AND BABY MAKES ... Too Many?
ON A THURSDAY IN MID-JULY, SUPPORTERS OF FAMILY PLANNING FELT THEY FINALLY SAW THE TRUE FACE OF THEIR MOST FORMIDABLE OPPONENT ON CAPITOL HILL.
Casual viewers of C-SPAN could not have been expecting a conflagration of any significance as they took in the debate in the U.S. House of Representatives over the mundane-sounding Treasury and General Government Appropriations Act. But Nita Lowey, a New York Democrat and a fierce defender of women's issues, had proposed an amendment for federal workers that would require their health-care providers who cover prescription drugs to also pay for prescribed contraceptives. Viagra, the male impotency drug, was covered by many health insurers, argued Lowey and her allies; why not birth control?
Suddenly, Christopher H. Smith of New Jersey had the floor. Some have labelled the right-wing Republican "the scariest person in Washington," because of his Ahab-like obsession with stopping abortion. Now he was proposing an amendment--that Lowey's act not include coverage for "abortifascients."
"Many of the chemicals, many of the devices that are now employed, that are permitted under the Federal Employees Health Benefits Program, do indeed result in many abortions, newly created lives that are not permitted to implant in their mother's womb," he explained.
"Let us at least make it clear that the gentlelady's language exclude abortion-inducing chemicals. That is what my amendment very simply seeks to do."
Despite Smith's denials, proponents of family planning say his mission was clear. If life, as he suggested, begins at fertilization, what else were most contraceptives other than abortion inducing? Earlier in the year, Smith had tried to gouge U.S. funding for international family planning by tying it to abortion. Now, barrier methods excepted, he was taking aim at birth control.
Said Lowey, angrily: "It seems to me, from this discussion, that the gentleman from New Jersey is saying to every woman who may take the birth control pill or use another one of five accepted methods of contraception that they are abortionists."
Smith's amendment went down in defeat; Lowey's passed and moved along for future consideration.
But something profound, yet unspoken, was revealed that summer day: The battle lines over family planning were now clearly drawn. For their part, Smith and his allies publicly disclosed that they opposed more than just surgical abortion, that their agenda extended to birth control, too. On the other side, defenders of family planning saw that they had capable allies in Lowey, and Republican Nancy Johnson of Connecticut, the latter of whom lectured her Republican colleagues that day like a schoolteacher disciplining naughty pupils: "For us to make the decision that a woman must choose a means of contraception that reflects any one individual's determination as to when that process of conception, life, actually begins is a level of intrusion into conscience, into independence, into freedom, that, frankly, I have never witnessed."
Smith lost that round. But make no mistake, family planning is under siege in America--from the halls of Congress to the boardrooms of Catholic healthcare providers. In recent years, opponents such as Smith and the small but powerful Christian Coalition have masterfully seized the debate, sweeping family planning under the cover of abortion politics.
In Congress, where the extreme right wing has grown more outspoken and more incendiary, the result has been a relentless chipping-away process--slashing funding here, restricting programs there--which has hobbled the Clinton administration's support for reproductive health issues, both domestically and abroad. What's more, the attacks have gone largely unnoticed by a public that predominantly supports family planning, but that seems to have taken it for granted.
"What we are seeing in the U.S. Congress is a concerted attack on family planning," says Judith M. DeSarno, president of the National Family Planning and Reproductive Health Association. "And it's not only in the U.S., in programs that serve poor women, but probably more so internationally."
"The leadership in Congress is not listening to the American people," writes Gloria Feldt, president of the Planned Parenthood Federation of America, in a recent op-ed piece in USA Today. "They're listening to folks like the Reverend James Dobson of Focus on the Family and Gary Bauer of the Family Research Council--religious political extremists with an antichoice, anti-family planning agenda."
Crowding the Planet
Ironically enough, family planning is not a sexy issue; thus its lack of headlines. Nor does the average citizen easily make the mental leap from use of birth control to survival of the planet. Yet it stands as the best solution--and a non-coercive, virtually painless one at that--to a potential population crisis of destructive proportions.
