New Contraceptives Mandate Announcement: Imperfect Proposals
On Friday, Feb. 1, the federal government released another iteration of its attempt to respond to the religious freedom and conscience concerns raised by the health reform law’s requirement that health plans must include a wide range of free preventive women’s health services, including contraceptives, sterilization, and emergency contraceptives that many consider to be abortifacients. Some have celebrated the proposals as resolving the long-standing religious freedom concerns, but there is little that is new and every reason to expect that protests and lawsuits will continue.
The administration rightly decided in August, 2011, when it specified that the mandatory free coverage must include “all FDA-approved contraceptives services,” that religious freedom protections were required. But its series of efforts to provide such protection have evoked multiple protests and a large and growing number of lawsuits from religious organizations and businesses operated by religious owners.
Federal Register (scheduled for Feb. 6), the administration will receive comments for 60 days before revising, promulgating, or possibly withdrawing the rules it has proposed here. (Comments are due by April 5.) Moreover, in the case of organizations that self-insure, the administration still is only “considering alternative approaches”–soliciting comments on several possibilities, after which, presumably, it will publish an actual “proposed rule,” solicit public comments, and then–finally–adopt actual new regulations. So no regulation has yet been changed.
But some different ideas have been proposed. Here are the main changes proposed or suggested:
1. Proposed revised definition of exempt religious employer.
The current definition of exempt religious employer specifies that the organization must meet all four of these criteria: (1) has as its purpose the “inculcation of religious values”; (2) primarily employs co-religionists; (3) primarily serves co-religionists; (4) falls within Internal Revenue Code sections that refer to nonprofit organizations that are churches, their integrated auxiliaries, conventions or associations of churches, and the “exclusively religious activities of any religious order.”
The administration is proposing to drop all but criterion 4. Thus, for example, a church that operates a soup kitchen that serves the general public will not for that reason be excluded from the exemption. The administration says it is not intending to expand the exemption beyond houses of worship and their programs, but only to clarify that a church is not disqualified from the exemption by providing “benevolent services” to the community.
Still, some significant number of church-related schools likely fit the IRS classification of being an “integrated auxiliary” of a church. Under the existing definition, they are probably not exempt (because their primary purpose is not “inculcating religious” and they may serve some children and families not of the same church or denomination). If the definition is revised as proposed, then they will be exempt.
The newly proposed definition is this: (1) the organization is opposed for religious reasons to providing some or all of the contraceptive services; (2) it is organized and operated as a nonprofit; (3) it holds itself out as a religious organization; (4) it self-certifies that it fulfills criteria 1-3.
What is positive: The organization need object only to some of the contraceptives, e.g., the abortifacients, without rejecting all contraceptive coverage; it need only “hold itself out” as a religious organization, rather than matching some detailed government list of approved religious characteristics; and it self-certifies that it is entitled to the accommodation, rather than being subject to some official’s probing.
What is negative: The government goes out of its way to exclude all businesses. It claims that the religious accommodations in other federal laws do not cover for-profit organizations, and in court has argued against Hobby Lobby and other businesses operated by religious owners that for-profit organizations by definition do not exercise religion and cannot be accorded religious freedom protections. In considering requests by businesses for preliminary injunctions against the mandate, however, in 11 of the 14 cases so far ruled on, the courts have granted relief to the religious business owners. And it is striking that the just-released proposed rules specify that it is “for-profit secular employers” that are excluded-an admission that there might actually be “for-profit [non-secular] employers”?
Also negative: Fitting into the proposed definition only makes an organization eligible for the accommodation, not for an actual exemption-which remains open only to houses of worship.
3. Proposed details on the accommodation-insured plans. Here’s the proposed deal: the religious organization that has a religious objection to covering some or all contraceptive services in the health insurance it offers to its employees can buy a policy from its insurer that excludes those contraceptives. It must give the insurer the self-certification document that proves that it has the right to exclude the contraceptives. In turn, the insurer must “automatically” give (not offer) to each of the employees a policy that provides, without charge to the employees or the employer, exactly the contraceptive services to which the employer has a religious objection (more on the “free” contraceptives below). And the insurer must give notice of this special contraceptives coverage to the employees at the same time, if possible, that they learn the details of the employer’s health plan for them. The notice will say that the contraceptives coverage is separate from the employer’s health plan and that it is not connected “in any way” to that plan. And yet it is precisely because these employees work for a religious employer that objects to including the contraceptives coverage that those same employees will get exactly that same contraceptives coverage in this alternative way.
