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Contraception, health-insurance reform & religious freedom

From the editorial, "An Illiberal Mandate," just posted on the homepage:

In August, the Department of Health and Human Services issued a draft ruling that would mandate coverage of contraception and sterilization in health-insurance plans, including those provided to employees of Catholic institutions. The ruling offers an exemption from the mandate only to religious institutions that primarily employ and serve coreligionists, and whose work is strictly religious. As HHS sees it, access to contraception is a fundamental component of any health-care plan, especially for women. That claim seems commonsensical to many people, including many Catholics. The USCCB argues that compelling the church to pay for plans that cover services the church has long held to be immoral violates the religious-freedom guarantee of the First Amendment. Catholic hospitals, universities, and social-service agencies see their mission as caring for people of all faiths or none, and they employ many non-Catholics. Given this understanding of mission, inevitably there will be a degree of entanglement between any large religious institution and the modern state. That should not be an excuse, however, for imposing secular values on more traditional religious communities. Religious diversity is impossible without a degree of autonomy from the state. Is there any evidence that such autonomy poses a serious threat to liberal democracy?...[E]xcept when life or limb is at stake, it is hard to see what is liberal in coercing religious individuals and institutions. There are other ways that contraception can be made available to employees of Catholic institutions, should they choose to use it. One does not need to oppose contraception to see that, in this case, its far less important than the principle, and practice, of religious freedom.

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Show me where it is written in Writ that to be a Catholic one has to attend mass at least once a week?

Um, David and Barbara, it's been more than 4 years since Wal-Mart announced that it was selling two contraceptives for $9 a month. http://www.nytimes.com/2007/09/27/business/27cnd-drug.html If you really want to prevent births, you can even double up on condoms, and your overall birth control expense will still be cheaper than just about anything else that it's possible to buy, except for maybe chewing gum and the like.

Studebaker,Perhaps I am misreading you, but your essential message seems to be, "If the b_tches wanna have sex when they shouldn't, let them go to the nearest gas station and buy a condom."The most widely used form of contraception in the United States is the pill, not the condom. Women get the pill from their doctors, as of course they should and must, because it is a prescription drug. Most Americans, including most Catholics, don't see anything wrong with that. About 50% of major health plans do cover contraception, so on the one hand, admittedly the new regulation is a major change, but on the other hand, it is not so outlandish that half of insurance plans don't already cover it. I have heard good arguments in favor of high-deductible plans that pay for only unexpected medical costs, and I could probably do reasonably well with one myself. But many peopleprobably most peoplewould find it difficult to afford decent health care with a high-deductible plan. They just wouldn't go to the doctor, wouldn't take their kids to the doctor, and wouldn't buy prescription drugs. According to one site I looked at, oral contraceptives cost about $30 a month. For many people, that's not a lot, but for many people it is. I do understand the religious freedom angle to this, but you tend largely to frame it as an issue of sluts who shouldn't have sex at all, and if they do, they shouldn't be freeloading off of good folks like yourself to get free contraceptives. Maybe it's all unintentional on your part, or I am misreading you, but you simply sound scornful and contemptuous of women who use contraceptives (or maybe even women in general).

David -- I haven't said anything that even remotely justifies what you just wrote, and I'd thank you not to put words in my mouth. I'd be just as scornful of anyone who thought it necessary to have the federal government mandate that insurance companies cover the cost of all the drugs on Wal-Mart's "$4 a month" program. Insurance companies probably already do just that, of course, but I think it's silly to mandate "insurance" for such routine and cheap expenses. That's not what "insurance" is for, and if you can't afford $4 a month, you need cash transfers more than you need further regulation of whatever is labeled "insurance." Similarly, all I've said here is that it's fairly absurd to think that the entire mechanism of the insurance industry needs to kick in gear to help people establish a payment plan for items that cost as little as $9 a month (30 cents a day). Name anything else that you can buy for 30 cents a day -- the cheapest candy bar or can of soda costs more than that these days. Are we next going to hear demands that health "insurance" cover the cost of sugar-free gum? The purchasing power argument is interesting, although I'd suggest that its implications seem morally wrong to me. If 1) people part of a large "insurance" plan get everything cheaper b/c of purchasing power, and if 2) people not part of a large "insurance" plan are, on average, less privileged in life, then the purchasing power of insurance companies merely serves to redistribute money from less privileged people to more privileged people. Wal-Mart and Target seem to be doing a much better job of using purchasing power to give cheaper drugs to everyone, not just to the more privileged people with good jobs.

