and the Initiation of Sexual Activity and Teen Pregnancy,” Kohler, Manhart, & Lafferty. Journal of Adolescent Health, 31 January 2008.

Comprehensive Sex Education for Teens is More Effective than Abstinence,” Carter. American Journal of Nursing (Vol. 112, Issue 3), March 2012.

Abstinence-Only Education Does Not Lead to Abstinent Behavior, UGA Researchers Find,” Chelsea Toledo. University of Georgia, 29 November 2011.

The Efficacy of Abstinence Only Education: Culminating Experience,” Jennie Watt McAdams. Wright State University (Thesis Paper), 2012.

The Content of Federally Funded Abstinence-Only Programs,” Committee on Government Reform — Minority Staff. Rep. Henry Waxman, December 2004.

 

Band-Aid Plan To Fix Health Care Won’t Work

(Published in the Main Line Times and the Delco Times)

As the attempt to reform our health-care system crescendos, it is difficult to pinpoint exactly where the debate lost its way. Perhaps it never truly began in the right direction.

Between the fear-mongering and the screaming, it seems some of the most pressing issues – medical inflation and warped incentives – have been sidelined. And why? Perhaps because they are more complex. These issues require quite a bit of explanation and historical context, which doesn’t always fly too well in a sound-bite culture.

One of the main problems regarding our health-care industry is its lack of any organization. There was no grand design in its creation; it is a Frankenstein monster, cobbled and patched carelessly together since its birth in the wage controls of the World War II era, with little regard for consequences.

Yet, any grand design is practically doomed from the beginning, as the only two viable options – a single-payer system or a complete overhaul of incentives and the creation of a truly free market – are both met with opposition. Consequently, we receive a bill that is the worst of both worlds.

True, the House bill does work at creating a marketplace in the health insurance exchanges (an important, but underplayed, provision), but it also includes a public option. Supposedly, the public option is meant to control prices by adding a more virtuous competition into the marketplace, but when you look at the details – its limited eligibility, and the fact that prices will be set by negotiations with health care providers – it doesn’t seem as if it will control prices at all. After all, medical inflation has not left Medicare and Medicaid, two government plans, unscathed.

So, who is to blame? The Democrats or the Republicans? Both. To their credit, the Democrats have actually gotten the ball rolling on health-care reform and have put forth a bill, though their proposal remains flawed.

The Republicans, on the other hand, are too busy trying to give President Barack Obama his “Waterloo” (this can be seen in the misnomer “Obamacare,” which would be more accurately titled “Congresscare”) and preaching about fictional provisions such as nonexistent “death panels” to actually provide legitimate criticism and a legitimate alternative.

Both accept money from the big health insurance and pharmaceutical giants and allow them to actively craft the bill as well.

We, the citizens, are also to blame. We are too easily led by the talking heads to one particular conclusion. A single-payer system is not the devil, and it does not ration care any more than our current system does. Any system we adopt will require a give-and-take.

A single-payer system will cover everyone, unburden businesses that pay for employees’ health care (and thus help small businesses). It will purge the system of waste, but everyone will be required to pay through taxes and waiting lines — secondary, optional care will be a bit longer (though primary care may very well be shorter, as it is in Britain).

Remember, the government is already inextricably involved in our health-care system. A complete rebuilding of the health-care free market, hand in hand with other reforms (like tort reform), can control prices through innovative market forces and reshaped incentives. Both plans are bold and both have their strong and weak points. What we can’t afford is another plan that simply slaps a Band Aid on the issue and kicks it along to the next generation.


What You Need to Know About the House Health Care Bill

The House of Representatives passed their version of the health care reform bill last night. But what does it all mean? The media coverage on the issue has been decidedly mixed. I’ll try to boil down for you the most important points on the House bill.

The first thing I should probably spend some time on is clarification. With all this debate over the validity of so-called “Obamacare”, many people may not realize that there are various versions of health care reforms bills floating around, and that none of them were authored by Obama (hence the irony of the name “Obamacare”).

Here are the details of the House version of the bill: (a good source of information are the NYTimes, and an NPR podcast entitled Health Care Legislation Deconstructed)

How the House Bill Expands Coverage to Uninsured Americans

  • Projected to cover 96% of legal residents under age 65.
  • Provides subsidies for individuals up to 400% of the federal poverty level $88,000 for a family of 4)
  • Expands Medicaid to 150% of federal poverty level ($16,000 for an individual; $33,000 for a family of 4)
  • No denial of coverage or higher premiums due to pre-existing conditions

How the House Bill Effects Businesses

  • Most employers will be required to provide health care for employees or pay a penalty of up to 8% of payroll.
  • Businesses up to $500,000 in payroll a year are exempt.
  • Penalties are phased in for businesses from $500,000 to $750,000
  • Small businesses are provided with tax credits to help them purchase health care

The House Bill’s Public Option

  • No state opt-out
  • Negotiated Rates — the public plan will talk to hospitals, doctors, and health care providers to negotiate a state-level payment rate

Costs of the House Bill

  • Gross Cost $1.1 trillion over ten years.
  • However, the Net Cost is $894 billion because of revenue raisers.
  • Revenue will come from surcharge on high income earners (taxes on individuals that earn above $500,000, or on couples that earn above $1 million  – projected to raise $460 billion)
  • Penalties for businesses who don’t provide health care (up to 8% of payroll)
  • Penalties for individuals who don’t buy health care (2.5% of income — but can apply for hardship waivers if can’t afford)
  • Medicaid/Medicare cuts
  • Corporate taxes/ fees

Health Insurance Exchange

  • The Exchange is essentially a marketplace where people can go to shop for health insurance. Currently, with our employer-based system, you can only really choose from the plan(s) your employer offers. Going out and buying your own insurance is expensive and messy. The Exchange creates a market of insurances options and allows you to choose which plan you want, allowing market forces to take their toll — the better plans will thrive and the uncompetitive ones will die.
  • Would begin in 2013.

Lobbyists’ Role in the Bill

  • Why was there no large-scale campaign launched against this reform by insurance industries, drug companies, and the like? Because this time around, they were brought into the fold. Yet, with lobbyists winning, the biggest loser stands to be — in many instances — the consumer. The pharmaceutical industry has lobbied for amendments, like one that would grant 12-year exclusivity to biologics, instead of 5. Read the article in TIME for more on that, but basically, it means that instead of allowing generics onto the market after a shorter waiting period (say, 5 years), it will now take 12 years for this to happen, when concerning biologics, which is rapidly growing. The downside to this is that generics help control costs by offering similar solutions for much less money. Essentially, this monopolizes the market for 12 years for each new biologic.

There was a Republican alternative to the House Bill, which included:

  • No public option
  • Individual mandate
  • State high risk pools
  • Not having language barring pre-existing conditions
  • Businesses can combine resources and buy health insurance across state lines
  • Reforms to control costs