Wanted to do a quick primer on the large business provisions in the PPACA, before we get surrounded by conservatives setting up round tables and spewing oceans of abstract theory. It’s probably too late, because if there’s anything I’ve learned in following the “health care debate” is it that no one, no one, ever wants to talk about health care. We’re going to talk about death panels or religious liberty or really anything else we can come up with rather than reach health care.
Here’s the issue. In the Administration’s view The Catholic Church should be being treated as any other “large business” under federal law. The issue is that the Catholic Church is a “large business” so must comply with the rules, in this case, the PPACA. The issue isn’t that the Catholic Church receives federal money, although it surely does receive lots and lots of federal money. Religious entities are granted certain exceptions under the law. The Catholic Church objects to the scope of the exemptions that they have been granted.
Here’s the bare bones of the law:
What is considered a large business?
You are generally considered a large business if you have more than 50 employees.
Do I have to provide health insurance to my employees?
The law does not require employers to provide health insurance.
Starting in 2014, large businesses (those with 50 or more full-time workers) that do not provide adequate health insurance will be required to pay an assessment if their employees receive premium tax credits to buy their own insurance. These assessments will offset part of the cost of these tax credits. The assessment for a large employer that does not offer coverage will be $2,000 per full-time employee beyond the company’s first 30 workers
If large employers won’t offer insurance that is comparable or better to that offered on the exchanges, their employees will be eligible for federal subsidies to purchase insurance on the exchange, and large employers are going to have to pay for that. “Adequate” is the key word there. I don’t know if you’ve ever looked at a policy Wal Mart offers, but I have, and it is not adequate.
And here’s what all the fuss is about:
Historic new guidelines that will ensure women receive preventive health services at no additional cost were announced today by the U.S. Department of Health and Human Services (HHS). Developed by the independent Institute of Medicine, the new guidelines require new health insurance plans to cover women’s preventive services such as well-woman visits, breastfeeding support, domestic violence screening, and contraception without charging a co-payment, co-insurance or a deductible.
“The Affordable Care Act helps stop health problems before they start,” said HHS Secretary Kathleen Sebelius. “These historic guidelines are based on science and existing literature and will help ensure women get the preventive health benefits they need.”
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. Often because of cost, Americans used preventive services at about half the recommended rate.
Last summer, HHS released new insurance market rules under the Affordable Care Act requiring all new private health plans to cover several evidence-based preventive services like mammograms, colonoscopies, blood pressure checks, and childhood immunizations without charging a copayment, deductible or coinsurance. The Affordable Care Act also made recommended preventive services free for people on Medicare.
Today’s announcement builds on that progress by making sure women have access to a full range of recommended preventive services without cost sharing, including:
• well-woman visits;
• screening for gestational diabetes;
• human papillomavirus (HPV) DNA testing for women 30 years and older;
• sexually-transmitted infection counseling;
• human immunodeficiency virus (HIV) screening and counseling;
• FDA-approved contraception methods and contraceptive counseling;
• breastfeeding support, supplies, and counseling; and
• domestic violence screening and counseling.
New health plans will need to include these services without cost sharing for insurance policies with plan years beginning on or after August 1, 2012. The administration also released an amendment to the prevention regulation that allows religious institutions that offer insurance to their employees the choice of whether or not to cover contraception services. This regulation is modeled on the most common accommodation for churches available in the majority of the 28 states that already require insurance companies to cover contraception.
Here is the broad exemption for religious employers issued by HHS:
The IFR defines a “religious employer” that qualifies for an exemption as an organization
that meets all of the following criteria:
(1) The inculcation of religious values is the purpose of the organization.
(2) The organization primarily employs persons who share the religious tenets of the
(3) The organization serves primarily persons who share the religious tenets of the organization.
(4) The organization is a nonprofit organization as described in section 6033(a)(1) and section 6033(a)(3)(A)(i) or (iii) of the Internal Revenue Code
This is the rule that California and New York follow, and it has survived court challenge. Obviously, the Catholic Church does not meet at least 2 of those requirements, and (arguably) does not meet 3 out of 4, so they are going to have to offer those employees who are not involved in core religious ministry contraception coverage with no out of pocket cost.