Studebaker,I have excellent health insurance, but I have a $10 copay for generic drugs (90 day supply) and a $25 for brand name drugs. (And this is only if I use the designated mail-order pharmacy.) So let organizations who don't want to pay for contraceptives have a $10 copay for generic drugs, require them to use Wal-Mart or Target to fill prescriptions by mail order, and cover only the inexpensive generics in the insurance plan's formulary. Problem solved.

Grant (1:09pm) brings up worker's compensation. In most cases discussed, the funds that an employer pays to an insurance company under contract are acquired through the work of the employees. For health insurance, both an employee-paid share and employer-paid share become fundable only because of the employees' work and the money it brings in. Such "benefits" are not gifts to the workers. They are compensation for labor. The benefit I receive is the enhanced buying power of the employer using money I worked to bring in. The employer is able to procure for me something valuable to my family and me, more efficiently than I could. Amidst the many legal constraints that apply, it is worth keeping in mind how and through whom the diocese, the bishop, or other came into control over the funds under discussion. Moral constraints remain the same, but their implementation might be more considerate of Catholics and non-Catholics who work. Suggestion of limiting coverage to catastrophic events requires some definition of 'catastrophe'. It is not hard for a sequence of events that are medically non-catastrophic but non-elective to accumulate in effects and costs over a year or ten and create an extreme financial burden on the family involved, independent of plans and income.

Grant Gallicho says: "isn't this cooperation quite remote?"If this article is correct, Fordham, Georgetown and DePaul universities think it is remote - or, at least, they don't consider it proximate.Fordham draws a distinction between providing insurance that covers contraception (which they do) and prescribing contraceptives in your own clinic (which they don't).many Catholic hospitals and universities have been covering contraception for their employees and students for years, and have managed to continue to serve non-Catholics and uphold their mission. Fordham University, Georgetown University, and DePaul University, for instance, all offer their employees health plans that cover contraception, as does Catholic Healthcare West, a large Catholic hospital system in California, Nevada and Arizona.Fordham, which is forced to cover contraception because it is ineligible for the religious exemption in New Yorks Womens Health and Wellness Act, gets around the rule by refusing to prescribe birth control on campus....A spokesman for Fordham University confirmed that the health center covers students' birth control but does not prescribe it. "Fordham is a Catholic university and follows church teachings on reproductive issues," he said.A Georgetown University spokeswoman said that it offers employees "access" to outside health insurance plans that cover contraception and abortion, but that the school's own insurance plan excludes those services. This way, Georgetown can comply with Virginia and Maryland's state mandates (the health plans are licensed in those states as well as D.C.) while adhering to its Catholic values.Catholic Healthcare West, which runs more than 40 Catholic hospitals, also provides birth control coverage options to its staff of more than 60,000, a spokesperson for Anthem Blue Cross confirmed in an email. CHW did not respond to calls for comment.http://www.huffingtonpost.com/mobileweb/2011/11/29/catholic-clergy-bisho... guess my worry would be that some bishop(s) will teach that it's proximate "because if we do that people will think we approve of artificial birth control."

