Health Care Policy Analysis

Introduction

Women’s reproductive rights have been an ongoing issue the United States has dealt with for decades. The main issues surrounding women’s rights, namely the woman’s right to choose, has been debated and politicized, often times with out the actual input from a woman. This policy analysis will examine the relationship between politicizing the reproductive rights of women coupled with the rights of employers to refuse coverage for birth control and the policies surrounding these issues.

In 2018, Federal policy makers finalized policy changes that gives employers the right to deny or opt out of coverage of birth control to women on the grounds of religion or moral conflict.

The number of women this will effect is not well numerated; however, one can deduce that a multitude of women and families will be affected. Many of which who do not share the same moral or religious convictions of their employer.

Roe vs. Wade is a court decision made by the supreme court in 1973, with this decision the supreme court ruled that a woman has the right to safe and legal abortion. The ruling cemented the right to abortions at a time when women died during or after unsafe illegal abortions. In 2019, with the confirmation of supreme court justice Kavanaugh, a political conservative, abortion rights are at risk of being overturned, or weakened. With this comes the concern that overturning of the federal policy, will give the decision to the individual state as to the decision of abortion rights. In some states this may lead to the outright restriction of abortion without exception, especially abortion greater than 20 weeks.

The issue becomes intensified given that some employers, especially those with religious affiliations, have banned coverage for birth control. This presents an important moral dilemma for the woman, on one hand she can’t obtain birth control, on the other when she gets pregnant, she does not have the option to a safe legal abortion. This is important because it completely takes the authority over one’s own body from the woman. It places the dominion and power of a woman into the hands of politicians and policy makers.

Problem Statement

There is currently, and historically, a need for birth control for women to have autonomy over the timeframe she wants to have a child, if at all. Taking the option for insurance covered birth control away from the woman, while simultaneously reversing abortion laws such as Roe vs wade has dangerous implications for the health, physical and social well-being, political position and rights of a woman. This sets a precedence for an attack on womanhood, reproductive rights and family planning on ones on time. This also gives forced religious conformity on the woman, based on the religious beliefs of her employer.

Relevance and timeliness of this issue is evidence by the recent appointment of conservative supreme court justice Kavanaugh, as well as the recent supreme court ruling in Burwell Vs. Hobby Lobby. In Burwell vs. Hobby Lobby the supreme court ruled that companies had the right to refuse coverage of contraception to their employees. These employers were given a year's “safe haven” to work with stakeholders to determine contraceptive coverage in each state. In this way, control over religious exemption policies for contraceptive coverage has been devolved to individual states. Policies in California and New York, for example, mirror the narrow criteria for religious exemption outlined in the original Affordable Care Act language. In contrast, Florida and Texas have no official policies on exemption, making it easier to refuse coverage on religious grounds. Also, attacks on the affordable care act has, finalized late 2018, allowed religious organizations to claim exemptions on to the affordable care act, allowing them to decline birth control coverage based on moral and religious objections (Batra & Bird 2015).

Understanding the political agenda to restrict women’s reproductive rights is important. According to Fried (2013), Immediately following the Roe vs Wade decision, the anti-abortion movement gained momentum. It became part of the burgeoning New Right-Wing agenda, which, with the election of President Reagan, consolidated its power. Steeped in religious dogma and fear-mongering, the issue of abortion and birth control went from a decision up to an individual, to the political agenda of the conservatives. Much of the current debate surrounding family planning focuses on women’s reproductive rights and health. In the 1960s, however, proponents of these programs often emphasized their links to the economy. Both President Lyndon Johnson and President Nixon stressed how family planning programs would promote the opportunities of children and families and thus drive economic growth (Bailey, 2013)

The stakeholders in this ongoing issue are the woman, the organization withholding the coverage of birth control and the pro-life movement. Pro-life movements such as the American Life League, ALL, the Catholic church and other religious groups opposes abortion and contraception under any circumstances. Other stakeholders include organizations such as planned parenthood which is a pro-choice organization. According to Planned Parenthood, the stance they take regarding the issue includes the belief that, women facing an unintended pregnancy must have access to safe, legal abortion services without exception. Also, they believe that all people deserve access to birth control and other preventative services. Planned Parenthood vigorously opposes the religious and moral exemptions to deny access to contraception, stating, refusal laws are a license to discriminate.