Contraception is a preventative health issue. That’s why the administration included contraception in the list of those benefits that must be covered with no out of pocket expenses. That’s their only interest in this. Contraception will not, of course, be “free”, despite what I see in internet comments from outraged moralists/fantasists. Employees who contract with an employer receive a salary package that includes health insurance. They earn health insurance just like they earn a pay check. They’re paying for contraception just like they’re paying for “well woman visits” or “diabetes screening” because the cost is included in the cost of the health insurance premium, but it’s much more fun for moralists to yell “free birth control!” than it is for them to yell “free well woman visits!” or “free diabetes screening!.”
The broad policy behind the Obama Administration standardizing health benefits that must be offered by large employers is worth defending. There are two parts. First, the PPACA seeks to cover everyone with at least a minimum standard of coverage. That’s humane, and it’s a good and worthwhile goal. Second, and this is hard-headed, the administration seeks to avoid the situation we have now, where some large employers may offer less than adequate insurance or no insurance, thus off-loading all or part of the health care costs of their employees to state government or the federal government or other people. I don’t know that the Catholic Church is doing that, they may offer fine health insurance, but that’s the core idea behind requiring a basic list of benefits, and requiring that certain benefits not involve out of pocket costs.
If we start granting exceptions to the rules for some large employers, we’re going to be back at square one, where people have a patchwork of coverage depending on where they work. If we start granting exceptions, some large employers will lobby to get a free ride by seeking exemptions and providing insurance that is less comprehensive than the plans that will be offered on the exchanges. The basic hard-headed and not at all touchy-feely premise is this: when large employers don’t cover their employees adequately, those employees end up receiving health care one way or another, and if their employees can’t pay for it themselves, someone else ends up picking up the tab because nothing is “free”.
Health food companies should have an exemption, too, for the diabetes coverage, since many health food folks believe that Type 2 diabetes is entirely preventable and treatable with healthy eating. Why should they have to pay for diabetes coverage for employees that eat too many carbs!? Huh? Answer me that, Ms. Smartypants.
thanks for this, kay.
It’d be fascinating to see a breakdown of Services provided by the Catholic Church non-church businesses, a la Planned Parenthood’s handy charts.
Thank you, Kay. You must have read my mind. I was hoping that someone would explain exactly what was involved in this decision. This is the first good explanation I have seen. I appreciate the good homework you do for your posts.
Get out of here with you and your “facts.”
Seriously, great work, Kay.
This has me confused. Are you saying that the Catholic Church itself doesn’t “primarily employ persons who share the religious tenets of the organization.” I was under the impression that the regulation doesn’t apply to the church but to Catholic universities and hospitals, etc.
Villago Delenda Est
Fantastic summary of what this is all about.
Please note the feature of this that basically tells large companies that they will NOT offload THEIR problem on to local, state, and federal governments without penalty.
There ain’t no such thing as a free lunch applies as much to Galtian overlord types as it does to mooching non-productive employees who make the wealth of Galtian overlord types possible through disparities between the value of the labor they provide and what they’re compensated for.
I’m sorry, that is confusing. I should have said Catholic hospitals, universities etc. The Catholic Church itself fits into the exception, of course.
Villago Delenda Est
The Bishops want exemptions for every enterprise that their boy-buggering gang has their fingers into. Universities, hospitals, you name it.
@Villago Delenda Est:
I don’t know why no one ever talks about that. Of course it was happening. Huge low wage employers were basically free loading, either on Medicaid or on uncompensated care.
@kay: That’s what I thought. Now, as to whether, the Church actually “serves primarily persons who share the religious tenets of the organization” I have some doubts.
This is surely proof that conservatives are stupid.
Why else force poor and/or darkskinned women to birth more future liberals and democratic voters?
Kay, I’ve been hearing from many of our gasbag “betters” that there is a general feeling among lay Catholics (even those who believe in and practice birth control) that this requirement for comprehensive reproductive health care is a bridge too far and tramples on religious freedom. I just don’t see the majority of Catholics getting their knickers in a twist over this. NW Arkansas is not very Catholic so I don’t have many Catholic friends to poll. Since Ohio is a much more Catholic state, perhaps you have more insight as to how those in the pews view this.
