1. It effectively bans coverage for most abortions from all public and private health plans in the Exchange: In addition to prohibiting direct government funding for abortion, it also prohibits public money from being spent on any plan that covers abortion even if paid for entirely with private premiums. Therefore, no plan that covers abortion services can operate in the Exchange unless its subscribers can afford to pay 100% of their premiums with no assistance from government "affordability credits." As the vast majority of Americans in the Exchange will need to use some of these credits, it is highly unlikely any plan will want to offer abortion coverage (unless they decide to use it as a convenient proxy to discriminate against low- and moderate-income Americans who tend to have more health care needs and incur higher costs).

2. It includes only extremely narrow exceptions: Plans in the Exchange can only cover abortions in the case of rape or incest or "where a woman suffers from a physical disorder, physical injury, or physical illness that would, as certified by a physician, place the woman in danger of death." Given insurance companies' dexterity in denying claims, we can predict what they'll do with that language. Cases that are excluded: where the health but not the life of the woman is threatened by the pregnancy, severe fetal abnormalities, mental illness or anguish that will lead to suicide or self-harm, and the numerous other reasons women need to have an abortion.

3. It allows for a useless abortion "rider": Stupak and his allies claim his Amendment doesn't ban abortion from the Exchange because it allows plans to offer and women to purchase extra, stand-alone insurance known as a rider to cover abortion services. Hopefully the irony of this is immediately apparent: Stupak wants women to plan for a completely unexpected event.

4. It allows for discrimination against abortion providers: Previously, the health care bill included an evenhanded provision that prohibited discrimination against any health care provider or facility "because of its willingness or unwillingness to provide, pay for, provide coverage of, or refer for abortions." Now, it only protects those who are unwilling to provide such services.

1) Any policy that is sold within the Exchange: A strict interpretation of the Stupak language suggests that since the Exchange is established by the federal government, any plan that operates within the Exchange would not be able to provide abortion coverage. However, since Stupak allows insurers that operate plans within the Exchange to sell abortion riders, one could also assume that a policy in the Exchange could still offer abortion coverage.

2) Policies in the Exchange that receive risk-adjustment dollars: Even though the risk adjustment mechanism is distributed from a pool that is seeded with insurer dollars, the government distributes the dollars, which adjust for individuals who receive government-subsidized coverage. Moreover, one could also argue - like the Bishops did - that once insurer money enters a risk adjustment mechanism that is administered by the government, it automatically becomes government money. Under this explanation, insurers that sell abortion riders may not qualify for risk adjustment payments.

3) Policies in the Exchange that are directly subsidized by the government: Anyone who receives government affordability credits (Americans between 150-400% FPL) would not be able to purchase an insurance policy that includes abortion coverage. Insurers are also required to accept all applicants and would have to stop offering abortion coverage once it accepts its first federal-dollar beneficiary.

4) Employer-sponsored policies that receive reinsurance funds: The bill requires the Secretary of Health and Human Services to "establish a temporary reinsurance program to provide reimbursement to assist participating employment-based plans with the cost of providing health benefits to retirees and to eligible spouses, surviving spouses dependents of such retirees." Employer-sponsored plans that offer abortion would not be eligible for this funding or would have to forego the benefit.

5) Employer-sponsored policies that receive "wellness program grants": The bill allows the Secretary of Health and Human Services to award Wellness program grants to small employers. Employers would have to segregate their wellness programs from their health benefits in order to receive the credit and provide abortion coverage.

6) Employer-sponsored policies that receive small business credits: For small businesses that want to offer health insurance coverage, the bill provides a tax credit over a two-year period will help them transition to or continue providing health benefits to their employees. In order to receive the tax credit, small businesses would have to stop offering abortion coverage.

In effect, the size of the new market is large enough so that Stupak/Pitts can be expected to alter the "default" customs and practices that guide the health benefits industry as a whole, leading it to drop coverage in all markets in order to meet the lowest common denominator in both the exchange and expanded Medicaid markets. Furthermore, for the reasons outlined above, because the Stupak Amendment bars the subsidization of plan administration activities in connection with prohibited procedures, it can be expected to chill the development of abortion coverage supplements as well as entirely separate plans to non-subsidized women. .

- Amendment could chill the development of abortion coverage supplements: Since Stupak effectively requires that supplemental abortion coverage "be administered separately from other plans," the cost of supplemental abortion coverage "could be expected to be far higher than simply the cost" of any other supplemental policies.

- Companies would have to absorb the extra administrative costs of providing supplemental abortion coverage: "Not only would companies have to absorb all costs of administration into the supplemental or separate plan fee, but companies would confront having to expand provider networks to assure access to the full range of medically indicated abortions in the case of women who purchase expanded coverage."

- Cost of later-term abortions would be particularly expensive: The cost of abortions performed later in pregnancy can already "carry a price tag in the thousands of dollars." However, since this coverage will now be sold as supplement - excluded from the larger risk pool - "the cost of a supplement or a plan that carries additional coverage could be considerable."

- No incentive for companies to offer additional coverage for women who move into Exchange: While a migration over time of thousands of smaller employers (who offer abortion coverage) into the Exchange "might encourage health benefit services companies to create supplemental abortion coverage products," the Stupak amendment discourages their development. Currently, almost no insurers offer supplemental abortion coverage in states that already bar the sale of products that offer abortion coverage. The Stupak amendment is designed "to push the price of supplemental coverage higher by prohibiting the integration of administration costs into a single administrative scheme."

- What if the abortion procedure is part a broader treatment? Under Stupak, plan administrators can only pay for abortions that threaten the life of the mother. But what if the abortion procedure "is part of broader treatment for a serious health condition?" What if the procedure must be performed to in the course of treating a significant health problem? "In these circumstances, how are plan administrators to distinguish between the abortion procedure and the rest of the treatment? Will the entire cost of a course of treatment (e.g., surgery to repair a damaged pelvis following an automobile accident) be denied if abortion is part of the procedure? Health plan administrators, confronted with the prospect of a legal violation for paying for the excluded abortions, may elect to deny the treatment altogether, claiming that it is all related to the excluded treatment."