WASHINGTON -- The Trump administration's rules regarding insurance coverage for contraception and billing for health insurance premiums that pay for abortion coverage are drawing praise and criticism from both sides of the reproductive rights issue.
On Wednesday, the Trump administration issued two final rules on contraceptive coverage. "The first of today's final rules provides an exemption from the Affordable Care Act's (ACA) contraceptive coverage mandate to entities that object to services covered by the mandate on the basis of sincerely held religious beliefs," the Department of Health and Human Services (HHS) explained in a . "The second final rule provides protections to nonprofit organizations and small businesses that have non-religious moral convictions opposing services covered by the mandate."
Under the ACA, employers are required to cover all forms of contraception with no co-pay. Certain religiously affiliated employers, such as churches or religious-affiliated hospitals or universities, were exempted from this rule; however, once they signed paperwork stating that they did not want to provide coverage, the employer's insurer or third-party administrator then had to provide that same coverage, with no co-pay, to employees who needed it.
The new rules allow certain employers to refuse to cover contraceptives for any moral or religious reason. It also no longer requires employers to allow their insurers or third-party administrators to provide separate coverage, instead calling that arrangement an "optional" accommodation. In addition, "entities that object to covering some, but not all, contraceptive items would be exempt with respect to only those methods to which they object," according to the fact sheet.
The exemptions for moral reasons apply to nonprofit organizations and to closely held businesses, as well as to institutions of education, health insurance issuers serving exempt entities, and individuals. "The Departments [of Health and Human Services, Labor, and Treasury] considered public comments and decided at this time not to extend the moral exemptions to publicly traded businesses or government entities," the fact sheet noted.
Access and Health Concerns
Needless to say, ob/gyn groups had varied opinions on the rules. "The American College of Obstetricians and Gynecologists (ACOG) strongly objects to the administration's decision to implement the final rules ... that continue an alarming trend of reducing access to contraception," ACOG president Lisa Hollier, MD, MPH, . "These rules threaten to erode decades of progress in increasing women's reproductive autonomy. As the nation's largest professional organization for women's healthcare physicians, ACOG recognizes contraception as an integral component of women's healthcare and opposes any policy that seeks to restrict or eliminate women's meaningful access to the full range of contraceptive methods."
Women's health concerns are a major consideration, said Sanithia Williams, MD, a San Francisco ob/gyn and a fellow with Physicians for Reproductive Health, a pro-reproductive rights organization. "This has really far-reaching implications ... particularly for women who have other medical conditions that could make pregnancy life-threatening for them but even for those that don't," she said. "There are a lot of reasons why contraception and birth control can improve patients' lives."
"A lot of cardiovascular and other medical conditions can make pregnancy particularly dangerous, and pregnancy in general does have risk. I think people should be empowered to plan pregnancies, and contraception is one way they can do that."
But the American Association of Pro-Life Obstetricians & Gynecologists (AAPLOG) disagreed. "AAPLOG strongly supports the right of conscience for employers who choose not to fund drugs like Ella and devices like the IUD which clearly act to end the life of a human embryo," the group said in a statement sent to 51˶. "Our right of conscientious objection is at the very foundation of what it means to be an American citizen, and we do not check that right at the door when we come to work."
Who Will Be Affected?
One bone of contention about the rules is how many women they would affect. The Trump administration said, "The Departments estimate the exemptions should affect no more than approximately 200 employers with religious or moral objections, with many entities not being affected because they were already permitted not to cover contraceptives under the previous rules, or are protected by permanent court injunctions. The Departments estimate the exemptions may affect the coverage of approximately 6,400 women, and state that in no case will they impact more than 127,000 women, which the Departments suggest is far more than will actually be impacted."
But Adam Sonfield, senior policy manager at the Guttmacher Institute, a pro-abortion rights research organization, said that HHS is mostly basing its estimates on the employer groups that sued the Obama administration over the coverage mandate, such as religiously affiliated organizations like Little Sisters of the Poor. "That is one obvious group that very likely will use these exemptions, but well beyond that, the best information we have is from a by the Kaiser Family Foundation [which] estimated that 3% of all nonprofits and 10% of largest nonprofits" were using the earlier accommodation which allowed them to not pay for the coverage and instead have their insurers pay for it.
"Kaiser also noted that there are 1.4 million nonprofits in the country, so 3% of 1.4 million [employers] is quite a lot, a heck of a lot more than 200," he continued. "We don't know that every entity that was using [the other] accommodation would now seek an exemption ... but we can expect that some, perhaps many, will want to use [this] exemption instead, and that's quite a lot of people."
The rule also brings many questions for women seeking contraception, said Mindy McGrath, director of advocacy and communications for the National Family Planning and Reproductive Health Association, a provider organization based here. "This opens up a lot of uncertainty in terms of women knowing whether or not plans cover contraception, and therefore their provider having good information about what services are and are not covered," she said during a phone interview in which a public relations person was present.
To provide women with an additional option if their employer doesn't cover contraception due to moral or religious objections, the administration is also pushing for such women to be added to the group of eligible patients for contraceptive services under Title X, a federal law that previously covered mainly low-income women, McGrath added. "Title X was not conceived to meet the needs of women with employer-sponsored insurance; it is already underfunded and doesn't have capacity and resources to meet those needs."
Proposed Rule on Premiums Related to Abortion
Another rule the Trump administration issued Wednesday -- this one a proposed rule -- that requires insurers in the ACA's health insurance exchanges to send a separate bill and collect separate payments for the portion of the consumer's premium attributable to certain abortion services for which public funding is prohibited. This proposed rule "[serves] the dual purpose of helping issuers meet the statutory requirement to keep funds for these services separate from federal funds and helping consumers understand that they have selected a plan that includes this coverage," the Centers for Medicare & Medicaid Services, which administers the ACA's federally run exchanges, said in a .
However, pro-abortion rights groups see another agenda at work. "The bottom line is this is something that anti-abortion activists have been pushing quite a while -- banning private insurance coverage of abortion -- and this is the Trump administration helping them out," said Sonfield. "Current restrictions on abortion in the marketplace already are quite burdensome; we're already seeing plans not covering it even when they're allowed to. It seems the proposed rule's only real purpose is to make it more difficult for insurers to offer the coverage ... and the real goal is to get insurers to stop covering it altogether."
AAPLOG applauded the proposed rule. "By requiring insurers to inform their clients about how much money goes to cover elective abortion, clients can make a much more informed choice about which insurance company they choose to support with their money," the group said in a statement.