Government intervention on this issue is of major importance. According to the New York times, in federal Judge Haywood’s recent, the judge stated, decision women who lose their entitlement to cost-free contraceptives are less likely to use an effective method, or any method at all — resulting in unintended pregnancies. Moreover, many of these women are likely to turn to state programs to obtain free contraceptives, at significant cost to the states. This is one example that illustrates why the government should have an interest in this issue (Pear, 2019). More insurance covered birth control, will equal less cots to the states and less unwanted pregnancies. More un-intended pregnancies will lead to more illegal unsafe abortions. More access to effective contraception will lead to less unwanted abortions.

Church and state are also separated in the United states of America. Americans practice many different religious doctrines and have many different interpretations. According to work by Srikanthan and Reid (2008), religious and cultural factors have the potential to influence the acceptance and use of contraception by couples from different religious backgrounds in very distinct ways. Within religions, different sects may interpret religious teachings on this subject in varying ways, and individual women and their partners may choose to ignore religious teachings. Cultural factors are equally important in couples’ decisions about family size and contraception. According to research by Kavanaugh and Anderson (2013), access to safe, effective contraception is both a public health and feminist imperative. Family planning products and services are associated with a range of health benefits, including reduced unintended pregnancies, improved infant health, and lowered pregnancy-related morbidity and mortality. Kavanaugh and Anderson go on to state, couples who do not use contraception have an 85% chance of experiencing and unplanned pregnancy. All this illustrates the implications of denying and restricting access to birth control based on someone else’s religious will.

As policy is being shaped, and the affordable care act is being changed by the current administration to eliminate the mandate of all employers to provide birth control as a penetrative service, protection of women’s rights has become an issue at the fore front of current conversation. The current climate of political gender wars sets the climate for alternative concepts to protect the interest of women and families. Different methods should be explored and evaluated for practicality, that protect the religious freedoms of all involved parties, including the woman, at the center of this issue.

This issue also becomes a socio-economic attack on poorer women, it is a well-known fact that women in a higher socioeconomic class have less children than the women with lesser incomes, this troubling truth becomes exponentially wider when access to proper contraception coverage is blocked and denied by an employer.

Existing Policy

In November 2018, the current administration, under the leadership of President Trump, finalized policy that vastly expanded the types of employers that are exempt from the Affordable Care Acts requirement for preventative services such as contraception. Previous regulations, under the Obama administration, only gave exemptions to houses of worship or hospitals with religious affiliation. Current regulations allow nonprofit or for-profit employers with an objection to contraceptive coverage based on religious beliefs or moral objections to qualify for an exemption and drop contraceptive coverage from their plans. The current regulations also apply to institutions of higher learning that cover students. This opens the door for any employer or university to qualify for an exemption on the grounds of religious or moral opposition. This denies the female employee and student the option to birth control at no cost to her.

Policy makers and government officials at the individual state level should act in the wake of these recent federal changes. State coverage requirements are a strong defense for the women in the respective states. According to recommendations by Sonfield (2017), all states could act to ensure that health plans cover the full list of contraceptive methods and services required under the federal guarantee. That includes services such as female sterilization procedures and many contraceptive products sold over the counter including emergency contraception. Sonfield goes on to assert, advocates and policymakers should seize on that popularity and build on the momentum from new state policies. They should put public pressure on insurance companies and employers to retain full coverage of contraceptive care. And they should set the groundwork for a new federal law to override what would be a harmful and unpopular decision by the Trump administration.