Pat Waak, who heads the population and habitat campaign for the National Audubon Society, is often asked what a "bird group" like hers is doing knee-deep in the morass of family-planning politics. Why would any environmental group join the fray?
"We can do all the reduction-of-resource consumption possible in building sustainable communities around the world," answers Waak, "but if population growth continues in an unplanned way, it doesn't make any difference: We are going to exhaust the resources that are available to us, and we will get up against the wall, where there's nothing that's substitutable anymore."
Consider that it took until the beginning of the 19th century for mankind to reach one billion in number, according to the United Nations Population Fund. As public health care improved, particularly in developing nations, population has grown at a mind-boggling rate, to the point that 5.9 billion people today share the Earth. Even though the percentage growth rate has slowed in recent years, the actual number of people added each year is breathtaking. Fxperts expect the world's populous to breach six billion by mid-1999. One worst-case projection is that 27 billion people will be vying for space--and much more--by 2150. If so, the lack of resources will be unmatched by anything short of our scariest disaster movies. Even the more likely, pared-down estimate of 10.8 billion by 2150 has dire implications.
Virtually every environmental concern society now faces stands to be vastly exacerbated. If we can go to war over oil, just imagine the scene when it's water that's in short supply. Meanwhile, fisheries are already in perilous decline and could well bottom out. Habitat destruction. Extinction of even more species. Pollution. Global warming. "What happens when India, with 949 million people already, and China, with 1.2 billion, decide that they want air conditioning, refrigerators, and more cars?" asks Waak.
Internationally, particularly in developing nations, day-to-day survival often outweighs big-picture concerns like the environment. Food production per person in sub-Saharan Africa, for example, has fallen 16 percent in 30 years, according to Population Action International, a Washington, D.C.-based advocacy and research organization.
Some countries have implemented strict child-bearing policies. China, for one, has a highly-criticized, compulsive one-child policy. Other governments, such as Thailand's, have been successful at taming uncontrolled growth with a heavy dose of public education and distribution of free birth control.
Indeed, private U.S. groups like Population Services International (PSI), which sells millions of contraceptives at low cost in countries around the world, have witnessed great progress in those places willing to implement educational and voluntary family planning programs. PSI, according to spokeswoman Donna Good, has managed to avoid the political spotlight by neither providing nor counseling abortion.
Birth Control Backlash
In the U.S., family planning has widespread support. In 1995, 64 percent of American women, ages 15 to 44, used contraception, up from 56 percent in 1982, according to the Alan Guttmacher Institute, a New York-based think tank for reproductive issues. Still, nearly half of the nation's 6.3 million pregnancies each year are unintended. Teenagers, meanwhile, are responsible for 13 percent of all births in this country. Teens underwent 289,000 abortions in 1994 alone.
In light of such statistics, one would think that lack of information and ignorance would be the key problems facing advocates of family planning. Abortion politics, however, have overshadowed all other obstacles.
Many manufacturers, for instance, fear a political backlash for developing new methods of contraception. Mifepristone (RU-486), the so-called "French abortion pill," which expels an implanted egg, was used in France for years before anyone dared take steps to make it available here.
Relatively few American women, meanwhile, know that birth control pills taken after sex can prevent pregnancy. Higher doses of pills that millions of women already possess, taken within 72 hours of intercourse, can provide emergency contraception. But between abortion scare tactics and a fear of consumer lawsuits, companies have hesitated to relabel their products and advertise them as such. It's easy to understand why, considering the reaction that a $20 "emergency contraceptive kit" drew when it was approved by the Food and Drug Administration in September. The kit basically consists of a home-pregnancy test and four birth-control pills, with instructions about when to take them as "emergency" contraception. The pills cannot affect an established pregnancy, but that did not stop one right-to-life leader from slamming the "do-it-yourself abortion kit" and the FDA.
It was just four years ago, during the United Nations-sponsored International Conference on Population and Development, in Cairo, Egypt, that the U.S. made broad commitments to be a leader in fending off a global population crisis, with family planning being the first line of attack. Today, with the political landscape altered and Republicans holding power in Congress, many feel that America is reneging.