I know “no out of pocket on contraception” may seem minor, but I really do think they have to make a stab at standing up for the broader principle, which is that preventative services that primarily apply to women are worth including.
I have to say, too, I hate how this is being portrayed, as Obama “pandering” to women. Why wouldn’t Obama making a broad exception be Obama “pandering” to Catholic voters? Why are women reduced to the “pander” section? I’ll take pander or NOT pander, but I object to its use for only one side.
Wait, now I’m confused. If you work for a Catholic school, are you employed by the school or by the Catholic church?
I waver back and forth. On the one hand, I don’t think it’s a great idea for any pro-life org or entity to focus on contraception, because the vast majority of people accept contraception. On the other hand, if they’re successful at the “religious liberty” gambit, it’ll probably hurt him.
My honest opinion? At this point? I’m tired of media and politicians discussing womens health AT ALL. We never talk about womens health! EVER. Look at that list. Those are specific tests and procedures, and they’re science-based. But we’re off on the politics and the theology and the law. We’re always off in the weeds! No wonder no one understands this law.
Well, look at the rule. Do they primarily serve Catholics? Do they primarily hire Catholics?
That isn’t true of hospitals and universities, but it may be true of an elementary school, for example.
@kay: But do you think the majority of lay Catholics are upset by this rule?
Especially since ‘pandering’ to women is pandering to the majority of the population (51%). Not that I think minorities shouldn’t be served, but the pandering line implies that women’s issues are a small, specialized, unimportant issues of a tiny minority who can be easily dismissed.
I don’t know. I think the “liberty” argument has broad application in the US, and it fits in nicely with what I consider a wholly unfounded belief that “religion” is constantly “under attack”.
For me, it was fairly straightforward. They didn’t want to start exempting large businesses, and under the rule they’re a large business. I think it’s fair.
The whole PP-Obamacare-contraception issue has been just endlessly instructive to me, as far as how women are treated.
It’s like it’s okay to be ridiculously impractical when we’re talking about womens health, and every jerk in the world gets to EXPOUND on womens health and womens health and broader societal issues, where, really, I just want everyone to get the same access to care.
I don’t want to be in the middle of what I consider a proxy fight over every godammned thing IN THE WORLD.
@Nancy: Hi, Nancy. I’m a Catholic and work for a Catholic school and this whole thing has me wildly enraged. The bishops get to stand up and “protect” my religious freedom by denying me adequate health insurance? Gee, thanks, guys. Catholic women use contraception just like everyone else–very few laypeople follow the tenets of Humanae Vitae. I cannot begin to tell you how depressed I am that this is the public face of my church. Religious freedom, misogyny, is there really a difference? Sigh.
I know the Catholic grade school I went to didn’t employ more than 50 people, but I don’t know if the employer is considered the parish or the diocese. I would guess 70-80% of the students were Catholic. Is that serving “primarily persons who share the religious tenets of the organization”?
I hope you’re not charging me hourly for these answers.
You said it Kay. We’re treated not like individuals with vital health care needs, but anonymous female bodies to be bandied about like footballs in some ridiculous theological battle. The issue is health care and getting as many people access to it as possible. The “moral” opinion of Ross Douthat and the like about what women should or shouldn’t be doing with their bodies isn’t relevant.
Well, Mark S. I don’t know the answer.
I think the easy way to would be look at CA or NY and see how those states handled it, because that what they based the rule on.
I think CA and NY probably worked the bugs out.
@Rita R.: I agree with you and Kay, Rita. I am also thinking that a significant number of lay Catholic women are also getting tired of being bandied about like footballs. They have already spoken by their use of birth control. Not sure they will be in lock- step with the church on this. This may not be an easy sell for the church hierarchy and intelligentsia.
There is one error in this diary.
The “Catholic CHURCH” will be able to offer health care without contraception coverage.
But, Catholic Charities, most Catholic Hospittals, many Catholic educational instutuions (especially colleges and universities) and other entites who do not meet the test will be required to either provide comprehensive coverage or a subsidy to allow their employees to purhchase health care elsewhere.
One way to stop the argument would be to mandate that the exchanges offer a No/No* option at the same price as the comprehensive option – and if actuarial evidence finds that this option is less expensive (not likely as childbirth is very expensive), put any “excess” into the WIC or Head Start program.
