The disagreement between the US Catholic bishops and the Obama Administration over the obligations of Catholic employers under the Affordable Care Act to provide their workers with health insurance that pays for contraception as a basic benefit, adds another noteworthy chapter to the long-running story in American history of the peaceful settlement between strongly held religious conviction and the imperatives of political democracy.
Overlooked, however, in a debate that has sometimes veered into the metaphysical reaches of "how many angels can dance on the head of a pin," were the much more down-to-earth considerations of the actual health of actual women, health care experts say.
Dr. Paula Johnson is head of the Mary Horrigan Connors Center for Women's Health and Gender Biology. She is also the chief of the Division of Women's Health at Brigham and Women's Hospital in Boston. And Dr. Johnson says: "Thanks to passage of the new Affordable Care Act (ACA), being female is no longer a pre-existing condition."
Historically, says Johnson, that's been the stance taken by insurance companies that often denied pregnant women and mothers coverage for reproductive health services based on the self-serving idea that "pregnancy" was a pre-existing condition.
Yet, once advocates for women's reproductive health overcame industry obstruction to make birth control more readily available they faced a potentially greater hurdle in the objections of certain religious groups, particularly the Catholic Church, to easy access of preventative services.
Last August, Health and Human Services Secretary Kathleen Sebelius accepted the recommendation of an expert panel of the highly respected and non-partisan Institute of Medicine to provide contraceptive services free of charge under the ACA.
One of the key cost-saving features of the ACA, says Johnson, is expanded access to those health care services that help prevent the chronic diseases and conditions that are responsible for an estimated 7 of 10 deaths among Americans each year and as much as 75% of current health care spending.
Indeed, as an HHS advisory states, before health reform "too many Americans didn't get the preventive health care they need to stay healthy, avoid or delay the onset of disease, lead productive lives, and reduce health care costs."
Largely because of their cost, the HHS says "Americans used preventive services at about half the recommended rate."
The preventive care services now being covered free of charge under Sebelius' ruling, which President Obama recently affirmed to the outrage of many on the Right, included those products and procedures related to woman's wellness, breastfeeding, gestational diabetes, cervical cancer, sexually transmitted infections, domestic violence - and contraception.
"The immediate result of this mandate to include contraceptive services, which was made after a careful review of the scientific evidence, is the prevention of many of the estimated three million unintended pregnancies that occur each year in the United States -- nearly one out of every two," said Johnson.
Most workers in employer-sponsored plans are currently covered for contraceptives, HHS notes, and there are special exemptions for certain religious employers whose beliefs forbid the use of contraception.
But during the public comment period provided by HHS prior to the interim mandate becoming final next August, a number of religious groups, led by the US Conference of Catholic Bishops, weighed in against the HHS mandate, arguing that since contraception is contrary to their beliefs a requirement they include these services in the health plans offered to their employees constituted an infringement of religious liberty.
Before President Obama sided with HHS to make the mandate permanent, he did meet privately with representatives of religious organizations to consider their request to broaden the current religious exemption to include not only church employees but also the employees of any religiously-affiliated hospital, charitable organization, school, or higher education institution where the sponsoring faith objects to contraception as a matter of doctrine.
Religious liberty is among our most cherished rights as Americans and so must be taken very seriously. In this regard, President Obama has already shown himself extraordinarily respectful of the religious sensibilities of his fellow citizens.
This was particularly evident in the President's difficult and very controversial decision (especially among liberals) to stand by Secretary Sebelius last November when she took the unusual action of overruling the Food and Drug Administration's decision to make the Plan B morning after pill available without a prescription or parental consent to people younger than 17.
Like many of the President's supporters, Dr. Johnson said she was "surprised" by Secretary Sebelius's decision to veto what Johnson called "the carefully considered opinions of medical and scientific experts" that wider distribution of this drug was safe.
"But I also understand the concerns of those who were worried about making certain over-the-counter medicines available to minors without greater supervision," said Johnson.
Even though the Obama Administration faced growing pressure from religious groups to limit access to contraceptive coverage, Johnson insisted "the striking public health consequences of such a decision - and the financial burden it would impose on millions of American women and families - should not be lost in the broader political debate."
It's important to keep in mind that this is not a debate we would even be having if we lived in other parts of the industrialized world where residents either receive medical services from a government-run health care system, as in Great Britain or Canada, or from private providers who are compensated by means of the sort of universal, single-payer health insurance systems that conservatives in the US have rejected time and time again.
In such publicly-supported systems, decisions on care are based strictly on science, availability and cost. But in America, given our particular history, traditions, culture and values we have chosen instead a more complex social compact that emphasizes private initiatives, or public-private partnerships, for the provision of critical social programs like health care and retirement in place of the more centralized government-sponsored undertakings that are common elsewhere.
Yet, those who prefer a workplace-based health care system in which employers and employees share equally in the cost of purchasing health care in the private market, might want to consider the potential risks to that system -- and to the public support that undergirds it -- should millions of workers find they are routinely denied the services they want, and their doctors prescribe, based not on prohibitive costs or the lack of available science but due to their employer's particular politics, philosophies or religious reservations which these workers (and policyholders) do not share.
And the fact remains, says Johnson, that over 99% of American women choose to use contraceptives at some point in their lifetime, including the overwhelming majority of Catholic women.
"For decades, contraceptives have allowed women to make one of the most personal choices any of us can make - when to start a family," says Johnson, noting that the Centers for Disease Control recognizes that "widespread use of family planning has been one of the most significant public health achievements of the twentieth century."
Beyond the fundamental issue of fairness in providing millions of American women with the health coverage they want -- and which saves each woman hundreds of dollars a year in a tough economy -- the no-cost coverage for contraception and counseling under the ACA provides "vital preventative services and family planning tools that are crucial to our nation's health and well-being," says Johnson.
Not only does preventing unintended pregnancies hugely benefit the health and wellness of individual women and their families, says Johnson, "but increased access to family planning provides substantial benefits to public health at large."
Unintended pregnancies are linked to delays in prenatal care, she says, and for young women, particularly teenagers, "an unplanned pregnancy can limit education, employment possibilities, and economic opportunities."
Preventing unintended pregnancies provides the US with the unique opportunity to use the nation's finite health care resources more effectively, says Johnson. There is ample evidence that family planning services are cost-effective, providing significant savings to our health care system.
Additionally, access to family planning would lead to a reduction in abortion rates. "And given that unintended pregnancies result in increased risk of morbidity for the mother, preventing these pregnancies will help save women's lives," said Johnson.
In fact, says Johnson, the United Nations noted in 2010 that women in the US have a greater risk of dying of pregnancy-related causes than women in 49 other countries.
"Family planning services are highly effective in helping families time and space their pregnancies, resulting in important health, social, and economic benefits, and helping decrease many of the physical, emotional, and financial strains unintended pregnancies can impose," says Johnson. "And giving women and their families, regardless of their employer, full access to these essential services gives them the best chance at living happier and healthier lives."