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?

American Exceptionalism vs. the Myth of National Superiority

America has carried on not simply because of the skill or vision of those in high office, but because We the People have remained faithful to the ideals of our forbearers, and true to our founding documents. . . . The time has come to reaffirm our enduring spirit; to choose our better history; to carry forward that precious gift, that noble idea, passed on from generation to generation: the God-given promise that all are equal, all are free, and all deserve a chance to pursue their full measure of happiness.

--President Barack Obama, January 20, 2009.

Ever since our founding, Americans have believed that the United States plays a special and unique role in the world. 234 years into this grand experiment, most Americans continue to espouse some notion of American exceptionalism – the belief that the United States possesses a historical destiny placing it uniquely among the world’s nations as an arbiter of freedom and democracy. All American presidents, liberal and conservative, historically have spoken of the United States as the exemplar of liberty, and President Obama is no exception. Only in America, he often exclaims, could a black man with a funny sounding name become President.

But American conservatives in recent years have taken the concept of American exceptionalism further, believing that America is morally superior to other nations, and that our superiority entitles us aggressively to export our political and economic values to other parts of the world, with force if necessary. Where liberals and conservatives differ, where liberals become uncomfortable and conservatives unabashed, is in the notion of national superiority.

That we are superior to all countries in the world in every aspect of our governance, our culture, our society, is asserted often and rarely proved by empirical evidence or objective criteria. Ramesh Ponnuru and Richard Lowry of the National Review presented a conservative view of American exceptionalism in a March 2010 article, stating unequivocally that America is “freer, more individualistic, more democratic, and more open and dynamic than any other nation on earth.” While most Americans instinctively agree with this particular sentiment, it is essentially a statement of faith, not reason. Is America really the “most free, most democratic” country on earth? Conservatives tend to treat it as dogma, a theological creed essential for a true patriot. But is the sentiment supported by empirical facts? How substantially does the influence of money in our political system undermine our belief in one-man, one-vote? Is our two party system open to the establishment of new political parties? Four times in our history, the electoral college has allowed the popular-vote loser to become President of the United States. Corruption of our political leaders, particularly at the state and local level, is commonplace. Racism and discrimination have historically hampered economic mobility and educational advances. We imprison a larger share of our population than virtually any other democracy on earth.

If we could truly rate democracies on an objective, point-by-point scale, how would the United States stack up? Attempted earlier this year by Freedom House, a center-right, independent watchdog organization that, since 1941, has promoted democratic values and opposed dictatorships on the far right and the far left, Freedom House rated every country on earth for its commitment to “free” and “democratic” qualities. America, not surprisingly, scored well, as did many other democracies, mostly in Europe. But while we fell within the top tier (scoring the highest ranking of 1-1), we scored fairly low in comparison to many top tier countries on such things as “electoral process”, “rule of law”, and “freedom of expression”.

In several key social and economic indicators, we lag behind much of the advanced industrial world. Take health care. Conservatives claim that the United States has “the best health care system in the world,” as did House minority leader John Boehner last February. In reality, our for profit health care system, while providing very good care to those who can afford it, denies access to millions and covers fewer people at higher overall costs than do the health care systems of many other countries (mostly in Europe). And we have higher infant mortality rates and lower life expectancies than most of those countries. But it is deemed almost un-American to look to our European friends, or to Asia or Israel, for ideas on how to improve our health care system, or any other area of American life.

Many conservatives have criticized President Obama for stating during a European trip last spring, “I believe in American exceptionalism, just as I suspect that the Brits believe in British exceptionalism and the Greeks believe in Greek exceptionalism.” For conservatives, this statement proves that Obama rejects American exceptionalism, for if everyone claims to be exceptional then, in reality, no one is. There are two problems with this faulty logic. First, anyone who has ever met citizens of other countries knows that what Obama said is true – most Brits, most Greeks, most Germans, most Italians, most Swedes . . . each believe that their country is blessed with a uniquely special heritage; only Americans seem surprised to hear this. Second, the President actually endorsed American exceptionalism when he went on to say: “I’m enormously proud of my country and its role and history in the world. . . . [T]he United States remains the largest economy in the world. We have unmatched military capability. And I think that we have a core set of values that are enshrined in our Constitution, in our body of law, in our democratic practices, in our belief in free speech and equality that, though imperfect, are exceptional.”

