Moving Target: The Obama Administration's Shifting Message on the HHS Mandate

News Analysis: Contraception has long been pitched as a ‘solution’ for poverty; now that argument is being adapted to mainstream America.

Georgetown Law student Sandra Fluke (l) is greeted by U.S. U.S. Rep. Elijah Cummings (D-MD), House Minority Leader U.S. Rep. Nancy Pelosi (D-CA) and U.S. Rep. Carolyn Maloney (D-NY) after a hearing before the House Democratic Steering and Policy Committee Feb. 23.
Georgetown Law student Sandra Fluke (l) is greeted by U.S. U.S. Rep. Elijah Cummings (D-MD), House Minority Leader U.S. Rep. Nancy Pelosi (D-CA) and U.S. Rep. Carolyn Maloney (D-NY) after a hearing before the House Democratic Steering and Policy Committee Feb. 23. (photo: Alex Wong/Getty Images)

WASHINGTON — When the Obama administration first unveiled its contraception mandate last August, Americans were told that medical experts had compiled the list of co-pay-free “preventive services for women” and that “cost-effectiveness” played no role in the decision-making process.

Last week, the administration appeared to contradict its earlier message when Health and Human Services Secretary Kathleen Sebelius testified before the House Energy and Commerce Subcommittee on Health and claimed that expanded access to contraception would bring costs “down, not up” for insurance carriers.

Additional justification for the controversial policy was offered at another House hearing, which featured Dr. Linda Rosenstock, chairwoman of the Institute of Medicine’s Committee on Preventive Services for Women, which included contraception in its list of recommended co-pay-free services.

Rosenstock told the committee that contraception services “enable women and couples to avoid an unwanted pregnancy and to space their pregnancies to promote optimal birth outcomes.”

So what’s going on? Do American women need “free” contraception because it’s good for their health, or because it saves Uncle Sam and health insurance providers money? Is it for devoted couples spacing children, college students seeking hassle-free sex, or female patients with medical problems — as Sandra Fluke recently asserted in testimony before House Democrats?

For many Catholics, Sebelius’ statements before the House Energy and Commerce Committee are the most troubling, because they echo past arguments used to justify coercive population-control policies in developing countries. Advocates of such polices have argued that suppressing human births will promote a nation’s economic well-being — an assertion that demographic experts like Nicholas Eberstadt have strongly challenged.

In her testimony, Sebelius sought to explain why insurance carriers would accept President Obama’s Feb. 10 “accommodation,” designed to address the objections of religious groups that refused to cover abortion-inducing drugs and other services that violated their moral teachings.

The president determined that insurance carriers would be required to cover the costs of contraception coverage for private employers that objected to these services on moral or religious grounds. But critics have dismissed the “accommodation” as an “accounting trick,” and they have predicted that insurance carriers will pass on the costs of coverage to religious employers through increased premiums.

Not Having Babies a ‘Benefit’

Pressed to respond to this critique, Sebelius suggested that insurance companies would welcome the new policy: “The reduction in the number of pregnancies compensates for the cost of contraception.”

Rep. Tim Murphy, R-Pa., asked her, “So you are saying: By not having babies born, we are going to save money on health care?”

Sebelius replied, “Providing contraception is a critical preventive-health benefit for women and for their children.”

Murphy responded: “Not having babies born is a critical benefit. This is absolutely amazing to me. I yield back.”

Sebelius repeated: “Family planning is a critical health benefit in this country, according to the Institute of Medicine.”

Back in 2009, then-Speaker of the House Nancy Pelosi offered her version of the anti-poverty argument for contraception in a statement suggesting that government-funded birth control would actually boost the U.S. economy.

A similar assertion was made in an Aug. 1, 2011, CNN story marking the introduction of the HHS contraception mandate: “Supporters also say covering contraception helps the government save money up front. According to an analysis from the Guttmacher Institute, in 2006, of the 2 million publicly funded births, 51% resulted from unintended pregnancies, accounting for more than $11 billion in costs.”

But the contraception mandate requires private employers to provide contraception coverage, while CNN, like most Democratic supporters of the HHS mandate, cites data on the costs of “publicly funded births.”

There is on-going debate and conflicting research about whether access to contraception actually reduces unintended pregnancies or abortion rates. (Recent data confirm that out-of-wedlock births among U.S. women under 30 are now the norm, though it is not clear whether these births were “unintended” or merely growing evidence that sexual relationships, marriage and procreation have been compartmentalized—in part, say Catholic moral theologians, because of a “contraceptive mentality.”)  But, clearly, private health benefits will have no direct impact on at-risk teenagers and struggling single mothers in the inner city. So why make that argument?