* No/No = no-IVF, no vasectomy, no (intermitent) erectile disfunction, no contraception, no abortion
I thought of this parallel earlier. The Christian Science Monitor is a general-interest newspaper with some kind of affiliation with the Christian Science church. Journalists employed by the paper presumably have to be offered health benefits that include medications that Christian Scientists abhor. Does anyone feel that that would be a grave breach of religious liberty?
Seems to me that a Catholic hospital, or a Catholic university, should have to offer health benefits regardless of the tenets of the faith, because the people covered do not have to be Catholics or swear to abide by Catholic doctrines as a condition of employment. And, frankly, IMHO if you’re the groundskeeper of a Catholic church, you should be able to buy a health plan that covers contraception too. You’re a worker under contract to them, not a convert.
If a religious institution does secular business, they have to uphold the terms prescribed by the federal government, in my view, and if they don’t like it, they can work on overturning the goddamn Enlightenment.
Thanks, Kay for this. Unfortunately, it won’t matter what the facts are. The uproar on this is going to be big and we’ll see if the administration stands strong.
Obama seriously needs to get his people out and EXPLAIN the decision before it gets explained FOR them by the GOP liars. Or else we’re just going to see “OBAMA HATES CATHOLICS” looped on TV.
So is the Catholic Church admitting their members use birth control?
@WereBear (itouch): No, just the heathens who work for their hospitals and schools.
Villago Delenda Est
That is, in fact, what all this is ultimately about. As Michelle Bachmann once said, “the Renaissance was a mistake”.
JR in WVa
The numbers I’ve seen show that more than 90% of catholic women use birth control not approved by the church.
And why should a bunch of “celibate” elderly men make decisions about women’s health anyways? That’s like letting dogs decide what cattle can eat.
There are many, many lay Catholic women who are unhappy with the church on these issues. My Catholic mother for one, who more and more frequently is finding herself walking out of Mass on Sunday angry about homilies on abortion and the like instead of uplifted. She stays with the church because of her own beliefs of what Catholicism is really all about, but not because the institutional church is giving her any reason to.
But I’ve just about given up on a church that has decided in the past 20-30 years to make opposition to abortion, birth control and gay people its seeming raison d’etre. Not to mention all that covering up for and enabling of pedophilia in the priestly ranks.
@Villago Delenda Est:
Wow, did the crazy-eyed lady really say that? Explains a lot.
You’re right 22state, the church itself would be exempted.
Catholic Charities would not.
At this point “Catholic Charities” is almost deceptive naming, though because they get millions in government funding.
I’m not sure they’re completely straight-up with that name ;)
Might have been wholly charitable at one point, but no longer true.
Here in Wisconsin, Mayo had taken over the formerly Catholic hospital. I would be fascinated to find out what is going on over there. I remember a newpaper article a few years ago, before this merger, where the Catholic hospital was not giving out Plan B under any circumstances.
And do not imagine that the real fanatic anti-choicers can tell the difference between contraception and abortion. Even the pill, on the PP website, is described as possibly preventing implantation if by some ..ahem.. miracle the sperm gets through the thickened mucus and meets the egg that shouldn’t be there. They really truly see this as abortion.
I am so sick and tired of these assholes.
To be clear: Diet and exercise can ABSOLUTELY prevent type II diabetes in EVERY CASE. In nearly every case, it can effectively treat type II diabetes.
Crappy regulation that btw, it means that hiring the 51st worker has an extra marginal cost of $42,000, which could well be more than the employee’s salary.
Really? What is it, exactly, that contraception “preventates”?
More to the point, what does it even mean to “preventate” something?
[clue for the dense: look up “preventive”; now look up “preventative”; are you “orientated” yet?]
Random factoid: they are now discovering that some cases of “Type II diabetes” in adults are actually slow-onset Type I (they’re calling it “Type 1.5”). One of the ways you can tell is if diet and exercise doesn’t help control one’s blood sugar.
I don’t understand why you are buying the Church’s framing that what is at question here is whether “The Catholic Church” is a religious organization.
The point is that we’re not talking about “The Catholic Church” as some kind of unitary entity. We’re talking about Catholic universities and hospitals, which pretty clearly fail three out of the four listed criteria.