That would be similar to the approach taken in the minority report prior to he release of Humanae Vitae - i.e. to let worry about public perceptions become more important than the issue itself""If it should be declared that contraception is not evil in itself, then we should have to concede frankly that the Holy Spirit had been on the side of the Protestant churches in 1930 [when Casti Connubii was promulgated) and in 1951."It should likewise have to be admitted that for a half a century the Spirit failed to protect Pius XI, Pius XII, and a large part of the Catholic hierarchy from a very serious error. This would mean that the leaders of the Church, acting with extreme imprudence, had condemned thousands of innocent human acts, forbidding, under pain of eternal damnation, a practice which would now be sanctioned. The fact can neither be denied nor ignored that these same acts would now be declared licit on the grounds of principles cited by the Protestants, which Popes and Bishops have either condemned, or at least not approved."http://en.wikipedia.org/wiki/Pontifical_Commission_on_Birth_Control

Will these good Catholic places offer insurance (if there is any) that offers NFP resources?

Unfortunatly, MikeD could benefit from correcly interpreting statistics The statistics on world-wide married couples who practice periodic continence (PC) was taken from the following legitimat source: Population Reference Bureau, Family Planning Worldwide: 2002 Data Sheet (Washington D.C.: PBR, 2002), accessed July 14, 2011 at http://www.prb.org/famplanworldwide_eng.pdfThere have been numerous surveys that all conclude the same thing, about 3% of US Catholic married women practice PC-NFP. Ditto for married women internationally. In 2007, Dean Hoge's research documented the opinions of Catholic generational chorts. 67% of Catholics who attend "weekly Mass" assert that you can be a good Catholic without obeying the Church's teaching on birth control. In terms of cohorts, only 8-10% of all Catholics ages 18-39, and 40-62 say it is always morally wrong to use condoms or birth control pills. The point is clear and substantiated that priests look the other way in distributing the Eucharist to the overwhelming majority of Catholics who practice some form of birth regulation condemned by the Vatical as intrinsicaly evil. While only a small percent of Catholcs attend weekly Mass, most of them who fall within the fertiilty cycle of married life practice contraception.

About what insurance is for ==It seems to me that while it makes sense for companies to define it as sharing *risks*, it makes more sense for buyers of health insurance to define it simply as sharing total *costs*. In other words, my premiums are simply my share of my insurance company's bills. While it is true the buyers share risks to some extent, they also share non-risky, expected costs, like flu-shots and other preventive medicines.Yes, all sharing of total costs benefits the less affluent more than the well-to-do, but the well-to-do are also benefited because when the less affluent cannot afford premiums (ask Jean about this) the costs are greater for the well-to-do. Not to mention the fact that one of the greatest medical boons ever have been vaccines, and the wider their use the better protected even the very rich are. If Gordon Nordquist's servant had scarlet fever, he and his kids would be endangered. Moral: we're all in this together.

I regret the apparent demise of high deductible, high co-pay, low premium, non-comprehensive health insurance. I'd like to see the reasoning of the board of scientific experts that led to this turning point in health policy, though I can't help but think it wasn't science alone that led to the Sebelius decision. To the extent that medical providers have major influence my expectation is that maximally comprehensive coverage will be deemed absolutely necessary and very little weight will be given to either cost considerations or religious concerns.If that's the way the game is to be played then the "comprehensive" coverage should include payment for counseling at pro-life centers and courses in NFP and perhaps many other programs that favor traditional family practices. The more choices, the better, and expenses be damned.

Jimmy Mac says: "Will these good Catholic places offer insurance (if there is any) that offers NFP resources?"Maybe that's the answer. Get the bishops to push for a requirement that health insurance plans cover all family planning supplies - NFP as well as contraceptives. Then NFP users could buy that $500 computer/thermometer that some people are excited about. It's probably not covered now because you don't need a prescription.

A candidate for Catholic insurance coverage --- For $399, "New software offers high tech version of Natural Family Planning". This would publicize the fact that the Catholic bishops do allow birth control if done properly. Plus a unitive marital benefit, whether the couple's goal is to procreate or avoid it: We just started to see how the men enjoyed taking part, The men really enjoy charting their spouses cycles." http://www.lifesitenews.com/news/new-software-offers-high-tech-version-o...

