A Matter of Perspective

When I was first married, my mother-in-law sat down at her kitchen table and told me about the day she went to confession and told the priest that she and her husband were using birth control. She had several young children, times were difficult – really, she could have produced a list of reasons longer than your arm.

“You’re no better than a whore on the street,” said the priest.

This was . . . a long time ago. It’s just an explanation of why the bishops are not the only Roman Catholics who are touchy about the issue of contraception. – Gail Collins, The New York Times (“Tales From the Kitchen Table”).

There is nothing like a culture war to get people’s juices flowing. Some of the rhetoric coming from the Republican presidential candidates this past week has been, to say the least, over the top. Newt Gingrich accused President Obama of waging a war on religion. Mitt Romney said the President was trying to “impose a secular vision on Americans who believe that they should not have their religious freedom taken away.” Rick Santorum, who is personally opposed to contraception, suggested that Obama was a step away from bringing the guillotine to America.

Relax guys. There is no war on religion. There will be no guillotines. There is no attack on the Catholic Church, or any church. President Obama is not anti-religion. As I have pointed out before on these pages (“The President on Prayer, Humility, and the Search for Wisdom” and “The Role of Faith in the Public Square”), Obama is a committed Christian who possesses a compassionate and refreshing Christian orientation that is far more Christian than anything I hear coming from the mouths of Gingrich and Santorum. Although the Republicans won’t pass up any chance to shout inflammatory rhetoric and accuse Obama of trampling on the rights of believing Christians, I am quite certain that Jesus of Nazareth would be far more comfortable with the President’s brand of religion than with the hypocritical Newt or repressive Rick.

Somehow lost in most of the discussions and finger pointing this past week are the facts. The HHS regulation at issue simply requires that preventive health care services, which must be covered by employer health insurance policies without co-pays under the Affordable Care Act, include contraception. It does not require anyone to use birth control. It specifically exempts churches and any religious employer that primarily hires and serves its own faithful. Although it applies to religiously affiliated hospitals and universities that serve the public and engage in interstate commerce, no Catholic hospital must itself provide contraception or family planning services to their employees or patients. They simply cannot opt out of insurance policies that cover the cost of birth control to their employees, but must in fact offer the minimum level of insurance coverage for preventive health services as do all other employers under the Affordable Care Act.

Much overlooked is the fact that Catholic hospitals have complied with similar rules concerning contraception coverage already in place in 28 states. It has been the law in New York state for the past ten years. Fordham University, a Jesuit college in the Bronx, has a health plan for its employees and students that cover contraception, though it does not distribute birth control at its student health center. Manhattan College, founded in 1853 by the De LaSalle Christian brothers, a Catholic religious order, carries an insurance policy that covers birth control prescriptions. Many other Catholic health care systems and universities provide similar coverage to their employees. Somehow, none of these state requirements have inflicted the slightest blow to the teachings of the Roman Catholic Church.

As Linda Greenhouse of The New York Times noted, the 629-hospital Catholic health care system, which employs 765,000 people, constitutes 14 percent of the entire U.S. health care industry and serves one out of every six patients. Of the top ten revenue producing hospitals in the United States in 2010, four were Catholic. Catholic Health Initiatives, for example, in Denver, Colorado, operates 78 hospitals in 20 states and has revenues of $8.2 billion a year. Catholic Healthcare West in San Francisco is the fifth largest hospital system in the United States, with over $11 billion in assets. Ascension Hospital in St. Louis, Missouri, runs 67 acute health care centers in 20 states and the District of Columbia. As Greenhouse writes, “These institutions, as well as Catholic universities – not seminaries, but colleges and universities whose doors are open to all – are full participants in the public square, receiving a steady stream of federal dollars. They assert – indeed, have earned – the right to the same benefits that flow to their secular peers. What they now claim is a right to special treatment” as a result of religious doctrine.

These hospitals and schools hire hundreds of thousands of Catholic and non-Catholic employees alike – nurses, doctors, teachers, administrators, secretaries, and janitors – all of whom are entitled under the Affordable Care Act to preventive health services, including contraception, without having to pay costly co-pays. So, what is all the fuss about? Is it a violation of religious freedom to require Catholic hospitals and universities to provide their employees with insurance policies that cover contraception?

Under the Constitution, the Catholic Church has the absolute right to preach that birth control is immoral. While I believe the Catholic Church’s position on contraception is archaic, inhumane, and has contributed historically to human suffering and poverty, particularly in poorer countries where the doctrine is more likely to be followed, I respect the right of the Church to preach its version of the Truth. But when an institution engages in commercial and secular activities, its mere affiliation with the Catholic church, or any other religious group, does not give it the right to exemptions from laws and regulations that apply to everyone else. Nor does a religious affiliation entitle a hospital or university from depriving its employees of their rights under the law as citizens.

A religious body that does not like a public policy that affects its members is free to advocate and work to change such policies. But it cannot claim a special exemption from the law. In the case of Catholics and contraception, how principled is the opposition? I cannot help but think a large part of what is going on is political spin and a loss of perspective. Yes, the Catholic Church officially teaches that contraception is a sin, but 98% of American Catholics have at one time or another violated that teaching. So, is it really a matter of conscience? Would these same voices support the right of a school run by Christian Scientists to deprive its teachers and janitors of a health care plan because they do not believe in medications, surgery, or medical intervention, and instead believe only in prayer as a way to heal? If a church is opposed to blood transfusions, are they entitled to remove this procedure from its university health plans for the employees who clean the labs and mow the campus lawn? If we were talking about a sincere religious prescription against antibiotics instead of contraception, would the same people arguing over the Affordable Care Act be coming to the defense of these religious institutions? I think not.

