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Religious Institutions Matter. So Do Their Employees.

If you think the controversy over birth control and health insurance is simple, you probably haven't spent enough time hearing out the other side. I happen to support the administration's decision to make contraception coverage mandatory, limiting the rule's "conscience" exemption to churches and institutions that primarily employ co-religionists. But I also think the critics make some valid points.

Chief among them: Freedom of religion means the freedom to observe the tenets of one's faith. Even some administration allies, like Sister Carol Keehan of the Catholic Health Association, believe this new rule would force leaders of some larger religious-based institutions to violate their consciences. To dismiss that concern out of hand would be wrong. 

So why don't I find that view persuasive? As I suggested the other day, a key issue is the nature of health insurance – in particular, whether it belongs to the employer or the employee. Proponents of making contraceptive coverage universal tend to take the latter view. Here, for example, is Adam Sonfield, a senior policy associate at the Guttmacher Institute, writing for the American Medical Association’s Virtual Mentor:  

It is difficult to see why an employer has any more right to veto an employee’s use of her health benefits than it does to veto her use of her salary, sick leave, or other aspects of her compensation for the same contraceptive services.   

I agree with that. The checks to your insurance plan may have the name of a religious institution on them. But, as a matter of economics and of principle, the money is (or should be) yours. The only reason employers are in the middle of health insurance is that companies started offering coverage in the 1930s and, somewhat inadvertently, became the primary source of coverage for working Americans. It’s not as if somebody made the conscious decision to give your boss a vote on what medical services you get. 

The Affordable Care Act will alter those arrangements, but in ways that strengthen the case for the administration’s position.  The whole point of health care reform is to establish a minimum level of health insurance for every American. Basically, we’re turning health insurance into a right rather than a privilege – i.e., something to which we are entitled as citizens, rather than as employees. Most working-age Americans will continue to get coverage through employers, largely out of convenience: Lawmakers found it easier, practically and politically, to leave existing arrangements in place. But employer leeway to shape those benefits will, by design, diminish.

I respect those who disagree—whether it's those who think employee benefits morally implicate employers or those who wonder whether birth control even belongs in health insurance. And although many large Catholic institutions already provide birth control coverage, without evident difficulty, I understand that the leaders of other institutions may feel differently. But I wish the less nuanced critics of the administration’s policy (yes, Speaker Boehner, I'm looking at you) would show a similarly open mind, by acknowledging that improving access to contraception is a goal many of us believe is important. 

The issue isn't simply that most of us cherish the ability to decide when we have children and when we don't. It's that also that family planning has very real medical, economic, and social benefits, as the non-partisan Institute of Medicine noted when it first recommended making contraception coverage mandatory. Women with unplanned pregnancies are less likely to get proper prenatal care and, as a result, their children are more likely to have health problems. Married couples with unplanned pregnancies are more likely to get divorced. The children that come from unplanned pregnancies are more likely to suffer physical abuse. 

Is society’s interest in improving those odds legitimate? I think so. Does that interest outweigh the interest in respecting the beliefs of religious institutions? That’s the more complicated question—and why a compromise that accomplished both goals would be ideal. The administration has signaled a willingness to find that middle ground, as have allies like Sister Carol. (The Conference of Catholic Bishops, alas, are another story.) But the policy mechanics of such a compromise might be difficult. 

The obvious option is Hawaii's system, variants of which exist in Missouri, New York, and West Virginia. As I understand it, those states require that health insurance include contraception, but allow religious institutions to opt out, as long as those institutions inform employees about where they can find outside contraceptive coverage. I haven’t seen much reporting or research on how well those systems work. Hopefully we’ll get some in the next few days.

But grafting such a compromise onto our nation's new universal health care system would require, at the very least, some extremely original thinking. By declaring that contraception was part of preventative care, the Obama Administration wasn’t merely saying that all insurance policies must cover it. It was saying that all insurance policies must cover it free of charge. Although an arrangement like Hawaii's might be able to accomplish that goal, it would have to make sure that people had not just access to contraception coverage but the ability to pay for it. Sonfield’s article offers some useful guidelines, but the legal complications of such an effort would be considerable. 

This cost issue is no small matter. I assume that some people hear about this controversy and shrug, because they imagine it’s about a single twenty-something too cheap to pay for condoms. To some extent, it is. But the debate is also about a low-income worker at a large institution that happens to be religious—say, a janitor or clerk at Catholic hospital or university—who is trying to support a family on less than $30,000 of household income. If this person wants contraception through an implant or pills, which are the most reliable methods of birth control, the cost may be prohibitive—easily into the hundreds of dollars a year and even into four figures. 

Religious institutions matter, yes, but so do the people who work for them. It's about time this debate focused on both.

Update: Amy Sulivan has a characteristically smart critique of the administration and its decision, pointing out, among other things, that Sister Carol played a pivotal role in enactment of the Affordable Care Act.

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