A University of Maryland survey shows that 74 percent of Americans support assistance for international family planning. But in 1996, Congress actually cut foreign population assistance 35 percent and then delayed and restricted release of the money.
The U.S. spends a meager $385 million for international family planning, through the U. S. Agency for International Development, with another $25 million to the UN Population Fund--a pittance compared to the grand assurances offered in Cairo.
At times, the pro-life rhetoric has been unnervingly inflammatory. During the "abortifascient" debate in July, Representative Smith called RU-486 a "baby pesticide." An advertisement by the Christian Coalition dubbed foreign aid for family planning "the Clinton administration's overseas abortion crusade." And in one debate, Mark E. Souder, a Republican congressman from Indiana, cried, "American dollars shouldn't be used to kill innocent little children around the world!"
The root of this fight dates to 1993, when in the first days of Clinton's presidency, he overturned the Reagan-Bush "global gag rule," which denied U.S. funds to any foreign organization that performed or promoted abortion. Much of the policy was, in fact, already covered by law. But the mandate was so broadly worded that it included even informational activities that touched on abortion, including conferences and the like, even if the groups--foreign groups, no less--spent their own funds.
Smith, former head of the New Jersey branch of the National Right to Life Committee, has tried to reinstate the policy, demonstrating a pitbull's tenacity that has marveled even his foes. Two years running, Smith attached the global gag rule to bills that had nothing to do with family planning or abortion. The latest was a Clinton-favored measure to pay back-dues to the United Nations and shore up the coffers of the International Monetary Fund. Because Clinton vowed to veto legislation with the gag rule attached, Smith and his colleagues essentially killed the foreign-policy measures.
Smith, it should be noted, failed to respond to several requests to be interviewed for this article.
By using the volatile issue of abortion, extremists have twisted the issue to keep Clinton and those who support family planning on their heels, and have even marginalized them.
Abortion has never been the method of choice for those hoping to prevent unplanned births, say advocates of family planning. But they do want to leave the door open for it, if for no other reason than to curtail the staggering number of deaths from unsafe abortions--70,000 a year, according to the World Health Organization--in the Third World in particular.
A New York Times editorial called the gag-rule rider "an obnoxious amendment." Secretary of State Madeleine Albright icily told Congress that it was "legislative blackmail." But to those who have devoted their lives to family planning issues, it was just the latest display of a wear-them-down, hit-and-run style of legislative warfare that in the long run is proving successful, no matter how the individual skirmishes play out.
Over the last three years, more than 90 bills that would diminish reproductive rights have been introduced, all but 13 of which have passed.
Consider Title X of the Public Health Service Act, which, since President Nixon signed it in 1970, has provided family planning and other reproductive health services--not including abortion--for poor women across America. Despite all the bipartisan optimism and federal dollars that once rolled in, that picture began to change in the 1980s. Today, Title X receives $203 million.
When adjusted for inflation, Title X expenditures for contraceptive services dropped 65 percent between 1980 and 1994, notes the Alan Guttmacher Institute. Despite a 70 percent increase in Medicaid, total public expenditures for contraceptive services dropped 27 percent during that period.
More than four million women at some 4,200 clinics benefits from Title X, but attempts to eviscerate it continue. The latest is the never-ending quest by Representative Ernest Istook, a Republican from Oklahoma, to make it a requirement that teenagers have parental consent to use services at funded clinics, a restriction that certainly would increase unwanted pregnancies. This year, in fact, the fight over minors brought progress on the gargantuan, $82 billion Labor, Health and Human Services, and Education appropriations bill to a screeching, smoking halt, convincing many people that the right wing will stop at nothing to derail family planning efforts.
Not all the news from Congress, however, is bleak. After years of silence, debate is finally emerging on whether birth control should be a mandatory health insurance requirement. Today, there is optimism that Congress will pass a bill to require contraceptive coverage for federal workers. By this summer, both the House and Senate approved birth control amendments to appropriations bills.