I regret the apparent demise of high deductible, high co-pay, low premium, non-comprehensive health insurance. Patrick Malloy,From the New York Times, September 27, 2011:As the cost of health insurance continues to rise, workers can expect to see high-deductible plans, with ever-higher deductibles, becoming the norm, the president of the Kaiser Family Foundation predicts.Its the biggest tool in the toolbox that employers have to hold costs down, said Drew Altman, president and chief executive of the foundation, in a telephone call today with reporters.Mr. Altman made the remarks while discussing the findings of the annual Employer Health Benefits Survey conducted by the foundation and the Health Research & Educational Trust. The study is based on a telephone survey of 2,088 randomly selected public and private employers with three or more workers, conducted between January and May of this year. The study found that the average cost of work-based family health coverage rose by 9 percent this year, after several years of more modest increases.The survey reported that the number of employees covered by high-deductible health plans, and the number of companies offering the plans, jumped this year, as employers seek more affordable coverage options and are potentially seeking to shift increased costs to workers.This year, 17 percent of covered workers were enrolled in such plans, compared with 13 percent last year and just 8 percent in 2009. And 23 percent of firms offering health benefits offer them, up from 15 percent last year. The plans, which typically are paired with health savings or reimbursement accounts, generally carry lower premiums for workers, but have higher annual deductibles than other plans. Plans that can be used with health savings accounts, for instance, must have a deductible of least $1,200 for an individual and $2,400 for a family.Mr. Altman described the shift to high-deductible plans as a quiet revolution that was redefining employer-based health insurance in the United States, from a service that offered wide-ranging, comprehensive coverage to one that offered limited coverage: The nature of what we call health insurance is changing, without a great deal of analysis or debate.The idea behind the high-deductible plans is to have consumers pay closer attention to costs when they seek health care. But, as one reporter on the conference call noted, it remains difficult for patients to get reliable up-front information about the pricing of health procedures.

Patrick, you are probably thinking of the first generation of such plans. The trend has been to greater and greater adoption of such plans, in some cases, by making it the only plan or otherwise structuring contributions to make it the plan of choice. In addition to what David N. said above, however, the current generation of HSA/HDPs must exclude preventive care from their high deductible component. Thus, what counts as preventive care is an important concept. This still makes it hard for families with children that have chronic conditions, for instance, asthma, for which the drugs are not considered to be preventive, but that must be paid for year in and year out in such amounts that the deductible more or less acts as an additional premium (all but guaranteed expense associated with health insurance).

Barbara and David,I would not be surprised to see a temporary upsurge in these plans, in order to be grandfathered if nothing else. But I think Altmans observation. The nature of what we call health insurance is changing, without a great deal of analysis or debate, is important. When the act goes into full force the definition of comprehensive will have changed (isnt that what the editorial is about?) and my contention is that the change will be one-way. Which commissioner is going to say that what was once considered essential is no longer essential, against intense lobbying and in the face of horror stories in the press? So of course there may be more or less comprehensive plans allowed but the less comprehensive plans in the future will be more comprehensive than the less comprehensive plans of the past. An important option will have vanished in the name of reform. As one wag had it, the older less comprehensive plans will be thoroughly forbidden throughout the free world.And as Nancy Pelosi wisely told us, well just have to see whats in this plan after its passed and in place. We await further word from Secretary Sebelius and her experts. For the latest convolution in this confusing drama see: Kathleen Sebeliuss Health Care Muddlehttp://www.washingtonpost.com/opinions/kathleen-sebeliuss-health-care-mu... Nickol,You recently corrected someone for misspelling your name. Allow me to do the same. My last name is Molloy not Malloy as you have it when you respond to me. A helpful hint -- the middle letters ollo are symmetrical - thats how I remember the way to spell my name :-). More importantly there is a Rick Malloy, S.J. who blogs here occasionally and who would probably be deeply embarrassed to be associated with my views. I defer to Samuel Beckett who spelled the name authoritatively in his novel Molloy.

