In our January 13 editorial, we criticized a ruling from the Department of Health and Human Services that would require all employers to include "contraception and sterilization coverage in their health-insurance plans, including those provided to employees of religious institutions." Only religious organizations that primarily employ and serve co-religionists, and whose mission is to inculcate its values, according to the "interim final rule," could be exempt from the mandate. The U.S. Conference of Catholic Bishops, we wrote,
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.
So, we concluded, President Obama ought to expand the religious exemption to include organizations like universities and hospitals. Apparently he was not persuaded. (Bear with me, this is going to be a long post.)Friday, HHS announced that the rule would stand, but that religious institutions would have until August 2013 to figure out how to comply. In the meantime, secretary of HHS Kathleen Sebelius explained, organizations that do not currently offer contraception coverage will have to provide notice to employees that will include information about where they can obtain contraceptive services. Noting that the rule will have no effect on existing conscience-protection laws covering health-care providers -- meaning, for example, that a Catholic hospital won't be made to perform sterilizations -- Sebelius promised "to work closely with religious groups during this transitional period to discuss their concerns."
Obviously, the decision provides little comfort to religious groups that objected to the interim rule. Within hours of the announcement, the USCCB fired off a press release vowing "to fight [the] HHS edict." Archbishop Timothy Dolan of New York put out a brief video protesting the decision. In effect, the president is saying we have a year to figure out how to violate our consciences, Dolan said. And Sr. Carol Keehan, president of the Catholic Health Association -- and a key ally in the Obama administration's effort to pass the Affordable Care Act -- also expressed disappointment with the ruling. While noting that it was "important to have clarified by the president and the secretary of HHS that this decision will not undermine the current conscience protections in law and so very necessary for our ministries," she called the final ruling "a missed opportunity to be clear on appropriate conscience protection."
Keehan is right. The Obama administration blew a chance to correct far too narrow an exemption. Doing so would have avoided the specter of government forcing religious groups to act against their moral convictions. What's more, expanding the exemption would have maintained the status quo. That is, if HHS had expended the exemption, women who work for Catholic institutions that do not cover contraception would not lose anything they already had.But is Dolan correct? Is HHS just kicking the can down the road to make it impossible for the Supreme Court to rule on this before Election Day? Or could something be worked out that might satisfy the demands of Catholic moral teaching? One idea that's been proposed is the so-called Hawaii compromise.
Hawaii requires all employers in the state to include contraception services in their health-insurance coverage. As Wake Forest University's Melissa Rogers explains:
Under Hawaii law, religious employers that decline to cover contraceptives must provide written notification to enrollees disclosing that fact and describing alternate ways for enrollees to access coverage for contraceptive services. Hawaii law also requires health insurers to allow enrollees in a health plan of an objecting religious employer to purchase coverage of contraceptive services directly and to do so at a cost that does not exceed the enrollees pro rata share of the price the group purchaser would have paid for such coverage had the group plan not invoked a religious exemption.
Under Hawaii law, a religious organization that objects to providing contraception coverage to its employees can invoke a refusal clause that would allow the institution to exclude such services from employee health plans. Religious groups that invoke the refusal clause must -- as required by the HHS ruling -- provide written notice to employees informing them that contraception is not included in their health plans, and they must tell employees where such services can be obtained. A refusal clause only pertains to contraception services intended to avoid pregnancy. An employer must provide coverage for contraception prescribed to treat, for example, the symptoms of menopause. According to the law, an employee is entitled to buy contraception coverage from her insurer at a cost that is no higher than the enrollee's pro-rata share of the price the employer would have paid had it not exercised the religious exemption. So religious institutions do not have to subsidize insurance coverage including contraceptive services, and employees who want such coverage can purchase a separate rider with their own money.
Would that satisfy Catholic moral teaching? It seems so. According to the Catholic moral tradition, cooperation with "evil" (in this case, the use of contraception) is permitted in some circumstances. The USCCB objects to forcing Catholic institutions to fund contraception coverage for employees because it believes doing so would involve them in unacceptably proximate cooperation with evil. Catholic institution pays insurance premium. Insurance company pays for contraception. Employee uses contraception. (We'll get to whether that's a sound analysis in a moment.) But if HHS and religious employers can come to an agreement like the one reached in Hawaii, religious employers would not be directly contributing to the use of contraceptive services. It's true that, as a group purchaser, a religious institution's buying power would be used to set the price an employee would have to pay for a contraception rider, but that cooperation is too remote to be illicit because the good of providing health coverage to employees justifies the act.