Some feel that legislation will bode well for more broad-based bills that have emerged in both houses of Congress, the most notable being the Equity in Prescription Insurance and Contraceptive Coverage Act (EPICC), sponsored by Senators Olympia Snow, a Maine Republican, and Harry Reid, a Democrat from Nevada. The cost of the added coverage would be $21.40 per employee, per year, $17.12 of which would be the employer's cost, according to the Alan Guttmacher Institute.
Representative Smith notwithstanding, the bills not only have bipartisan backing, but supporters from both the pro-life and pro-choice forces. Insurers and managed-care providers have been steadfast in resistance, because of the cost and an industry-wide aversion to mandates.
By late summer, birth-control coverage measures had been proposed in 22 states. In April, Maryland became the first state to require that private insurance companies offer equitable contraceptive coverage.
Predictably, the Roman Catholic Church has also been a major opponent of family planning. Three decades have now passed since Pope Paul VI's famous Humanae Vitae reiterated the Church's stance against contraception. Catholic women, meanwhile, are among the top users of birth control worldwide. (Nearly 60 percent of all Catholic women in the U.S. use some form of contraception, compared to three percent who use natural family planning, according to a 1991 study. The numbers are similarly overwhelming in Catholic strongholds like Ireland, Italy and Latin America.)
The Catholic perspective was exceedingly clear at the international Cairo conference. Beforehand, the Vatican went so far as to accuse the U.S. and other western nations of "biological colonialism" for their efforts to bring contraception to the Third World.
And though lacking the legislative muscle of the Christian Coalition, the Church has one of the best-run lobbies in America. Its opposition to U.S. funding of international family planning has been palpable.
As expected, the Church did weigh in on the insurance coverage debate, winning concessions in the federal workers bills that would allow Catholic health plans an exemption from the contraception requirements. "The Church's response to contraceptive public policy is to say we don't want contraception to be made illegal; it's a private moral matter and the government ought not to step into it," says Helen Alvare, an official with the National Conference of Catholic Bishops.
More discomfitting to supporters of family planning, though, has been the outright elimination of reproductive health services when Catholic hospitals join or take over non-Catholic institutions. "There is no question it is not a perfect fit, and it does cause some inconvenience," the Reverend John Tuohey, an ethicist at Mercy Health System Oklahoma, told The Washington Post, about a related controversy involving his organization. "But we have to be faithful to the teachings of the Church."
Washington D.C.-based Catholics for a Free Choice (CFFC) tracked 84 mergers between 1990 and 1997 of Catholic and non-Catholic hospitals. Others are in the works. What's more, the Catholic organizations are forming networks, extending their influence and fortifying their leverage for future negotiations. Fifteen percent of the nation's nonfederal hospital beds are now in the hands of close to 600 Catholic hospitals. Often, the only hospital in a community is Catholic-run.
In the past, agreements at many facilities were structured to allow reproductive services to continue. But now the Church is taking a hard-line, bulldog's stance. "Increasingly, what we have seen is an effort by Church officials to prevent mergers from taking place unless the non-Catholic provider stops providing contraceptive services," says CFFC's Frances Kissling.
In 1995, the pope issued an encyclical threatening to remove Church sponsorship of those Catholic healthcare organizations that failed to strictly obey church doctrine on matters like sterilizations and contraception.
In Austin, Texas, the Vatican has been relentless in its efforts to alter an agreement between the Catholic-run Seton Healthcare Network and the city's Brackenridge Hospital. Three years ago, just as the issue was heating up in Rome, Seton agreed to a 30-year lease to run the hospital. To finesse the question of providing reproductive services, Seton brought in an outside group to provide staffing for sterilizations at the hospital. Meanwhile, reproductive health information and counseling became the responsibility of the Austin/Travis County Health and Human Services Department. Thus, information about abortion and birth control remained part of the hospital's services. (No abortions took place at Brackenridge, before or after Seton's taking over.)
When it learned the details, the Vatican was less than pleased. Soon, officials there began pressing local Bishop John McCarthy, demanding that the hospital "suspend at once all immoral procedures and programs." Seton officials go to great lengths to insist they were not involved in those discussions. Company officials, however, did end up reworking parts of the agreement with the city. At last word, reproductive services were expected to remain available, but with city employees likely to take over the medical staffing.