Although the President nailed it exactly, to many conservatives, what makes America exceptional is the belief that America was uniquely blessed by God at its founding. Conservatives tend to glorify America’s mythological history with an uncritical eye and dislike anyone who shines light on America’s past blemishes. While conservatives love to espouse the fiction that America has always been a land of opportunity, is there any doubt that America’s creed of liberty and equality was not historically open to all? African Americans were enslaved and treated as chattel; women could not vote until the 1920’s; the Jim Crow south denied full emancipation to blacks until well into the 1960’s; Japanese Americans were interned during the 1940’s; and many ethnic groups were denied full access to our best schools and the professions until fairly recently. It is liberals, not conservatives, who have consistently advocated and enacted policies to bring the country into closer conformity to the ideal of equal opportunity for all, who have sought to make the United States a fairer and freer nation for more of its citizens. In return, some conservatives, like Newt Gingrich and Dinesh D’Souza, believe that liberal ideals are somehow less authentically American, the result of a “Kenyan, anti-colonial” mindset.

To believe that America is unique in its devotion to freedom and liberty, or that we have nothing to learn from the rest of the world, results in an arrogant glorification of military power and obedience to an anti-internationalist xenophobia. Are we exceptional, or do we stand out for other reasons? In The Myth of American Exceptionalism, British author Geoffrey Hodgson writes:

From the very beginnings of American history, the commitment to freedom had been mixed not only with the ‘damned inheritance’ of slavery but with the ambitions and interests – for land, for wealth, for military glory – that were scarcely different from those of other peoples and other rulers in other times. And why should they be different? Americans, after all, were not angels. . . . They were men and women of the same clay as the rest of us, and specifically they were, in their great majority, Europeans who brought with them to America European hopes, European fears, European ideals, European prejudices, and a European worship of the nation state.

What makes America exceptional are the ideals embedded in our Constitution, our unique history, and because we have succeeded at great things when we act as one nation. But when we blindly assert our superiority and act with inflated self-regard, when we refuse to examine the things that work in other democracies, we do so at our peril. America's social, political and economic values did not develop in a vacuum and were influenced and affected by many great historical events and transformations that occurred or originated outside of the continental United States – oceanic trade, the Protestant Reformation, the Enlightenment, migration, democratic government, industrialization, the scientific revolution, and the creation of a global economy.

Some conservatives long nostalgically for laissez-faire economics and believe that President Obama -- the same president who bailed out the banks and compromised on the public option -- is a dangerous socialist out to destroy America. These conservative voices operate with a very short memory and a selective sense of history. We came close to unrestrained laissez-faire capitalism in this country back in the 19th and early 20th centuries. The result? Unsafe working conditions, exploitation of child labor, no minimum wage, no 40-hour work week, no required overtime and holiday pay, no product safety regulations, dirty air, dirty water, and pandemic inequality, poverty and injustice. It took progressives, who believed that capitalism and the pursuit of wealth needed checks and balances and a regulatory framework upon which to enforce higher ideals without sacrificing creativity and America’s entrepreneurial spirit, to correct these shortcomings. Today, because of reform oriented laws and regulations, almost all of which have historically been opposed by conservative forces in this country, we have a safer, healthier, more just, and fairer economy and society. Some of these reforms were borrowed from our European friends, and we are a better nation because of it. What makes us exceptional is that we are empowered as a people to make our government, our society, and our country better.

America is exceptional when we strive to achieve the ideals of our founding principles and when we choose, in the words of President Obama, “our better history.” We are the most ethnically and racially diverse country on earth; we have mostly avoided class warfare and have historically opened our borders to many who sought unbridled opportunity (ironically, conservative forces have mostly been opposed to new waves of immigrants, and still are). What is exceptional is our willingness to correct past injustices, to recognize our shortcomings, to learn from other nations and cultures when they have something worthwhile to share. What makes us exceptional is when our national actions are, as President Obama stated last year, “based on our Constitution, our principles, our values and our ideals.” When America stays true to its ideals, when we respect humans around the world and at home, when we tap into the potential of all of our citizens regardless of race, ethnicity, religion, or class, when we work together as one people to solve our national shortcomings – which requires a willingness to acknowledge and discuss them – only then is America truly exceptional.