Though the Senate health reform bill released Wednesday didn't contain the extreme abortion coverage restriction attached to the House bill, the bitter fight over abortion funding in healthcare reform isn't over. Senator Orrin Hatch has already promised to offer his own version of the House's Stupak amendment when the bill comes to the floor, and even if the bill makes it out of the Senate without it, another fight over the restrictions is all but inevitable when two bills go to conference.
The Senate bill offers prochoice advocates hope of reversing the disastrous House vote. But to keep Stupak's restrictions out of a Senate bill and, most importantly, the final legislation, it's necessary to understand why the well-organized and well-funded women's health movement wasn't able to avert the "Saturday night massacre" in the first place.
Consideration of the Stupak amendment, which would strip abortion coverage even from women who pay for premiums through the health insurance exchange with their own money if they use any federal subsidy at all, shouldn't have come as a shock. Similar amendments had been afloat in both the House and Senate  earlier this summer. And throughout that time, Stupak and his antiabortion colleagues had been threatening to do exactly as they did. What's more, despite prochoice gains in the last two election cycles, the House still doesn't have a prochoice majority. And indeed, a number of prochoice leaders report being unsurprised that antichoice House Democrats forced a vote on the extreme measure.
Even so, at least some of the Stupak problem was about how women's advocates played the game: extremely nicely. Women's groups were measured in their politics, trying hard to get along and keeping their gripes and dissatisfactions to themselves. But such good behavior rarely does well in Washington. And against the kind of strong-arm techniques that the bishops and antichoice Democrats wielded, it didn't stand a chance.
Stupak is even more of an insult to prochoice groups when you consider what they really wanted: to have abortion be treated as an integral part of healthcare. Rather than being paid for with dollars that are practically fingerprinted at every turn, abortion, in this view, would be more like a vasectomy--a routine, if personally delicate, outpatient procedure. But hoping not to muddy the overall health reform process, advocates tried, at first, to leave abortion politics out of the legislation. The tack was eminently reasonable; health reform, after all, was a much bigger issue. Why did abortion have to get mentioned at all?
By the end of June, they had their answer. Nineteen Democrats, including Bart Stupak, sent a letter to Pelosi announcing they would not "we cannot support any healthcare reform proposal unless it explicitly excludes abortion from the scope of any government-defined or subsidized health insurance plan," making it clear that the high-minded effort to keep a fight over abortion out of healthcare reform hadn't worked. Stupak's demand meant changing the status quo on abortion and indeed his amendment would ultimately result in many women losing abortion coverage they already have. It would also likely erode abortion coverage throughout the entire insurance industry, public and private, according to a a report from the George Washington University School of Public Health .
In July, prochoice California Democrat Lois Capps crafted a levelheaded compromise attempting to neutralize the issue. Since the Hyde Amendment already prohibits using federal funds to pay for abortion in almost all cases, Capps clarified that health reform wouldn't affect the status quo. Her amendment proposed that insurance plans offering abortion coverage keep public and private funds separate, and use only the private funds to pay for abortions.
Though prochoice and women's groups didn't like the Capps amendment, they, once again chose to be cooperative and agreed to the compromise. "We didn't want to beat up on Capps, because she was trying," says Judy Waxman, the vice president of health and reproductive rights at the National Women's Law Center. Yet, refraining from pummeling is different from truly supporting, and the prochoice approach to Capps, which amounted to something in between, may have been a strategic misstep. Because prochoice advocates didn't vocally criticize Capps, it may have seemed they were in a position to make further concessions. "It would have been perfect if an antichoice member had authored" Capps, notes Laura Hessburg, senior health policy advisor at the National Partnership for Women and Families. Then, perhaps, the public might have seen it as the compromise it was.
But nor did prochoice groups really get behind the supposed solution to their problems. "What was I supposed to say to an antichoice [Congressperson's] office if I don't really support Capps?" asks Hessburg. "We couldn't do our normal all-out effort. It's hard to be for something we're not really for."
Women's health advocates similarly held their fire about the failure to include birth control and other women's health services in the package of basic benefits that must be fully covered by insurers. Their reticence on that front has apparently backfired , too, since the Senate bill did not include an amendment authored by Barbara Mikulski that addressed the omission.