"This is really at the extreme edge of acceptability," says Kissling. "First of all, for the Vatican to intervene in a contractual relationship between a public hospital and a Catholic health corporation is pretty excessive in itself. Secondly, that they would do this with a public hospital, where the obligation to provide services is much greater than it would ever be, even in a private, nonprofit situation."
Just the sheer number of mergers in which Catholic-run organizations are involved, and the increase in Catholic HMOs, is unsettling to advocates of family planning. Not only do such changes narrow an individual's health-care choices, but in the long run, they stand to reduce the availability of contraceptive and other services that many people, Catholics included, want and need.
"The other element is that almost all hospitals, including Catholic hospitals, are largely publicly supported and financed through Medicaid reimbursement, as well as local and municipal bond issues," adds Kissling. "So in this sense, the notion that a hospital would be permitted to deny services that are publicly supported, that carry public funds with them, and that are legal, is really questionable."
And so the debates continue. As fears of overpopulation and its effect upon the world fester, family planning solutions remain constrained by a vocal minority in Congress and a Christian theology that most of the public--including much of the flock--considers irrelevant. Finding a common ground, let alone compromise, seems impossible. After all, the opposition sees itself not only on the side of right, but on the side of God.
For people like the National Audubon Society's Pat Waak, it is a point of sadness, and at times, frustration, that the sides cannot sit down and find answers. "The population issue is fixable," she says. "We have the technology. We have the knowledge. We have the ability. We can do it without doing what China did, or any other programs that tend to be coercive. Yet we've bound ourselves up with all of these excuses about why we don't need to do it, or don't want to do it."
CONTACT: The Alan Guttmacher Institute, 120 Wall Street, 21st Floor, New York, NY 10005/(212)248-1111; National Conference of Catholic Bishops, Secretariat for Prolife Activities, 3211 4th Street NE, Washington, DC 20017/(202)541-3000.
RELATED ARTICLE: WHO WILL PAY?
Insurers May Have to Ante Up
A new day may be dawning for birth control and insurance coverage.
Truth be told, contraception has never been a priority for health insurers. As strange as it sounds, most companies have been more willing to pay for surgery--tubal ligations, vasectomies and abortions--than less expensive methods like the birth control pill, Depo-Provera, Norplant, the IUD and the diaphragm. Eighty-six percent of indemnity plans cover tubal ligations, for instance, and 85 percent cover vasectomies, according to the Alan Guttmacher Institute. Only 33 percent cover the pill.
This year, the issue finally became part of the discourse in Congress. Passage of legislation that would require all insurers of federal employees that cover prescription drugs to also cover prescription birth control seems imminent. As a result, bipartisan bills that would apply similar standards for the general public, ignored for months, have found new life in both houses of Congress.
"The cost of covering contraception for a woman for a year is about $300," says Judith DeSarno, president of the National Family Planning and Reproductive Health Association. "The cost of a healthy delivery--forget prenatal care--is $3,600. And if you have a Cesarean section, it's $10,000. You would think that insurance companies and the U.S. Congress would understand just the economic sense of making contraception as available and as affordable as possible. It's just darn good policy."
Another powerful argument has been that insurers routinely cover other prescription drugs, but not birth control. As a result, poor women in particular will often choose less expensive, less reliable methods. "Women in this country should not be forced to choose among such unacceptable alternatives," said Planned Parenthood's Gloria Feldt, when she appeared before Congress this summer.
Apparently, the American public agrees. In a survey last spring, the Kaiser Family Foundation found that of the respondents familiar with the Congressional bills that would provide birthcontrol coverage for the general public, 75 percent "strongly supported" or "somewhat supported" them.
Insurance companies have responded true to form. "Insurers oppose mandates because they raise costs for consumers and can ultimately price consumers out of the insurance market," says Richard Coorsh, a spokesman for the Health Insurance Association of America, which represents 250 private insurers. "Already on the state level there exist some 1,200 mandated benefit requirements. I've yet to come across any advocacy organization suggesting that their particular mandate is not cost effective."