You recently corrected someone for misspelling your name. Allow me to do the same. Patrick Molloy,Apologies!

For the latest convolution in this confusing drama see: Kathleen Sebeliuss Health Care MuddleNote that that article is on the Post's "Opinion" page. Samuelson doesn't like Sibelius's decision to let each state set the minimum level of benefits to be provided in that state.

"For the latest convolution in this confusing drama see: Kathleen Sebeliuss Health Care Muddle"Note that that article is on the Post's "Opinion" page. Samuelson doesn't like Sibelius's decision to let each state set the minimum level of benefits to be provided in that state.

Patrick, I don't disagree with what you are saying, but the best way to deal with what you are talking about is to decouple more of what can be bought in the way of health care products from requirements for physician prescriptions. It can be done, it was done for Claritin, for instance, which we now all buy OTC, without a prescription, and without insurance coverage, but I am guessing it's a topic for another day and probably another audience.

I like the other comments that some Catholic institutions offer several health plans to employes (Catholic and non-Catholic). This is common based on my experience as a health benefits consultant to health plans, governments (Federal and State), and large employers. Sometimes the plan sponsor will set the price of the preferred or organizational plan as the benchmark. If another plan (with contraceptive coverage) is more, the employee pays the different in cost. This not always equitable since alternative plans can be HMOs or a Managed Health Plan, or an Indemnity Plan. Benefit levels are not always comparable and access is another issue as well. There are many ways to "skin the cat" and a one-size-fits-all plan does not work.I fall back on equity and non-discrimination criteria when it comes to plan design and employee contributions. The states usually control insurance law and many coverage rules. That is why we have a slew of state regulations, often different, in terms of mandatory coverage. We do not have a prefect system and the Federal Government will be implementing more of Obama Care next year, and that will likely make things worse. In my 30+ years of consulting, my experience with government plans and actuarial cost projections tells me that the cost savings of Obama Care was over-estimated, and prices and utilization under estimated.

"How do you cover that in your $175/year for the family? Trained health care providers are part of the cost if you choose to suggest better womens birth control options, with or without insurance."Sure, but the question at hand is, Should Catholic institutions be required to subsidize birth control? That is the scope of the HHS regulations under dispute, as I understand it. I expect that employee insurance plans offered by Catholic institutions include gynecological care. Both women on birth control and women not on birth control need that care. I don't know of any proposals or plans to discriminate in the delivery of gynecological care against women on birth control.

" It can be done, it was done for Claritin, for instance, which we now all buy OTC, without a prescription, and without insurance coverage, but I am guessing its a topic for another day and probably another audience."I've been using GERD "maintenance meds" for a number of years, and have had prescriptions to a variety of different medications as my employer has switched insurance carriers, and as costs have gone up and down. On at least one occasion, I've asked to switch because the medication I had been taking no longer required a doctor's prescription - and by buying it over the counter, my costs went up substantially (no insurance subsidy for OTC).Thank you to Barbara and all, btw, for this civil and informed discussion of a contentious and controversial issue.

The issue of employee cost sharing is a separate issue but one that needs to be part of the overall decision of providing coverage. Plan sponsors have been increasingly passing on a percentage of the total cost increase of healthcare plans for decades. This has beome problematic because there is a limit to passing on costs to employees. It is called affordability....which is you point. This is not lost on me. These are complex issues. However, I have a big problem with the issue of discrimination because many employees of Catholic institutions are non-Catholic. Take the example of a woman whose life is threatened by a pregnancy where the fetus will not survive under "any circumstance" but the mother's life could be saved if the pregnancy is terminated (e.g., the Phoenix case). Most hospitals consider this procredure medically necessary, and to many moral theologians in the Catholic Church this is "indirect abortion". How does the plan administrator abide by their Erisa-type responsibilities in approving or disapprroving this procedure as a covered expense, when the Church and the Catholic institution says it is a "direct abortion" and the Catholic hospital and medical staff say it is not. Keep in mind that "medically necessary" is often the litmus test for covered expenses. It is a medical opinion, not an opinion of the plan sponsor. This issue of direct and indirect may be defined by the plan sponsor, but this is rarely spelled out in plan descriptions of plan contracts. This issue gets more complicated when the patient is not Catholic!! As a public policy, non-discrimination rules benefit everyone.