One reason, perhaps, is that scary statistics make U.S. tax-payers nervous and lead some to conclude that these “unwanted”  children will end up on the public dole. Better, perhaps, to prevent those “unintended” pregnancies in the first place.  Indeed, a few years back, one social researcher actually made the argument that legal abortion had helped to reduce the nation’s crime rate.

15-Year-Old Recommendation

A different explanation for the HHS mandate was offered by Dr.Rosenstock, the UCLA public health expert who chaired the committee that decided which preventive services for women would be mandated under the new Patient Protection and Affordable Care Act.

Last week, in her testimony before the House Judiciary Committee, Rosenstock did not offer a cost-benefit analysis of “contraception services.” She sought to characterize the deliberations of her “independent” committee as scrupulously scientific and set apart from political or economic calculations.

Rosenstock reminded the committee that the Institute of Medicine “is the health arm of the National Academy of Sciences, an independent, nonprofit organization that provides unbiased and authoritative advice to decision makers and the public.”

“Women with unintended pregnancies are more likely to receive delayed or no prenatal care and to smoke, consume alcohol, be depressed and experience domestic violence during pregnancy,” she noted. “Unintended pregnancy also increases the risk of babies being born preterm or at a low birth weight, both of which increase their chances of health and developmental problems,” she told the House committee.

Her testimony did not distinguish between the needs of poor, at-risk female patients and other women holding jobs in private companies and nonprofits. Nor did Rosenstock acknowledge that representatives of Catholic health-care institutions — the second-largest group of health-care providers in the nation — were not invited to testify at the public forums organized by her committee.

Catholic health care was snubbed, at least in part,  because church-affiliated institutions reject both the anti-poverty argument for contraception, and the related notion that “pregnancy is a disease” — to repeat the USCCB characterizatation of the HHS mandate. Commentator Ross Douthat, in a Feb. 18 column in The New York Times, offered a secularized version of one argument against the mainstream public health community’s stance on contraception: “[I]t’s more important to promote chastity, monogamy and fidelity than to worry about whether there’s a prophylactic in every bedroom drawer or bathroom cabinet.”

In fact, the record suggests that Sebelius left little to chance when she asked the Institute of Medicine to compose a list of mandated services.  A Feb. 2, 2011, story in The New York Times notes that the IOM issued a report more than 15 years ago that called for “increasing the proportion of all health-insurance policies that cover contraceptive services and supplies, including both male and female sterilization, with no co-payments or other cost-sharing requirements.’”

The Times’ Take

In January 2011, five months before the IOM would release its report, the Times story outlined the administration’s game plan: The “Obama administration is examining whether the new health-care law can be used to require insurance plans to offer contraceptives and other family-planning services to women free of charge.”

The Times reported that the administration “expected the list to include contraception and family planning because a large body of scientific evidence showed the effectiveness of those services. But the officials said they preferred to have the panel of independent experts make the initial recommendations so the public would see them as based on science, not politics.”

But the Times story also concluded with the anti-poverty argument for contraception.  Isabel Sawhill, an economist at the Brookings Institution told the reporter: “We have rigorous evidence that every dollar invested in family planning saves more than a dollar in welfare and social service costs for children that result from unintended births.”

Not a Fluke

So far, the American public appears to have accepted the argument that contraception coverage effectively addresses low-birth-weight problems and bulging welfare rolls. Even critics of the mandate have generally ignored the administration’s attempt to conflate the anti-poverty argument for contraception with the very different social and economic profile of women gainfully employed by private companies and nonprofits.

Yet the cost-benefit explanation doesn’t make an especially persuasive case for imposing the contraception mandate on religious employers. And perhaps that’s why House Democrats like Pelosi readily provided a public forum for the Georgetown Law School student Sandra Fluke.

“I attend a Jesuit law school that does not provide contraceptive coverage in its student health plan,” Fluke stated in testimony that also attacked two bills designed to protect the conscience rights of institutions and individuals that oppose the contraception mandate on moral or religious grounds. “And just as we students have faced financial, emotional and medical burdens as a result, employees at religiously affiliated hospitals and institutions and universities across the country have suffered similar burdens.”

Fluke’s most compelling stories dealt with unidentified female students who were technically able to receive needed medical assistance but didn’t for reasons that are not entirely clear. Yet, these stories were repeated in media coverage of her testimony and the related furor prompted by Rush Limbaugh’s attacks on the Georgetown law student.

The full impact of Fluke’s contribution to the public debate has yet to be determined. At the very least, Fluke offers another voice and another argument, joining Sebelius, Pelosi and a host of experts in making the case for an iron-clad federal contraception mandate.

Register senior editor Joan Frawley Desmond writes from Chevy Chase, Maryland.