IV Selecting the evaluation criteria

Criteria that if met, would rectify or mitigate the problem include the utilitarian approach that states that actions are morally right if and only if they maximize the well-being or, alternatively, minimizes the bad. It moves beyond the scope of one’s own interest or beliefs and takes into account the interest of others. As such, restriction of contraception paid by employers should be eliminated, because it does not maximize the well-being of the woman. Nor does it minimize the bad for the woman and family in that the elimination of authority on ones on body creates the possibility for unwanted pregnancy. To rectify the problem, the option for employers to claim religious and moral exemptions should be eliminates. In evaluation of this criteria, the following where applied; Efficiency, Improved health outcomes, Equity.

Efficiency

As summarized by Sonfield (2014), a 2012 analysis by the U.S. Department of Health and Human Services, coverage of contraception without patient out-of-pocket costs should not raise insurance costs and is likely cost-saving. The federal government, the nation’s largest employer, reported no increase in costs after Congress required coverage of contraceptives for federal employees in 1998. Moreover, studies comparing the cost-effectiveness of contraceptives find that all methods save insurers money, after the costs of unintended pregnancies averted are accounted for with the most effective methods being among the most cost-effective ones. Additionally, according to Frost, Zolna and Frohwirth (2013) by helping women avoid unintended pregnancies, public funding for contraceptive services in 2010 resulted in net public savings of $10.5 billion, or $5.68 for every dollar spent. Those savings accrue to Medicaid for costs of pregnancy-related care and infant care.

Improved Health Outcomes

Contraception use results in unintended pregnancy and reduces therapeutic abortion. Adolescents who receive comprehensive counseling and face no cost barriers to contraception continue to use them long-term resulting in fewer unwanted pregnancies in that population. A no-cost contraceptive program in Colorado demonstrated an impressive 29% decrease in teen pregnancies among users compared with those relying on other methods (Batra, 2015). Unintended pregnancy may present an unacceptably high health risk for women who have underlying medical conditions, some of which are exacerbated by pregnancy. Abortion is often an indication of unintended pregnancy. The vast majority of abortions in the United States are performed safely and thus have very few negative health consequences for women. Some of the strongest evidence regarding the link between family planning and health outcomes supports the conclusion that helping women and couples to time their pregnancies and births directly improves birth outcomes. This is important because avoiding preterm birth (before 37 weeks’ gestation) and low birth weight (less than 5.5 pounds) significantly decreases the chances of infant mortality, birth complications and medical challenges for the baby at birth and beyond. Short birth intervals have been linked with numerous negative perinatal outcomes. (Kavanaugh & Anderson 2013).

Equity

Clearly this issue affects women only and it disproportionally affects minority and poor women. As stated previously, women with higher socioeconomic levels have less children than women with lesser incomes. Therefore, the burden of contraception restriction is placed heavier on women in lower socioeconomic class. Changing the current policy will also change the distribution of burdens and benefits in society, making it more equitable. This manifest the utilitarian approach, of being for the benefit of the greater good of women, not just the upper-echelon women in our society.

Constructing the Options

State government has to select and examine several options to rectify the problems on the federal government’s changes to the cost-sharing options for birth control portion of the Affordable care act. The alternatives include: comprehensive contraception coverage among all employers; government assuming the cost of contraception coverage; offer a religious or moral exemption for a much narrower set of explicitly religious non for-profit employers.

Comprehensive Contraception Coverage

Missouri could act to ensure that health plans cover the full list of contraceptive methods and services required under the federal guarantee, this includes; emergency contraception, IUD, female sterilization, oral contraception etc. Adding to this would be the elimination of cost sharing methods, which could be a potential barrier, such as copayments, deductibles and any other out-of-pocket costs. Sonfield (2017) even asserts that, states could help close gaps in coverage that have persisted even under the federal contraceptive coverage guarantee. They could require health plans to cover vasectomy and male condoms, Illinois, Maryland and Vermont have already required coverage for vasectomy. Other recommendations made by Sonfield include, States joining Maryland in requiring plans to cover over-the-counter contraception obtained without a prescription; currently, plans may require a prescription for these methods, which negates the advantages of over-the-counter status. States should put public pressure on insurance companies and employers to retain full coverage of contraceptive care. And they should set the groundwork for a new federal law to override what is a harmful and unpopular decision by the Trump administration.