Thanks for this information, Kay, but how do you think Catholic hospitals and the like will respond to this? The incentive would seem to be for them to just drop health insurance coverage if they don’t want to include contraception coverage in their employee plans. Then what? Would the hospitals etc, then be assessed some fee to offset the costs of providing the insurance through the market exchanges?
The state governments of California and New York are not bound by the Religious Freedom Restoration Act. The federal government is still bound by the provisions of that law, which means that strict scrutiny review applies to this decision (as opposed to the more-lenient rational basis review that California’s Supreme Court applied).
Requiring Catholic hospitals to provide birth control to their employees violates a core tenet of Catholic belief- that life begins at conception. It is almost certainly unconstitutional, and if it results in the mass closure of Catholic hospitals it will create a national healthcare crisis.
Currently, roughly 12.5% of all community hospitals nationally are Catholic hospitals. In 20 states, those hospitals accounted for more than 20% of admissions. In some rural areas, 100% of emergency care access is provided by Catholic healthcare systems. I don’t see America spending the necessary revenue in the near future to replace that infrastructure, so it’s the only access many Americans (particularly in rural areas) have to healthcare. If the Catholic Church shut down Catholic Charities, many people would die- many more than would die from a reasonable compromise like opening more Planned Parenthood clinics and bringing the public option into the ACA (a pipe dream, I know).
If the free exercise of religion means anything, it means not having to participate in activities deemed abhorrent under one’s religious views. This nation would not exist if people were required by its laws to perform activities that they considered abhorrent. One may despise religion and religious people, but under the Constitution people still have the right to possess and practice their religious beliefs. Requiring the Catholic Church to provide birth control to the employees of its affiliated charities- and on this issue, the piety of individual Catholics is completely irrelevant, as the number of lay Catholics who personally use birth control has nothing to do with what the Church itself professes- violates the beliefs of the Catholic Church just as surely as it would violate the beliefs of an atheist if the government mandated that they pay a Church tithe.
I am convinced that the Obama Administration is violating the Religious Freedom Restoration Act, which states that “Government shall not substantially burden a person’s exercise of religion even if the burden results from a rule of general applicability.” I believe Supreme Court will overturn the Obama Administration’s decision on the issue if prior federal caselaw is any indication, and I believe that the fact that women can get birth control and abortions from Planned Parenthood on a need-based sliding scale proves that there are methods of achieving the government’s purpose that do not involve infringing on the religious beliefs of the Catholic Church.
Given that less-intrusive methods of achieving the government’s goal exist, and given that the government’s purpose here cannot surpass the strict scrutiny analysis that the RFRA would require of it, I can’t see how this decision would stand in federal court. Nor do I think it should; Catholics view charity as a religious necessity, and the Obama Administration has effectively decreed that they must directly subsidize actions they view as murder if they intend to continue to engage in charitable activities.
@47 Name – February 6, 2012 | 11:39 am · Link
Look, no. States are bound by the constitution. They’re government, and may not violate amendments to the US constitution regarding government as a whole. You’d have to posit an entirely alternate theory which has not operated since we had this thing called ‘the civil war’. States don’t get to violate civil rights. Period. End of sentence.
Second, you argument that Catholic hospitals serve a larger portion of the country than are Catholic also breaks your point – they are no longer serving a ‘primarily’ Catholic audience.
Thirdly, this has nothing to do with burdening religion. At no point are they required to personally procure or use contraception. No court has ever held that health insurance covering blood draws or any other medically indicated procedure violates someone’s ability to be religious.
Exemption for employers because the employer is religious? Ridiculous. Why should an employer get to ignore regulations or labor law because they have some personal belief? We don’t allow people to violate health codes because their religion doesn’t include the germ theory of disease; we don’t allow people to own slaves because their religious beliefs include it; we don’t allow them to use pay scales from the bible if they violate the minimum wage.
Lastly, I don’t think this has anything to do with the Obama administration’s goals – it has to do with the goals of those who wish to impose their religious views upon the rest of us. Upon patients who need medical care; upon employees who need honest wages. Nor do I think Catholics will turn against
Obama for this; who nearly unanimously do use church-disapproved contraception.