But what if such a compromise cannot be reached? What if religious institutions outside the narrow exemption are made to cover contraceptive services that an employee may or may not use? In the USCCB's response to Friday's decision, Archbishop Dolan is quoted saying, "To force American citizens to choose between violating their consciences and forgoing their healthcare is literally unconscionable. It is as much an attack on access to health care as on religious freedom." Is he implying that if the religious exemption is not broadened, Catholic institutions will stop providing health care to employees? He wouldn't be the first. Late last year, Bishop Robert Lynch of St. Petersburg threatened to stop providing health coverage to diocesan employees if HHS refused to expand the exemption. Instead, he would offer employees a lump sum they could use to purchase coverage on the open market. How many bishops would follow Lynch's lead? And is that the only course of action permitted by Catholic moral teaching? I don't think so.
(Here I'm cribbing from comments I left on another thread.) In the United States, benefits are part of an employees compensation package. Thats why Bishop Lynch said he would offer diocesan workers more money on top of their base salary, which they could use to buy insurance on the open market. Those plans will likely be more expensive and less comprehensive than those offered by the diocese, and they might include contraception and abortion coverage. What happens when a diocesan employee buys coverage that includes abortion and contraception with money provided by the diocese? What happens when an employee can't get good coverage because he lacks the diocese's purchasing power, and ends up with a pile of medical bills he can't pay? Or forgoes treatment because it could bankrupt him?
To what extent is the institutional church cooperating with evil when its employees purchase contraceptives with their salaries? What is the difference between a diocese giving employees money they can spend freely and giving an insurance company money for coverage that may or may not include procedures and drugs the institutional church deems gravely immoral, or necessary to a gravely evil act? What does it mean morally for a diocese to pay, say, Aetna for a plan excluding the pill and abortions, when other Aetna plans include such services? Does the bishop believe Aetna is not using diocesan funds to cover other plans that do include contraception? By Lynch's logic, are bishops already cooperating with evil by paying insurance companies at all? If so, how remotely? More remotely than they would be if they paid for coverage that could lead to a Catholic employee violating church teaching against contraception? How might a bishop justify such a thing? Perhaps by weighing it against the good of health coverage for his employees -- coverage individuals could not get for themselves on the open market.
Paying for health-insurance that includes contraception coverage does not amount to formal material cooperation with evil because an 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 remotely cooperating with evil. Remote material cooperation is permissible, according to Catholic tradition, when there are proportionate reasons. 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 evil.
So much for the moral-theological analysis (and, moral theologians, I'm happy to be corrected). What about the politics of Obama's decision?
My initial response to the decision was, "This is politically daft and philosophically illiberal." Why risk the Catholic vote Obama worked so hard to win in 2008? I still think the HHS rule is profoundly wrong-headed, but I'm not so sure it's politically foolish, especially not when Obama has been so strongly criticized from the left. Michael Sean Winters has announced that Obama lost his vote over this. Is he typical of most Catholic voters? Obama knows most Catholics disagree with church teaching against contraception, and that they want contraception coverage. He also knows Catholics don't respond well when they think bishops are telling them how to vote. By shoring up his base on this issue -- and reducing unintended pregnancies is something he ran on -- Obama is risking the portion of the Catholic vote that is sensitive into the argument that even if you think contraceptive services should be provided as a matter of basic health care, it's wrong to force religious institutions to violate their moral precepts by paying to cover them. How many voters are keyed in to that question? How many are paying attention to their bishops' statements on election-year issues? Not many, it seems. And it's not as though the bishops have made much noise about the fact that twenty-eight states already require religious institutions to cover contraception, and eight of them lack a religious exemption. So perhaps Obama figured that he couldn't win with the USCCB -- not when its former president feels free to call his "the most secularist administration in history" -- and decided that expanding contraception coverage was worth the criticism.
We'll know in eight months.