Federal government could avoid imposing the cost on employers claiming a religious objection by instead taking on the burden itself. This option must be used only for employers who have true religious or moral objections to contraception, not just any employer who may choose to use the exemption to save expenses on pregnancy related care. The option to have women pay up front, with a reimbursement from the government later, should be excluded. As, this would create the same financial burden to the woman as having the woman cover the cost herself. While this option is not the most feasible cost wise due to the already strained system, it is better than the alternatives.

When granting exemptions to institutions, policymakers should limit them based on characteristics such as whether the institution is nonprofit or whether it is explicitly a house of worship such as a church, temple, or synagogue. Another option within this context is to allow the religious or moral exemption to be granted for services such as abortion and sterilization. However, religious and moral exemption needs to be strictly prohibited for services such as; counseling, information or referrals, to help ensure that patients understand their options, have informed consent, are not effectively abandoned by the health care system. Another option is to continue the stipulations in the original Obama era, Affordable care act. In this option Employers won’t have to arrange or pay for contraceptive coverage, but employees will still be able to access free contraceptive services at no cost, through a third party, as long as they maintain their employer plan. This ensures the religious liberty of actual religious organizations, not just and organization that has a moral objection which may not be in line with the beliefs of the actual woman.

This method does have the promise of being highly efficient and cost saving. This option will provide coverage of birth control as a comprehensive option for all. Our own federal government implemented this alternative and found no increase in cost, and high efficiency. The avoidance of unintended pregnancy, in itself, saves insurers money and as such provides evidence of the efficiency of this option. This option will naturally lead to improved health outcomes in that, contraception usage results in fewer unintended pregnancies and reduces therapeutic abortion. Also, increased autonomy over one’s own body is directly linked to increased feelings of self-esteem, leading to improved mental health and wellbeing. The criterion of equity is satisfied in that it more evenly distributes the playing field among women of color and women of lower socioeconomic levels. Satisfies the utilitarian value of being for the greater good.

This option would consist of the government taking on the cost of paying for birth control coverage for the individual whose employer has opted for the religious and moral exclusion. While this method would eliminate the woman being without coverage, it would not be highly efficient. Having the government of each state responsible for birth control coverage, would prove to put even more of a strain on an already over overwhelmed system. As with the previous option, this option will reduce unintended pregnancy. As previously stated, unintended pregnancy may present an unacceptably high health risk for women who have underlying medical conditions, some of which are exacerbated by pregnancy. Reduction of unintended pregnancy improves health outcomes for women. Changing the current policy to this alternative will change the distribution of burdens and benefits in society, making this an equitable alternative.

Efficiency in this alternative is high. Employers and insurers will still have to provide coverage for the individual regardless of moral or religious objections unless the employer is a strict place of worship. Improvements in health outcomes is high, as with the other alternative’s avoidance of unwanted pregnancy and abortion is the primary consequence. Finally, equity in this particular alternative may not be as simple. On one hand this alternative may deem equitable in that it More evenly distributes the playing field among women of color and women of lower socioeconomic levels. However, on the other hand, the employers who are unable to opt for the religious and moral objection may have the sense that their religious liberties are infringed upon. This would be an unintended consequence of this alternative.

Recommendation

Based on this policy analysis, the recommended alternative for the reformation on employer covered birth control is to provide comprehensive contraception coverage. This option has a high degree of efficiency, improved health outcomes, and proves to be equitable for the individual women. It eliminates the option that allows any employer to opt out of contraception coverage for religious or moral grounds, making it fair across the board in that it does not favor one type of employer. Women will have the added assurance of being able to plan for pregnancy rather than viewing pregnancy as something out of their control, leading to improved health outcomes. The societal distribution of opportunity will be more equitable for women of all racial and socioeconomic levels. This alternative satisfies the utilitarian value of being for the greater good of society as a whole.

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