Contraceptive mandate (United States)

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A contraceptive mandate is a state or federal regulation or law that requires health insurers, or employers that provide their employees with health insurance, to cover some contraceptive costs in their health insurance plans. In 1978, the U.S. Congress made it clear that discrimination on the basis of pregnancy was discrimination on the basis of sex.[1] In 2000, the Equal Employment Opportunity Commission ruled that companies that provided insurance for prescription drugs to their employees but excluded birth control were violating the Civil Rights Act of 1964.[2] President Obama signed the Patient Protection and Affordable Care Act (ACA) on 23 March 2010. As of 1 August 2011, contraception was added to a list of preventive services covered by the ACA that would be provided without patient co-payment. The federal mandate applies to all new health insurance plans in all states from 1 August 2012.[3][4] Grandfathered plans do not have to comply unless they change substantially.[5] To be grandfathered, a group plan must have existed or an individual plan must have been sold before President Obama signed the law; otherwise they must comply with the new law.[6] The Guttmacher Institute noted that even before the federal mandate was implemented, twenty-eight states had their own mandates that required health insurance to cover the prescription contraceptives, but the federal mandate innovated by forbidding insurance companies from charging part of the cost to the patient.[7]

Birth control and unintended pregnancy[edit]

In the United States, contraceptive use saves about $19 billion in direct medical costs each year.[8]

About half of U.S. pregnancies are unintended.[8] Highly effective contraceptives, such as intrauterine devices (IUDs), are underused in the United States.[9] Increasing use of highly effective contraceptives could help meet the goal set forward in Healthy People 2020 to decrease unintended pregnancy by 10% before 2020.[9] Cost to the user is one factor preventing many US women from using more effective contraceptives.[9] Making contraceptives available without a copay increases use of highly effective methods, reduces unintended pregnancies, and may be instrumental in achieving the Healthy People 2020 goal.[9]

Contraceptives in schools[edit]

Some public school districts in the United States have mandated that programs providing contraception to students be offered. Some such schools include the New London High School[10][11] in New London, Connecticut, as well as some schools in New York City.[12] The theory behind offering contraceptives in schools is that by offering barrier-free methods of obtaining contraception, students are more likely to use them.[13] These programs also aim to reduce incidents of teen pregnancy,[13] as well as reduce transmission of STDs among teenagers. In practice, studies have found that providing contraception to students fails to increase the rate of sexual activity.[13] Mandates on contraceptives in school have faced opposition from special interest groups, who fear that providing contraceptives to students will increase sexual activity.

Federal female contraception mandate before ACA[edit]

Certain aspects of the contraception mandate did not start with the ACA. In December 2000, the Equal Employment Opportunity Commission ruled that companies that provided prescription drugs to their employees but didn't provide birth control were in violation of Title VII of the 1964 Civil Rights Act, which prevents discrimination on the basis of sex. That opinion, which the George W. Bush administration did nothing to alter or withdraw when it took office the next month, is still in effect today – and because it relies on Title VII of the Civil Rights Act, it applies to all employers with 15 or more employees.[2] Currently, employers that don't offer prescription coverage or don't offer insurance at all are exempt, because they treat men and women equally, but the new mandate will require prescription coverage.[citation needed]

After the EEOC opinion was approved in 2000, reproductive rights groups and employees who wanted birth control access sued employers that refused to comply. The next year, in Erickson v. Bartell Drug Co., a federal court agreed with the EEOC's reasoning. Reproductive rights groups and others used that decision as leverage to force other companies to settle lawsuits and agree to change their insurance plans to include birth control. Some subsequent court decisions echoed Erickson, and some went the other way, but the rule (absent a Supreme Court decision) remained, and over the following decade, the percentage of employer-based plans offering contraceptive coverage tripled to 90 percent.[14]

ACA mandatory coverage for contraceptives[edit]

With the exception of churches and houses of worship, the Patient Protection and Affordable Care Act mandates contraceptive coverage for all employers and educational institutions, even though the mandate itself is not included in the wording of the law(s)[15] passed by Congress. The mandate applies to all new health insurance plans effective August 2012. It controversially includes Christian hospitals, Christian charities, Catholic universities, and other enterprises owned or controlled by religious organizations that oppose contraception on doctrinal grounds.

On January 20, 2012, U.S. Department of Health and Human Services Secretary Kathleen Sebelius announced a (then) final rule of an August 1, 2011 interim final rule on health insurance coverage with no cost sharing for FDA-approved contraceptives and contraceptive services (including female sterilization) for women of reproductive age if prescribed by health care providers, as part of women's preventive health services guidelines adopted by the Health Resources and Services Administration (HRSA) for the Affordable Care Act. Male contraception is not eligible.[16]

Regulations[17] made under the act rely on the recommendations of the independent Institute of Medicine (IOM) in its July 19, 2011 report Clinical Preventive Services for Women: Closing the Gaps, which concluded that birth control is medically necessary "to ensure women's health and well-being."