Clearly, part of the reason for such restraint was women's groups' interest in keeping their recently acquired seat at the negotiating table. For years, Republican-dominated politics had kept them marginalized. Yet, when the Democrats began to gain power in Congress in 2004, it was partly because the party, seeking Congressional seats in historically Republican districts, agreed to support antiabortion candidates--a decision made over the objections of mostly female prochoice Democrats.
"It was as though women, while we turned out the vote, were useless," says Frances Kissling, a visiting fellow at the Center for Bioethics and the former president of Catholics for Choice. As Kissling sees it, health reform was a chance for women to once again have a say and prove themselves as political players--which, paradoxically, meant limiting their demands. "There was this enormous feeling that if health care failed because of abortion, on our side, we would be blamed," says Kissling. "And then we would never get out of the hole of not being important."
But if being reasonable let women keep a seat at the table, the cost of that seat was soon apparent. By the time Saturday night was upon them, the Catholic bishops were already in a position to control the debate. Though only ten  House members who supported health reform were wedded to the antiabortion language, this particular handful, who had been unyielding, wound up in control. Escalating threats from Church had positioned them to put their feet down at the last minute--and they did.
The political tactics that achieved this unlikely feat were, in contrast to those of women's groups, decidedly not reasonable. The United State Conference of Catholic Bishops were clear they would oppose the entire bill--services for little children, the elderly and all--if the Stupak amendment didn't go for a vote. They even littered church pews with memos urging parishioners to call Washington and distributed talking points to be thrown into Sunday sermons. The USCCB's statement was clear that the bishops wouldn't let anyone stand in their way--even their own people. ("If your Arch/bishop is not in agreement with disseminating the bulletin insert, you will be hearing from his office immediately," threatened an e-mail blast.)
Women's groups stayed away from such gamesmanship, choosing not to oppose, or even threaten to oppose, the reform bill because it promised other important steps forward, including a chance for so many low-income women to get coverage, and a prohibition on charging women more simply because they're women. "There is so much in the health reform bill that's good for women," says Lois Uttley of Raising Women's Voices, adding that women's groups were only "part of a coalition that wanted to get health reform passed."
To some, this was a matter of integrity. "We're not the bishops. This is not the 1960s, this isn't a time where we're going to become people like that, who really don't care about anything else," says the National Women's Law Center's Waxman. "Our agenda includes the poor and educational opportunities."
Should women pretend to be willing to oppose health reform, even if, in their hearts, they are not? "I don't want to get down in the gutter with our opponents," says Laura MacCleery of the Center for Reproductive Rights. Though, of course, the bishops emerged from that gutter with a big victory. (Perhaps this is what emboldened them to threaten to stop providing social services in the District of Columbia if the city didn't back away from marriage equality legislation.)
Perhaps being more vocal about what they really wanted, more aggressive in their politics, would have given women more room to maneuver with the House bill and averted the last-minute debacle. On the other hand, they might have lost their position from which to negotiate altogether. It's impossible to know. Whatever the answer, prochoice groups clearly must rock the boat this time around.
To their credit, NARAL and Planned Parenthood are have already shown their willingness to do what's necessary to win this next round. They have threatened to withhold funding from Ciro Rodriguez and Harry Teague, the two members of Congress who got money from the groups in the last election cycle and proceeded to vote for Stupak anyway. And Planned Parenthood has announced its intentions to pull its support from any reform bill that includes Stupak.
There's more hardball to be played. These groups, along with the prochoice PAC EMILY's List, could announce that they'll "score" a vote for a healthcare bill that contains abortion restrictions like the Stupak amendment as an antichoice vote, for instance. That's important because these lobbying organizations use their scores to determine which legislators gets their money--and how much. (Planned Parenthood and NARAL have not yet decided how to score votes on health reform bills that contain antiabortion provisions, though NARAL's policy director, Donna Crane said, "That's a very serious question being discussed in our organization." EMILY's List has not returned calls.)
To win, prochoice groups have to use all the money and political power they can harness to get what they want. It won't be pretty. And this time, if further restrictions on abortion funding make it into law, prochoice groups will have given it their all.