CONTACT: National Family Planning and Reproductive Health Association, 122 C Street NW, Suite 380, Washington, DC 20001/(202)628-3535, http://www.nfprha.org.
RELATED ARTICLE: STEMMING THE TIDE
Who's Who In Fighting Overpopulation
Family planning works. That's the message from numerous activists and politicians from both parties, including many pro-life supporters. A 30 percent reduction in unintended pregnancies would result in 200,000 fewer unintended births and some 800,000 fewer abortions in the U.S. each year, according to a study by the Institute of Medicine.
Despite widespread public support for family planning, a small but powerful segment of Congress, among others, has sidetracked America's role in helping stem the tide of world population growth. As a result, a variety of groups have stepped up their efforts to promote reproductive health issues. The Planned Parenthood Federation of America, for one, recently announced its "Responsible Choices Action Agenda," to strengthen its legislative and grassroots campaigns. Others, such as Negative Population Growth, are pursuing campaigns that encourage people to have no more than two children.
To get involved, here are some of the main organizations to contact:
THE NATIONAL AUDUBON SOCIETY'S POPULATION AND HABITAT CAMPAIGN--Seeks to "educate and mobilize" people around the U.S. regarding the link between population and threats to the environment. 1901 Pennsylvania Avenue NW, Suite 1100, Washington, DC 20006/(202)861-2242, http://www.audubon.org.
THE SIERRA CLUB'S INTERNATIONAL POPULATION PROGRAM--Works to affect change on legislation concerning family planning and related issues. Supports grassroots organizing, operates speakers bureau, and provides outreach in Mexico and Latin America. 408 C Street NE, Washington, DC 20002/(202)547-1141, http://www.sierraclub.org.
ZERO POPULATION GROWTH--Focuses on population and its impact on the world, with strong advocacy and education programs. 1400 16th Street NW, Suite 320, Washington, DC 20036/ (202)332-2200, http://www.zpg.org.
PLANNED PARENTHOOD FEDERATION OF AMERICA--Devoted to the individual's right "to choose when and whether to have children." Operates 900 clinics in 47 states and the District of Columbia, with medical and educational services. 810 7th Avenue, New York, NY 10019/(212)541-7800, http://www.plannedparenthood.org.
POPULATION ACTION INTERNATIONAL--"Dedicated to advancing policies and programs that slow population growth in order to enhance the quality of life for all people." Strong research, publications and international advocacy components. 1120 19th Street NW, Washington, DC 20036/(202)659-1833, http://www.populationaction.org.
POPULATION SERVICES INTERNATIONAL--The leading contraceptive marketing organization in the world, PSI evaluates health needs, educates, and provides family planning products to millions of low-income people, worldwide. 1120 19th Street NW, Suite 600, Washington, DC 20036/(202)785-0072, http://www.psiwash.org.
CATHOLICS FOR A FREE CHOICE--This independent, not-for-profit engages in research, policy analysis, education and advocacy on matters of gender equality, reproductive health and Church reform. 1436 U Street NW, Suite 301, Washington, DC 20009/(202)986-6093, firstname.lastname@example.org.
UNITED NATIONS POPULATION FUND--Provides technical assistance and support to improve reproductive programs around the world. Active in research, policy analysis and data collection. Also supports advocacy groups in areas of sexual and reproductive health. 220 East 42nd Street, New York, NY 10017/(212)297-5020, http://www.unfpa.org.
NEGATIVE POPULATION GROWTH--Advocacy and educational group seeking "to stabilize the U.S. population at a smaller, more sustainable level." 1608 20th Street NW, Washington, DC 20009/(202)667-8950, email@example.com.
POPULATION-ENVIRONMENT BALANCE--A grassroots advocacy organization focusing on stabilizing U.S. population, with particular attention to immigration and the environment. 2000 P Street NW, Suite 210, Washington, DC 20036/(800)866-6269, http://www.balance.org.
Stephen Sawicki is editor-at-large of E.
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|Date:||Nov 1, 1998|
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