We kicked off our blog last week with a few thoughts about contraception. As we all know, the Catholic Church and some other religious institutions oppose it. That’s fine; we have religious freedom in this country. People don’t have to agree on everything. But the Government decided that, notwithstanding any contrary beliefs, religious institutions had to pay for contraception if they had employees. That is, they had to offer contraception as a part of any health insurance they provided to their workforce. Why? Because it was necessary; the greater good required it.
This led to a firestorm, with lots of politics, headlines and acrimony. And the apparent damage was so bad that the President intervened near the end of the week with a compromise. He said that “if a woman’s employer is a charity or a hospital that has a religious objection to providing contraceptive services as part of their health plan, the insurance company” will bear the cost. Not the religious institution. Issue resolved.
Maybe yes, maybe no. Our thought at the time was that, even though the President intervened, the political repercussions would echo on for a while. And so they have. People are still talking about religious liberty, and the Administration’s attitude toward it. This week a Washington Post columnist called the whole affair an “epic blunder.” Not to be outdone, the Wall Street Journal followed with a legal analysis of the protections religious institutions have in this country. And, of course, the Congress is taking an interest in the whole affair.
For my own part, I was confused when contraception popped up as a major political issue. How did this get to be such a big deal? Well, because our Constitution guarantees that the Government will not inhibit the free exercise of religion. So didn’t the Administration know that there would be objections? Why weren’t they resolved sooner?
I’m not so much interested in the Constitutional issues – other people are handling them quite well, thank you – but in the decision-making process. What was the public told, how did they respond, and how did the Administration deal with conflicts?
These are relevant questions because the Obama people did manage to touch off a firestorm. To proceed, however, we had to first identify and analyze the key administration paperwork. Larry had some free time, so he volunteered to spearhead the effort.
He called me yesterday, and said he had read all of the stuff he could find, and had drawn some preliminary conclusions. He worried that, so far, his work product is incomplete; but frankly at this point I’ll take anything I can get. Time's flying, and we all have other projects.
“So, take it away, Larry. How did the Administration manage to get itself into this fix?”
“You’re asking a philosophical question, G. I don’t think I’m equipped to answer it. Why don’t I just tell you what happened, so we can move on from there?”
“Fine, it’s always wise to start with the facts. We’ll speculate later. But let’s keep the fact part short, if we can.”
“OK, here’s the short version. On August 3 of last year the Administration published an interim final rule to cover ‘preventive services’ to women under the Patient Protection and Affordable Care Act.”
“That’s the statute that Republicans today call ‘Obama-Care,’ right?
“Yes.”
“And what does the rule say about ‘preventive services’?”
“Let’s back up for a minute. The law contemplates that medical coverage under it will be provided through private insurance, self-insurance, or possibly under some other state or federal plan. This rule dealt with some of the minimum requirements that insured and self-insured group health plans had to meet and, more specifically, with the minimum coverage they had to provide to women.”
“Fine. But you didn’t answer my question. Obviously women are entitled to preventive health care services. What kind of services are we talking about?”
“The ‘interim final’ rule didn’t say. It simply referred to ‘preventive care and screenings provided for in binding comprehensive health plan coverage guidelines’ issued by another group, the Health Resources and Services Administration. Whatever HRSA identified, had to be provided. We’ll get into that later.
Anyway, the rule also said that it superseded state rules that contradicted it, except that if state provisions ‘impose[d] requirements on health insurance issuers that are stricter than the requirements’ of the federal rule, they could continue.”
“So let’s see if I understand you so far. If an employer has a group health plan, derived from private insurance or self-insurance, the plan must offer preventive health care services to women. But the ‘interim final’ rule didn’t define the nature and extent of those services.”
“Right. That’s what I said.”
“OK, what happened next?”
“There was a furor. The ‘Interim Final Rule’ appeared in the Federal Register on August 3, 2011, and allowed public comments up to September 30 of that year. By one report, over 200 thousand were received. I haven’t looked at most of them, but apparently lots were negative.
If we want to understand the objections, we have to look at what the opposition had to say. I think the position of the U.S. Conference of Catholic Bishops is instructive in this regard, and they are very much on the record in the matter. They issued a statement on August 31 calling for rescission of the rule. But more importantly for our purposes, on that same date the Bishops’ General Counsel filed detailed comments with HHS.
The comments are quite informative. Basically, the General Counsel argued that (1) prescriptions, contraceptives, … and related patient education, etc. are not ‘health services,’ because they do not prevent an illness or disease; pregnancy is not a ‘disease;’ and (2) the ‘religious exemption’ provided in the rule was too narrow, because it covered only a small subset of faith-based institutions.”
“Larry, you’ve already said that the rule is silent on the nature of the preventive services that will be required. How can the Catholic Bishops, or anybody for that matter, say that it requires contraceptives?”
“Good question. The actual rule simply changes an existing section of the Code of Federal Regulations. The change spoke only of ‘preventive care and screenings,’ not contraception. The actual guidelines for women’s health care are being developed by the HRSA. They’re not stated in the rule.
