It looks increasingly likely that anti-choice forces will have lots of difficulty inserting the Stupak amendment language into the Senate’s version of health care reform. When Bob Casey, perhaps the most insistent anti-choice Democrat in the Senate, hints that he wouldn’t vote for the restrictive measure, there’s not much chance many other Democrats would, let alone pro-choice Republicans like Lisa Murkowski, Olympia Snowe and Susan Collins. In fact, there are already 33 Senators pretty much on the record against the stricture, including several Senate moderates and Republicans. While Ben Nelson has hinted at conditioning his cloture vote on Stupak-like language, Democratic sources believe he can be moved on that point. And nobody else has made such a statement.

If they need another reason, they can understand how the Stupak language is bound to reach into more and more insurance markets over time – in fact, probably all of them.

Ezra Klein made the point that I made on Monday, that even if you read the Stupak amendment to be limited to the exchanges (and I don’t), those exchanges are scheduled to be expanded over time, further chipping away at coverage for reproductive choice services over time.

Only now, with the Stupak amendment, every one of those (exchange) expansions, to mid-size and then large employers and possibly even individuals who are offered employer coverage, would further restrict coverage for reproductive choice services. If the exchanges do expand – and they should – the result would be making all abortions purely an out-of-pocket scenario.

And then there’s the question of what is considered, in technical medical terms, as an abortion. Hospitals determine a terminated pregnancy where the fetus was not expelled as an abortion, requiring a “D&C” procedure. Under the Stupak amendment, insurance companies would not be allowed to cover this procedure either. It’s possible that this would fall under the “life of the mother” exemption, which is in the bill, but that would only be the case if the life of the mother was directly threatened. There is no “health of the mother” exemption [...]

Progressives generally support opening the exchanges, which would also open access to the public option. Under the Stupak amendment, that would have the effect of chipping away at abortion access slowly but surely.

This brings up an even bigger problem. Most health policy experts agree that the Stupak amendment would effectively ban reproductive choice services coverage in the exchanges. And the exchanges would have enough advantages on price and mandated coverage that the Stupak amendment wouldn’t be enough to stop anyone from staying off of it. But if the exchanges expand over time, at some point things would reach a tipping point – a point at which insurance companies would find it easier and more cost-effective to stop providing reproductive choice services coverage at all, whether on the exchange or not.

It would be similar to a large state adding a regulation that changes an overall market. In the 1970s, for example, California adopted a Motor Vehicle Emission Control Program that led to the usage of catalytic converters by car companies. Gradually, it made economic sense to the carmakers to change all their assembly lines to add catalytic converters to the vehicles, rather than send one type of Chevy to California and one to the rest of the country.

Insurance companies don’t make their policies on assembly lines. However, there is a tendency, from an administrative standpoint, to standardize insurance plans across markets, rather than varying coverage from state to state based on the law. And with more and more insurance provided by companies with national reach, that would eventually affect the ENTIRE insurance market. If abortion services cannot be provided in a big market like the exchanges, it would make economic sense to insurers not to cover it anywhere.

There is a precedent for this. Adam Sonfield, a senior public policy associate at the Guttmacher Institute, cited a 2002 study, the source of those statistics on abortion and insurance that pundits are misappropriating, which also included research on contraception. The study found that, once contraceptive services were mandated in enough markets, insurance companies began to standardize their coverage and offer it as part of their policies everywhere. “It makes business sense for them,” Sonfield said. “That’s why the individual insurance market is so expensive, because it’s so detailed in terms of what coverage people can pick up. For administrative and other reasons, insurance companies would rather offer cookie-cutter services that that can predict and control.”

NPR made a similar point about the exchanges themselves, but it could easily be expanded to the entire insurance market once the size of the exchange reaches critical mass:

(Health insurance industry consultant Robert) Laszewski says the problem is that by all estimates, the vast majority of people who will be shopping in the new exchanges will be getting subsidies, so they won’t be allowed to get abortion coverage. Thus, if a health insurer did offer a separate plan with abortion coverage, it would only be available to a small universe of buyers, and it simply wouldn’t make much business sense.

“It’s not an ideological issue, it’s not about abortion or not abortion,” Laszewski says. “It’s about what is administratively simpler, easier to administer. It just adds a level of complexity they will likely avoid.”

Sara Rosenbaum, a health lawyer and professor at George Washington University, agrees that it’s impractical to expect health insurance plans to cover abortion in the exchanges, even for people paying the full premiums without federal help.

“If you speak to insurers in the industry, they will tell you that they simply can’t operate under these circumstances,” Rosenbaum says. “They need to be able to offer standard products that get administered in a standard way for everybody.”

That’s true of the entire market, and if you ban abortion coverage for enough of it, eventually insurance companies will find the cost too great to offer that coverage anywhere.

Planned Parenthood has more about the impact of the Stupak amendment.