Jim: Every time an employee of a Catholic institution buys birth control with her or his paycheck, that institution is subsidizing artificial contraception.

Studebaker wrote: "its been more than 4 years since Wal-Mart announced that it was selling two contraceptives for $9 a month."David N replied: "I have excellent health insurance, but I have a $10 copay for generic drugs (90 day supply) and a $25 for brand name drugs. "I admit I've never gone to Target or Wal-Mart to fill prescriptions (maybe I should), but I assume that it would be cheaper for a person on David N's insurance plan to go to Target and pay for the prescription out-of-pocket for $4 or $9 than to pay a $10 or $25 copay and having a pharmacy submit a claim for the remainder to the insurance company. Yes?That I don't do this already (my insurance plan is not identical to David's but sort of in the same neighborhood) illustrates that I'm not a very savvy consumer, which is not news to me nor to anyone who knows me. I wonder how many people like me there are out there? Or, I guess the answer is, If I'm too thick or lazy to shop for a better price, then I deserve to pay more.

"Jim: Every time an employee of a Catholic institution buys birth control with her or his paycheck, that institution is subsidizing artificial contraception."Morally and legally, this is not true. To illustrate with a common example: if my employer throws a Christmas party in which unlimited alcoholic beverages are served for free to the employees, and one of them drives home drunk and causes an accident, the employers I know believe that the employer may be liable - and I expect that most reasonable people would agree that the employer was morally negligent. On the other hand, if the employer serves no alcohol at the party, but an employee drinks too much anyway, drives drunk and causes an accident, the employers I know believe that their liability is substantially less, because they took reasonable precautions. There seems to be a moral and legal difference between subsidizing and not subsidizing something.To apply your logic to health care: Why should I offer my employees any health care insurance whatsoever? By your logic, I'm already subsidizing their health care by paying them a paycheck. What they do with their money is their affair. Every payday, it seems that I'm fulfilling my moral duty.

What do morals and laws have to do with the question of whether compensation for labor amounts to employer subsidies of what employees decide to do with their pay?

A little history and information.1. Since the advent of some retail chains offering specific generic drugs for a flat retail price, that is often less than a member's copay, Rx administrators have a provision in their legal contracts with pharmacies that call for the pharmacy to collect the "lower of" the copay or the usual retail price. This is sometimes very confusing and often prone to abuse or error on the part of the pharmacy is requesting the copay. If this issue is something important to you, you should talk to your Rx carrier about it.2. Benefits are part of an employee's total compensation. The issue is not about being responsible for the things employees purchase with their cash compensation, but rather the issue about benefits is about a state or federal regulation requiring plan sponsors to offer coverage in their health plans for contraceptive medicine/drugs because it conflicts with the plan sponsor's religious beliefs as a "religious institution". As mentioned, these are thorny and complex issues. In the past, if a plan sponsor wanted to exclude certain expenses as a covered expense in their health plans, they would have to exclude it for all classes of employess. This varied by plan sponsor and also by state, since state laws govern health plans (as do some aspects of federal law). After so many years, we ended up with non-uniform coverage rules and regulations that were expensive and complex to administer. Some states required health plans to offer coverage regardless if the contract was issued in another state. This meant that an employers plan would have coverage for certain expenses in some stated and not in others. It forced some plan sponsors to make the coverage available in all states. The federal government decided that "certain expenses" were required to be included in all health plans to make thing uniform, and cosistent with non-discrimination laws and medical necessary provisions. This is one example of how healthcare costs have been increasing.How the Obama administration will handle the "religious institution excepton" is anyone's guess.

