Marci A. Hamilton

Why the Stupak Amendment to the Healthcare Reform Bill Is Unconstitutional

By MARCI A. HAMILTON
Thursday, November 12, 2009

The United States Conference of Catholic Bishops registered a major victory this week, when it succeeded in pressuring members of the House to include in the healthcare reform bill the so-called "Stupak Amendment." The Amendment is a provision that carves out new territory for those organizations and persons who oppose abortion -- virtually all of whom are religiously-motivated. It does so by forbidding federal funds from being applied to abortions in any instance, including when those funds are being used to subsidize the purchase by low- or middle-income individuals of private insurance on the open market. Under the Stupak Amendment, federal funds cannot be used to pay for "any part" of an insurance plan that would fund abortions.

Before the Stupak Amendment was added, the bill had already included a compromise provision that grandfathered in the approach taken by a prior federal law that sharply restricts funding for abortions. That law, known as the Hyde Amendment, has forbidden federal spending by Medicaid on non-therapeutic abortions since 1976. There have been times in recent history when no abortions could be federally-funded, but at this point a few circumstances permit federal funding, including a pregnancy deriving from incest or rape, or a threat to the life of the pregnant woman. Despite its burden on women's rights, the Hyde Amendment has been upheld in a series of Supreme Court cases, including Maher v. Roe.

The Health Care Reform Act in the House had included a compromise provision that recognized the Hyde Amendment principle, but did not extend the prohibition to the funding of abortions through private insurance plans. But the addition of the Stupak Amendment changed all that when it extended the ban on funding for abortions to private insurance plans, thus creating a world in which the vast majority of plans are unlikely to cover abortion and in which almost all women will have no choice but to pay for abortions out of pocket. This is a remarkable attempt to overreach into the private sphere, and to force all Americans' healthcare plans to reflect the religious beliefs of one subset of Americans.

At this point, it appears unlikely that the Stupak Amendment will survive the healthcare reform battles in the Senate. President Obama quickly criticized it and Senator Boxer produced a list of 40 Senators who would not vote for healthcare reform with such onerous restrictions on women. But the anti-abortion lobbyists have shown their hand: They fully intend to use the federalization of healthcare to further their religious agenda. Therefore, this is unlikely to be the last we hear of the Amendment, even if it does not survive the Senate this time around.

Although many have attacked the Amendment as a policy matter, the constitutional arguments against have been underplayed. That is a shame, because under any reasonable reading of the Constitution, the Stupak Amendment is unconstitutional: Indeed, it violates three different constitutional principles.

How the Stupak Amendment Violates The Establishment Clause

First, the Amendment violates the Constitution's separation of church and state. The anti-abortion movement is plainly religious in motivation, and its lobbyists and spokespersons represent religious groups, as is illustrated by the fact that the most visible lobbyists in the Stupak Amendment's favor have been the Catholic Bishops. This is a brazen and frank attempt to impose a minority's religious worldview on the entirety of American healthcare. (A majority of Americans have favored a woman's right to choose for many years.) There is no secular purpose for the extension of the Hyde Amendment to all private health insurance plans as well. Accordingly, whatever secular purpose might be devised by those trying to defend the Stupak Amendment in court would be a sham purpose, intended to cover the frankly religious pandering the Amendment represents.

One of the clearest Establishment Clause principles is that the government may not impose a certain group's religious beliefs on those with different beliefs. The principle was articulated by the framer of the First Amendment, James Madison, in his important work "Memorial and Remonstrance," and it has been a mainstay of Establishment Clause doctrine. The Stupak Amendment violates this principle by imposing on the entire country a religious worldview that millions of Americans do not share. Moreover, this imposition of religious belief in the private sphere is in the context of healthcare, which every American needs.

How the Stupak Amendment Violates The Equal Protection Clause

The Stupak Amendment also discriminates on the basis of gender. Only women have to deal with the difficult question of abortion. Conspicuously missing are parallel exemptions barring funding for Viagra, or for, say, prostate surgery treatments, which can leave a man sterile and therefore operate as a birth control measure.

In addition, the exemption (the purpose of which is, again, obviously a religious one) does not serve any medical end, when serving medical ends is presumably the overall and most important purpose of the Health Care Reform Act. If health is truly to be served, then refusing to permit women to obtain even private health insurance that covers unplanned pregnancies, or pregnancies involving fetuses with fatal abnormalities, is not just discriminatory, but outright irrational.

How the Stupak Amendment Violates Substantive Due Process and Privacy Rights

Finally, the Stupak Amendment attempts to curtail -- across the board – the privacy rights that Roe v. Wade and its progeny secured for women. While other restrictions on abortion (including the Hyde Amendment) have been upheld by the Supreme Court, this is a far more expansive and repressive move against women, and it surely institutes an undue burden on a woman's right to obtain an abortion in consultation with her doctor. Although it is not clear precisely where the boundary line lies, it is very clear that this move transgresses any reasonable interpretation of the line the Court's cases draw.

The Stupak Amendment is also a harbinger of future constitutional violations, for it erects a slippery slope of top-down control of the spectrum of healthcare options. Abortion is surely just the first foray of the religious lobbyists' battle to take away Americans' right to choose among the full panoply of healthcare options. Attempts to control and halt the funding of both emergency and ordinary contraception surely are not far behind, for such attempts are part of the very same politico-religious platform that includes the Stupak Amendment. There is no more obvious violation of Griswold v. Connecticut – which established that laws prohibiting contraception are unconstitutional under the Court's right-of-privacy doctrine -- than for the federal government to reduce the affordability and, therefore, the availability of contraceptives for all Americans.

Conservative Senators who are pandering to religious interests (and/or simply imposing their own religious beliefs on the country) have been quoted recently as saying that they will not permit the Health Care Reform Act to backtrack on abortion issues. But backtracking is a misleading description of what the religious lobbyists are seeking. The truth, instead, is that the Stupak Amendment is a far reach beyond the already repressive Hyde Amendment, and that the advent of the federalization of healthcare is giving anti-abortion religious believers a one-stop lobbying opportunity on an issue that they were previously having to address on a state-by-state basis.

In sum, if the millions of Americans who believe in choice do not act quickly and in a concerted fashion, then we will have a historic rollback of women's liberties. That would be a true disaster, for not only is the Stupak Amendment repressive and regressive, but it also violates constitutional rights.


Marci Hamilton, a FindLaw columnist, is the Paul R. Verkuil Chair in Public Law at Benjamin N. Cardozo School of Law and author of Justice Denied: What America Must Do to Protect Its Children (Cambridge 2008). A review of Justice Denied appeared on this site on June 25, 2008. Her previous book is God vs. the Gavel: Religion and the Rule of Law (Cambridge University Press 2005), now available in paperback. Her email is hamilton02@aol.com.

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