Thinking about the HHS mandate

In an article in Monday’s Wall Street Journal, Harvard Law professor (and former U.S. ambassador to the Vatican) Mary Ann Glendon stated:

“The main goal of the mandate is not, as HHS claimed, to protect women’s health. It is rather a move to conscript religious organizations into a political agenda, forcing them to facilitate and fund services that violate their beliefs, within their own institutions.”

I’ve been trying to think about the HHS mandate from a broader perspective. If designed well, I would support something like an extension of Medicare (government provided payment, individually selected physicians) to everyone. It’s not perfect – but most people over 65 prefer it to the health insurance they had as employees.  That made me wonder what I would mandate – and what I would not – and how I would decide amongst competing claims.

If not universal coverage, then…

In the absence of that kind of universal plan, the question arises: are there certain situations which every type of medical insurance should cover. There are a few obvious ones – emergency trauma or heart attack/stroke treatment, immunizations to protect public health, cancer and heart disease therapies. Most people would probably agree that treatments should be covered if they directly save lives or prevent disability.

But opinions become mixed as soon as one moves away from the central core. I would be willing to forego coverage for most hair transplant, viagra, and botox treatments, but others could argue their necessity for mental health and well-being. I would promote a wide range of health-promotion services (exercise, smoking-cessation) because of the potential win-win: a healthier person with high well-being and low medical costs. Reasonable people could disagree on either of these.  In these areas, the basis for supporting or opposing coverage clearly rests within the moral and ethical framework of the individual or organization.

Health care legislation options

The Obama health care reform could have taken a very narrow path – trying to make sure that all Americans had insurance to cover those situations in which loss of life or the possibility of disability was apparent. This isn’t as easy as it sounds; the early manifestation of some conditions (an abcessed tooth, for instance) may not seem life-threatening, but are seen as such when someone dies for lack of care.

If coverage is not going to be universal for every condition – a budgetary impossibility – then either a governmental agency will decide on a single list, or individual insurers will be able to put forward plans with different coverage and deductible provisions. The consumer can choose what mix of coverage and payment meshes with their income and their ethics.  Even in this scenario, though, the government would have an interest in making sure that “save life / avoid disability” coverage was included.

What to mandate?

I’ve been pondering the question: if I were starting from scratch, what items that are not always covered under current policies would I mandate?

NPR reported on Amber Cooper whose insurance stopped paying for the anti-rejection medication  and blood tests that are required due to her liver transplant at age 10. I have heard about lack of treatment for asthma, or difficulty getting on-going treatment for psychosis.  These seem like good candidates for mandatory coverage according to the “save life / avoid disability” criterion.

What did HHS mandate?

From this perspective, the specific mandate to cover contraceptives, sterilizations, and abortifacient drugs does not make sense to me. Even if one ignores the evidence-backed claims that these drugs and procedures do not have the high safety record that their proponents state, they simply don’t rise to the level of many other types of treatment whose coverage is not mandated in the health care legislation.

Moreover, as Mary Ann Glendon’s article makes clear, these are services about which people hold a variety of views deriving from Constitutionally-protected religious freedom. Up until now, the Supreme Court has been very circumspect in requiring that medical treatment be provided contrary to religious views. A person whose religion forbids blood transfusions must be allowed to make that choice, even when all medical personnel disagree. The few exceptions are generally instances in which the Court allows intervention to save the life of a child – sometimes including an unborn child, when a mother’s behavior must be controlled to prevent damage to the child.

The HHS mandate speaks of “preventive” women’s reproductive care, but – as the USCCB Talking Points state so succinctly – it does not prevent any form of illness or disease. It prevents or terminates a healthy normal state, pregnancy.  It can lead to increased risk of breast cancer or heart disease (contraception) or depression (abortifacient drugs).

Missed opportunity

Many Catholics – and the USCCB – supported the idea of health care reform legislation, either as a Medicare-like program administered centrally or as an insurance-based program administered by employers and insurers.  I was among them. We all had in mind the importance of making sure everyone in the country had access to services to save lives and avoid disability.

It was a rude shock to find that this support was highjacked – that our support for those basic core services became the basis for a mandate for religious employers to pay for non-essential services that violate their consciences. There are two very important missed opportunities here:

  • The entire health care reform enterprise is jeopardized because the opportunity to gather and maximize support for universal coverage of core essential services is lost.
  • The opportunity for faith-based and progressive political leaders to work together on other issues is reduced (as when the highest-rank provider of services to trafficked people was denied a renewal of its contract because, in accord with its Catholic mission, it did not provide abortion counseling).

It is probably too late for the Obama Administration to salvage any trust with the Catholic and other faith-based social service providers.  It may be too late to create pared-back regulations so that faith-based providers could at least support some aspects of the health care reform.

President Obama had a chance to be remembered as the President who extended the basic right to medical care more broadly through the population.  I fear he will lose this opportunity out of ideological – or political – commitment that is not central to the issue.

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