The supplementary information that came with the rule, however, discussed contraception. It said that, in a prior round of comments, many commenters recommended:
HRSA Guidelines include contraceptive services for all women and that this requirement be binding on all group health plans and health insurance issuers with no religious exemption.
So the explanation pretty much hinted that HRSA would recommend contraception at some point. And once contraception was included in the list, the employer – religious or secular – would have to pay for it.”
“So, you’re saying that the Bishops objected to contraception because they saw it coming down the road, even though it hadn’t arrived yet. Yes?”
“Yes, sort of. I’m not sure what guidelines had come out from HRSA at the time the Bishops made their comments. In fact, I haven’t seen any of the guidelines. Apparently they aren’t a part of any formal rulemaking. But clearly the Bishops expected that at some point HRSA would include contraception as a required service.”
“All right, let’s move on to the Bishops’ second objection, that the so-called ‘religious exemption’ is too narrow. How did that come about?”
“Well, according to the supplementary information, HHS felt that it was appropriate to make an accommodation to exempt some religious organizations from the need to provide contraceptive services. Specifically, they said that they intended to respect ‘the unique relationship between a house of worship and its employees in ministerial positions.’”
“This part of the ‘interim final’ rule specifically mentioned contraceptive services? Although they weren't at the moment required?”
“Yes. And it applied only to HRSA. It said that (a) if HRSA guidelines require contraceptive services, (b) HRSA may exempt some religious employers from that requirement.”
“So, I guess the Bishops were right; HHS did expect the HRSA to mandate contraception at some point or another. Otherwise why provide for an exemption? Did the Bishops say ‘thank you’ for the exemption?”
“Not likely. They said that the exemption was far too narrow. It exempts only ‘religious employers’ who, by definition, are those who (a) intend to inculcate religious values, (b) ‘primarily’ employ only people who share the same religious tenets, and (c) primarily serve only persons who share the same religious tenets.
According to the Bishops, this provided ‘no protection at all for individuals or insurers with moral objections to contraceptives … who will experience burdens to conscience under this new mandate.’ By definition they are not ‘religious employers.’
Moreover, the definition of ‘religious employer’ was so narrow that it also excluded many of the charitable activities of religious organizations, such as running hospitals, group homes, soup kitchens and the like. Typically those services are offered to anyone who needs them; the poor are not excluded based on their religion.”
“All right, Larry, I see the issues. If a church decides to offer services to the poor, without restricting the services to people within their own religious group, the church also will have to provide contraceptive services to their employees, whether the church wants to or not. That does seem a bit strange. What happened next?”
“For several months, not very much happened. Comments were submitted, the deadline to submit more comments passed, and for a time HHS took no apparent action. But the pot began to boil again in late 2011.
In early December some in the media reported that HHS intended to require health plans to cover ‘contraception, sterilization and drugs known to induce abortion.’ Other sources indicated that the Secretary of HHS had decided to declare contraception a ‘preventative service’ under Obama-Care, and require providers to cover 100% of the cost.
As we all know, this started a political firestorm. Major candidates for the Republican Presidential nomination denounced HHS, and that agency defended itself. Interestingly, it didn’t say that ‘no decision had been made.’ Instead, the HHS Secretary argued that ‘virtually all American women used contraception at some point in their lives,’ and ‘the public health case for making sure insurance covers contraception is clear.’ So basically HHS admitted that it would add contraception to the list of things required under the health care law.
In the midst of the controversy, and after conferences at the White House, the Administration modified the HHS approach. President Obama said:
…if a woman’s employer is a charity or a hospital that has a religious objection to providing contraceptive services as part of their health plan, the insurance company – not the hospital, not the charity – will be required to reach out and offer the woman contraceptive care free of charge without co-pays and without hassle.
So there you have it. The Administration developed a compromise that it thought should satisfy all parties, but, by the way, didn’t consult the Catholic bishops while doing it.”
“Good summary, Larry; I assume that the compromise will be included in the final rule that HHS intends to issue someday. You know, pursuant to the rule making it started back on August 3, 2011?”
“Not really,” He said. “HHS issued its final rule on February 15. The final rule is the same as the one proposed on August 3, 2011; no changes were made to it.”
“No changes? Not even to the religious exemption? After all this controversy and a Presidential compromise? You know, one of the advantages of writing rules is that, if you have one, both the Government and the public know where they stand. If not in the rule that started all of this, just where will the President’s compromise be written down?”
“I don’t know, G. Perhaps HHS staff don’t want to formalize the compromise in a rule because they’re hoping that, it time, the public will forget about it. Then staff will be free to do whatever they think they need to do.”
“Good speculation, Larry. The President can’t control his bureaucracy. Not an unusual state of affairs for Presidents. I think we’ll close on that note. Perhaps next time I can come up with a less confusing topic.
By the way, Elemental Zoo will be on vacation next week, so our next post probably will be in early March.”