". . . one of them drives home drunk and causes an accident, the employers I know believe that the employer may be liable and I expect that most reasonable people would agree that the employer was morally negligent."Jim P. ==This is the sort of thinking that turns me more conservative than I used to be. I don't think it is in the least bit "rational" to assume that employers *do* have the intelligence and virtue to avoid getting drunk when offered free drinks while employees do *not* have the requisite control to limit their drinking. Sure, if an employer pressured an alcoholic to take a drink, then he should be liable -- and the opposite should also hold. From what you say it looks like corporations are turning into nanny-institutions, just like the federal government. If the adult citizens of this country don't have the brains and will power to accept responsibility for their own actions, how in the hell can we expect them to be good parents or to vote sensibly or do any of the things adults are responsible for? (Excuse my French, as they used to say.) Not only that, this sort of thinking seems to be just a projection of the old sort of paternalism based on medieval (in the bad sense) attitudes towards peasants.Sure, because single policies are so very expensive it makes economic sense both for an employer and the employees to have a company health plan as part of employee compensation. On the other hand, if there were one insurance provider for everyone, the pool of insurees would be even larger and the premiums would be even less expensive. So a national health plan also makes great good sense for employers and employees (except for insurance companies, you can bet your bippie.). This is not paternalism, but sound business practice and governmental policy.

Grant, I thought the issue at hand was both legal (HHS regulations have legal force) and moral (subsidizing contraception violates Catholic institutions' moral beliefs).I apologize if I was too dismissive in my previous comment to you. You've raised an interesting question. I'm looking at it through the lens of what I believe to be your take on the overall issue, and one with which I agree: that at some point, the connection between the Catholic employer and the employee becomes remote enough that the employer can reasonably conclude that its not formally cooperating in the procurement and use of artificial birth control.If I've correctly described your approach, then your comment that paying an employee cash which she can then spend as she wishes is the equivalent of a specific subsidy of the immorality in question really did confuse me. If that wasn't the intent of that comment, perhaps you could clarify what you meant in claiming that a paycheck is a form of a subsidy. Because to me, the two scenarios - subsidizing contraception, vs. paying the employee a salary which she can choose to spend however she wishes - are, morally speaking, quite different. Very likely, the distinction between the two scenarios is the distinction between material and remote cooperation in the act under consideration (using contraception with contraceptive intent).Once again, Ascension Health's little primer on ethics is helpful. As laid out in the link below, I'd classify a subsidy for contraception as a form of mediate material cooperation, and I'd suggest that a forced subsidy of contraception fails to meet the three criteria given to justify mediate material cooperation in evil."Mediate Material Cooperation. Mediate material cooperation occurs when the cooperator participates in circumstances that are not essential to the commission of an action, such that the action could occur even without this cooperation. Mediate material cooperation in an immoral act might be justifiable under three basic conditions:* If there is a proportionately serious reason for the cooperation (i.e., for the sake of protecting an important good or for avoiding a worse harm); the graver the evil the more serious a reason required for the cooperation;* The importance of the reason for cooperation must be proportionate to the causal proximity of the cooperators action to the action of the principal agent (the distinction between proximate and remote);* The danger of scandal (i.e., leading others into doing evil, leading others into error, or spreading confusion) must be avoided."http://www.ascensionhealth.org/index.php?option=com_content&view=article...