The Catholic Church does a lot of great work in this country, and throughout the world, in providing social services, health care, and aid to the poor, all consistent with its view of the Gospels, to care for all of God’s children. I disagree with the Catholic Church’s rigid position on abortion, but I have always respected its pro-life consistency in opposing abortion and capital punishment alike and advocating economic justice for children and the poor; they don’t abandon the children after they are born, but advocate for governmental aid for poor children, and work to assist poor families through the many good works of Catholic Charities and other church-based organizations. Complying with the Affordable Care Act and the HHS regulation, which as modified by the President later this week is endorsed by the Catholic Health Association and Catholic Charities, violates no one’s religious freedom.

Irrespective of the religious freedom issue, underlying much of the opposition from the right is a deep-seated hostility to the concept of birth control as preventive health care, as well as a belief that the government simply has no business in ensuring that American citizens have a right to basic health care services. Is contraception a legitimate health care issue? What business does the government have in making contraception affordable and accessible?

There are many compelling reasons why contraceptive services are properly included under the definition of preventive care, and it is, frankly, a shame and a disgrace that the Catholic Church, the Republican presidential candidates, and many Evangelical Christians who, while not agreeing with the Catholic Church on birth control, nevertheless see an opportunity to accuse Obama of being anti-religion, fail to acknowledge the positive impact contraception has had on the health of women. It is a matter supported by countless studies and painstaking research. For example, according to a January 2011 report submitted by the Guttmacher Institute to the Institute of Medicine, the health arm of the National Academy of Sciences, contraception is a crucial component of preventive health services for women, helping to avoid unintended pregnancies, reduce abortions, improve birth spacing, and increase the overall health of women and children. A national study in 2006, for example, found that nine million clients receiving publicly funded contraceptive services resulted in 1.94 million fewer unintended pregnancies and 810,000 fewer abortions. A 2007 study in California showed that publicly funded family planning services resulted in 287,000 fewer unintended pregnancies, including 79,000 to teenagers, and 118,200 fewer abortions.

The positive health benefits of contraceptive services extend well beyond merely preventing unintended pregnancies. Short birth intervals between pregnancies, which occur when contraception is not easily accessible or affordable, often lead to lower birth weights, preterm births, and small size for gestational age. Women who become pregnant without planning are less likely to recognize a pregnancy within the first six weeks or so, resulting in fewer prenatal care visits to doctors and more damaging behavior (alcohol and tobacco consumption, poor nutrition) during the early stages of pregnancy. Oral contraceptives have been shown to help women reduce the risk of developing endometrial and ovarian cancer and to provide short-term protection against colorectal cancer. Condom use among males prevents sexually transmitted diseases, including HIV, and may also reduce the risk of cervical cancer for women.

According to the Centers for Disease Control and Prevention (CDC), the development of and improved access to contraception are among the 10 great public health achievements of the 20th century, along with the development of smallpox and polio vaccines and public health campaigns to reduce tobacco use. Access to contraception has “contributed to the better health of infants, children, and women, and have improved the social and economic role of women.” Indeed, the use and coverage of contraceptive services as part of preventive health care services has been recommended by the American Medical Association, the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, and the Society for Adolescent Health and Medicine.

Then why the need to provide contraception coverage free of costly co-pays? Because the costs associated with contraceptive use, while minimal for more affluent members of society, can be considerable for those of lesser means. Average costs for contraception, particularly women using the pill, and other devices, can exceed $100 a month. A 2010 study found that the out-of-pocket expenditures for a full year’s worth of birth control pills amounted to 29% of the average woman’s annual out-of-pocket expenditures for all health services.

Moreover, when it comes to reducing the overall costs to society of health care expenditures, contraceptive services are extremely cost effective. According to the Guttmacher Institute, every dollar invested by the government for contraception saves $3.74 in Medicaid expenditures for pregnancy-related care related to births from unintended pregnancies. This is a huge savings. In 2008 alone, the services provided at publicly funded family planning clinics saved over $5 billion in health care expenditures. Savings to health insurance companies and employer provided health insurance plans are equally dramatic.

None of this, of course, matters to those on the right who oppose the President on every action he takes, every policy he pronounces. When they see an opportunity to claim that “Obama is out to get your momma,” then by God, they are going to play that card. After the outcry from the Roman Catholic bishops and others, including Democratic allies in the Catholic community, the President revised the rule on birth control coverage so that religiously-affiliated hospitals and universities could shift the cost of contraception coverage to their insurance companies. Some on the left have criticized the President for caving to tyrannical bishops and right-wing zealots; many on the right are just as unhappy with the compromise as with the original regulation. So be it. Unlike his political opponents, Obama has proven once again that he is serious about governing, not political pandering; that he is willing to accommodate the concerns expressed by Catholic institutions while assuring universal access to contraceptive services.

There is no war on religion. The First Amendment remains an enduring and essential element of our constitutional democracy. The Catholic Church can continue to preach against contraception and its hospitals and universities will not be forced to provide contraception services. But the people who work for those institutions, and all other Americans, are entitled to an essential component of health care reform that is good for women’s health, reduces unintended pregnancies and abortions, and enhances the lives and health of millions of Americans. The only remaining question for conservatives is to what are you really opposed? Any principled “religious freedom” argument is gone. So, is it contraception you oppose? Affordable contraception? Access to affordable contraception? Expanded access to preventive health care services for all Americans? The rights of women? Or are you just cynically and politically motivated to oppose the President’s every move? What kind of religion is that?