“Free” coverage? The government insists again that an insurer can provide the contraceptives at no net cost to itself, and thus need not charge either the employer or any employee-therefore the employer should not consider itself complicit in the contraceptives coverage offered by the insurer to the employees. How? “Actuaries, economists, and insurers estimate that providing contraceptive coverage is at least cost neutral, and may result in cost-savings when taking into account all costs and benefits for the insurer.” Birth control now, fewer costly pregnancies, problem pregnancies, and unhealthy newborns later. Maybe. Yet the proposed rules claim the same neutrality or savings when the insurer is providing student health insurance–a short-term arrangement giving little opportunity for long-run cost-savings–and when there is more than one insurer, one of which only covers pharmaceutical drugs–and this is the insurer presumably that will have to provide the free contraceptives coverage.
The administration, at least, does think its proposed new arrangement relieves the objecting religious organization of some liability for the contraceptives coverage: once such an organization has delivered its self-certification to the insurer, then the legal liability for making sure that the employees get contraceptive coverage falls on the insurer and not on the religious organization. Still, it is those employees of that organization that get precisely the contraceptives coverage that the organization believes it ought not to provide to its employees.
4. More questions on the accommodation-self-insured plans. Many religious organizations self-insure rather than buying health insurance–in some cases exactly so that they could escape from a contraceptives mandate imposed under a state law. Such organizatons are both the insured and the insurer. There is no insurance company out there that can be required by the federal government to give allegedly free contraceptives to the employees after the organization has decided on religious grounds that it would be wrong to give contraceptives to the employees.
Last March’s ANPRM sketched out several scenarios about just which organization would be responsible for supplying the contraceptives coverage and how it would be paid for. Friday’s “proposed rules” only elaborated the scenarios, giving more detail on how this method or that method might work, and seeking comments on the various ideas.
In other words, almost a year after the ANPRM there still is no actual proposed rule for the “accommodation” for religious nonprofits that self-insure.
In short: imperfect proposals. Various commentators have celebrated last Friday’s announcement as just the solution to the conundrum created by the administration and the health law: promising that non-church religious organizations can refuse to have contraceptives coverage in the health insurance they buy for their employees while ensuring that those employees, because they are employees of that organization–with health insurance that does not cover contraceptives–will get just the contraceptives that the employer plan has purposefully and for religious reasons excluded.
But many religious organizations and persons of faith are not celebrating. It still is the case that only houses of worship are exempt from the mandate. Faith-based service organizations are promised only an “accommodation.” That accommodation, while purportedly allowing organizations to exclude from the health insurance they offer their employees contraceptives coverage to which they object will result in the employees being given the same contraceptives coverage, just in another way.
Moreover, for-profit companies, no matter how religious their aims and activities (a religious broadcaster, publisher, bookstore, retirement home, camp), no matter the desire and policy of their owners to operate in accordance with the tenets of their religion-they receive no religious freedom protection whatsoever.
Nor is any protection offered to secular nonprofit organizations, for example, a non-religious crisis pregnancy center that for moral reasons, based on religious or secular sources, works to persuade pregnant women not to abort an unborn child. If the center offers health insurance, that health insurance will have to directly provide coverage of abortifacients!
And individuals with a deep objection to contraceptives or to abortifacient drugs? Unless they are employed by a house of worship, they will not be able to avoid health insurance coverage that includes contraceptive drugs and services. If their employer does not include these items in its health insurance, then its insurance company, or, if it self-insures, a third-party administrator, will give them the coverage they object to. If, to escape these dilemmas their employer drops health insurance entirely (becoming subject to hefty fines in 2014 unless it is a small employer), then the individual will have to buy individual insurance that will include the contraceptives coverage.
The proposed rules announced last Friday include some genuine advances. But there is no magic. It still is not possible for the religious objections of employers to contraceptive coverage in their health insurance to be adequately respected while at the same time having some other entity automatically give that contraceptive coverage to the employees, just by another path.