Jim,Here's one of my points--the one responding to your claim that providing health insurance amounts to subsidizing an employee's health-care purchases: In the United States, benefits are part of an employee's compensation package. That's why Bishop Lynch, after threatening to stop providing health insurance to his employees, said he'd offer diocesan workers more money on top of their base salary, which they could use to buy insurance on the open market. That means an employer is subsidizing, in one form or another, his employees' purchases. Workers spend most of their wages on food and shelter, obviously. But there will always be employees who spend their money on things the church considers immoral--or things necessary for immoral acts. That is true whether the employee is spending cash on condoms or co-paying for birth-control pills mostly covered by the health insurance she earns by working for the diocese. But even if you disagree with me about the nature of compensation in the United States--namely that benefits are properly construed as part of a worker's wages (this is how employers think of it, by the way)--then you still have to figure out whether paying for a health-care plan that may result in some employees' using it to purchase artificial contraception (for non-medically indicated reasons) necessarily involves the bishop in formal material cooperation with an act the church considers evil. I don't believe paying for health-insurance that includes contraception coverage amounts to formal material cooperation with evil because the employee may or may not take advantage of the benefit, and the act of using artificial contraception is something an employee could engage in with or without health insurance.Rather, when a Catholic institution pays for health insurance that includes birth control, it is--according to Catholic moral thought--remotely, freely cooperating with evil. Remote material cooperation is permissible when there are proportionate reasons. It seems to me that providing health care for someone who could not get comparable coverage as an individual on the open market (and at this point an individual could not) is sufficient reason to freely and remotely cooperate with an act the institutional church considers evil.Another reason I believe bishops who threaten to stop providing health insurance to employees are not thinking clearly is that the nature of the act of paying for non-contraceptive-covering policies is not at all pure. As I mentioned above, when a diocese pays Aetna for a plan that excludes contraception coverage, does the bishop believe Aetna is not using diocesan funds to cover other plans that do include contraception? By such bishops' logic, they are already formally cooperating with evil by paying insurance companies. (That curious way of thinking appeared in several forms during the health-care debate.)

"you still have to figure out whether paying for a health-care plan that may result in some employees using it to purchase artificial contraception (for non-medically indicated reasons) necessarily involves the bishop in formal material cooperation with an act the church considers evil. I dont believe paying for health-insurance that includes contraception coverage amounts to formal material cooperation with evil because the employee may or may not take advantage of the benefit, and the act of using artificial contraception is something an employee could engage in with or without health insurance.Rather, when a Catholic institution pays for health insurance that includes birth control, it isaccording to Catholic moral thoughtremotely, freely cooperating with evil. Remote material cooperation is permissible when there are proportionate reasons. It seems to me that providing health care for someone who could not get comparable coverage as an individual on the open market (and at this point an individual could not) is sufficient reason to freely and remotely cooperate with an act the institutional church considers evil."Let me just say first of all that this is defensible - maybe even persuasive :-) - moral analysis.Also, as Michael Barberi has said more than once now, this is extremely complex.I've suggested, and continue to hold, that the nature of the Catholic institution's moral cooperation would be neither formal cooperation nor remote cooperation, but mediate material cooperation - which is still *material* (not remote) cooperation. From an accounting and finance point of view, I agree that to an employer, compensation is compensation, whether it is paid as cash or as an insurance benefit. But even if there isn't a monetary difference, there is a vast moral chasm between birth control being funded by the institution's funds (as would be the case when it is subsidized by the institution's insurance premiums) vs. when it is funded out of the employee's own checking account. The institution is able to exert considerable influence over the use of funds in the former, and no influence whatsoever over the latter. If intention counts for anything, as it surely does in this case of a non-intrinsic evil like birth control medication, then the difference between the two sources of funds is the difference in the employer's intention. When an employee pays for her own birth control, she is doing so *despite* the intention of the Catholic institution.Having said all that: your point is very well-taken. As I've said before, there are many worse sins in the world than contraception. Procuring health care in the United States is not an even playing field between those who have employer-subsidized health care and those who don't. If the choice is between a health care plan that includes birth control, and no health care plan at all, that seems to be a no-brainer. But best of all is a health care plan that doesn't require a Catholic institution to cooperate in evil. Even if, for the sake of conversation, I agree with you that such would constitute remote cooperation, I would say that even remote cooperation should be avoided if it can be.At any rate, Commonweal's editors and I seem to have ended up at the same position. I agree with Paul Moses: it's an awesome editorial.

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