Insurance Fraud

The June issue of California Lawyer magazine features a story about the recent announcements from two Catholic universities, Loyola Marymount University and Santa Clara University, that their employee health insurance policy would no longer cover elective abortion.

Unsurprisingly, reactions varied greatly. In some quarters, there was incredulity that Catholic institutions had ever been providing abortion coverage. On the other hand, many faculty members of these institutions expressed outrage over the decision to deny “full health care coverage.” Others chose to hide their agenda behind denunciations of the process by which the decision was made.

The process, as I discovered in my investigation of the issue, was this: For years these universities, and every other employer in California with a fully insured employee health plan, has been told, incorrectly, that California law requires abortion coverage in such plans. When the universities finally learned that it was in fact possible to exclude coverage for elective abortion, the only moral option was to exclude the coverage, which they did. One can speculate that, in acting without first “consulting” with the faculty, university officials were also hoping to avoid exactly the sort of embarrassing public disclosure of the moral bankruptcy of some of their faculty that has ensued. It can’t be fun for the administration of a Catholic university to have faculty members vociferously decrying its decision to exclude abortion coverage and complaining that “theology is taking precedence over health.”

The basis for the longstanding rumor that California law mandates coverage of abortion is found in the language of the Knox-Keene Act of 1975, which governs fully insured (as opposed to self-insured) health care plans in California. The critical language of Knox-Keene mandates coverage of all “medically necessary” health services. For years, the California Department of Managed Health Care (DMHC), the agency charged with ensuring that all fully insured health plans in California comply with Knox- Keene, has disallowed any plan that did not cover all abortions. Only recently did DMHC apparently reconsider its interpretation of the “medically necessary” language of Knox Keene as applied to elective abortion. The question is thus, is “elective abortion” a “medically necessary” health service?

The [obvious] answer is found in the very definition of “elective abortion.” Several medical dictionaries define “elective abortion” as “an abortion without medical justification but done in a legal way, as in the United States.” The McGraw-Hill Concise Dictionary of Modern Medicine defines “elective abortion” as “a voluntary interruption of pregnancy before fetal viability, which is performed voluntarily at the request of the mother for reasons unrelated to concerns for maternal or fetal health or welfare.” This dictionary goes on helpfully to note: “most abortions are elective.”

By definition, “elective abortion” and “medically necessary abortion” are mutually exclusive terms. It’s not a matter of whether there is overlap or ambiguity, sometimes yes, sometimes no. “Elective abortion” means precisely abortion that is not medically necessary

Undeterred by facts or logic, the usual suspects are decrying this radical shift by the DMHC. Margaret Crosby of the ACLU of Northern California asserted, “‘Medically necessary’ is a broad term that basically means a service the doctor thinks is OK.” She believes that the California constitution requires the state to force private insurers to cover all abortions.

Susan Berke Fogel at the National Health Law Program claimed, “Anthem [an insurance provider] is redefining ‘medically necessary.’ But abortion is a medical service to treat a condition— pregnancy. Any treatment for pregnancy is medically necessary.” Got that? While claiming that an insurance company is redefining “medically necessary,” Ms. Fogel is redefining “treatment.” Or rather, coining an entirely new term, “treatment for pregnancy.” There is no “treatment for pregnancy” any more than there is a “treatment for adolescence.” Treatment may be required for complications associated with it, but the condition itself is not a disease. An expectant mother receives “pregnancy care,” not “pregnancy treatment.” And, no, an abortion is not “care” for a pregnancy.

Beth Parker, chief counsel for Planned Parenthood Affiliates of California, stated ominously, “We would have been all over this if we’d known.” And unfortunately, now that they do know, they may still get all over it. In California, Planned Parenthood is the fifth branch of government (the fourth being public employee unions). So it would not be surprising to see some attempt by Planned Parenthood through regulation/legislation/litigation to restore the “correct” interpretation of “medically necessary” services.

Planned Parenthood and other abortion advocates could be deterred from such efforts by a doubt that they might—just might—be overplaying their hand to try to force Catholic universities to pay for direct, surgical abortions, procedures that the majority of Americans believe take a human life. On the other hand, the universities’ moral position is severely undercut by the fact that many of their faculty members, whom the universities knowingly trust to instruct their students, are themselves noisily clamoring for abortion coverage. Alas, chickens do indeed come home to roost.

1 The California Lawyer article Uncovered is available online


This article originally appeared in Lifeline (Summer 2014).