The administration allowed a religious exemption. The exemption initially applied to church organizations themselves, but not to affiliated nonprofit corporations, like hospitals, that do not rely primarily on members of the faith as employees.[18] An amendment, the Blunt Amendment, was proposed that "would have allowed employers to refuse to include contraception in health care coverage if it violated their religious or moral beliefs,"[19] but it was voted down 51-48 by the U.S. Senate on March 1, 2012.[20]

Opposition to contraceptive mandate[edit]

In February 2012, a major political controversy erupted with candidates for the Republican nomination for President viewing the regulations as a "direct attack on religious liberty".[21] The United States Conference of Catholic Bishops has since taken the lead in opposition to the regulations[22] Cardinal Timothy M. Dolan, the archbishop of New York and president of the United States Conference of Catholic Bishops stated that the provision "represents a challenge and a compromise of our religious liberty".[23] The regulations issued under the act are also opposed by active Christian Evangelicals.[24] Other organizations, such as Planned Parenthood, supported the provision.[25]

Compromise by Obama Administration[edit]

The Obama administration proposed changes in response to the criticism under which birth control medication would be provided by the insurers, without direct involvement by the religious organization. Regulations were issued on March 16, 2012 which ensure coverage for employees of enterprises controlled by religious institutions which self insure. Regulations were also issued on March 16, 2012 which require coverage for students at institutions controlled by religious organizations which purchase insurance. It is believed by the federal government that it is not possible under current law to require contraceptive coverage for students at institutions controlled by religious organizations which self insure.[26][27]

Response to compromise[edit]

The Catholic Health Association (CHA) accepted this compromise. Although initially more supportive, Sister Carol Keehan, CEO of the CHA, registered opposition in a five-page letter to the U.S. Department of Health and Human Services.[28] The vice president of Catholic identity and mission at Mount St. Mary's University, Stuart Swetland, said, "It shows [Obama] and the administration are listening to our concerns", but reserved the right to "examine the details". However, the United States Conference of Catholic Bishops continued to oppose the regulation, saying that the regulation still requires Catholics in the insurance industry to violate their consciences.[25] Catholic opinion is split with a The New York Times/CBS News poll showing 57% support of the regulations among Catholic voters and about the same by non-Catholics.[29][30]

In June 2013, the Tenth Circuit Court of Appeals allowed a lawsuit against the mandate by arts and crafts retailer, Hobby Lobby to proceed. The Green family objects to contraceptives which they believe may prevent implantation of a fertilized egg, which according to the Association of American Physicians and Surgeons, American Association of Pro-Life Obstetricians & Gynecologists, Christian Medical Association, Catholic Medical Association, National Catholic Bioethics Center, Physicians for Life, and National Association of Pro Life Nurses include the emergency contraceptives Plan B (levonorgestrel), ella (ulipristal acetate), and copper IUDs.[31][32] In July 2013, the Third Circuit denied a preliminary injunction requested by Conestoga Wood Specialties Corporation, a cabinet manufacturing company owned by a Menonite family, requesting an exemption from the mandate on religious grounds.[33] Both of these rulings were appealed to the Supreme Court, which granted certiorari on the consolidated cases to resolve the split.[34][35] Another decision by the Sixth Circuit in a similar case has been appealed to the Supreme Court, and is being held pending the court's decision in the other two cases.[36]

As of January 2014, at least 28 states in the US have contraceptive mandates; however, 20 of them allow some exceptions; four of those attempt to bridge the gap by letting employees buy coverage at the group rate.[37]

Supreme Court ruling[edit]

On June 30, 2014, the Supreme Court ruled 5 to 4 in Burwell v. Hobby Lobby that under the Religious Freedom Restoration Act (RFRA), closely held for-profit corporations are exempt from the contraceptive mandate, if they object on religious grounds, because the accommodation offered to objecting non-profits would be a less restrictive way to achieve the ACA's interest. Justice Anthony Kennedy, one of the majority justices, wrote in a concurring opinion that the government "makes the case that the mandate serves the Government’s compelling interest in providing insurance coverage that is necessary to protect the health of female employees", but that the RFRA's least-restrictive way requirement was not met because "there is an existing, recognized, workable, and already-implemented framework to provide coverage", the non-profit accommodation.[38]


More Democratic politicians favor these mandates than Republican politicians.[39] Sen. Barbara Boxer (D-CA) and House Minority Leader Nancy Pelosi favor the Obama policy.[40]

Rep. Darrell Issa (R-CA) said that Americans are divided on this issue: "While some Americans may not feel that forcing them to pay for contraception are an infringement on their religious beliefs, others consider it to be an assault against their freedom of conscience."[41] Issa's February 2012 hearing on the matter was criticized for including only men from conservative religious institutions, and no women.[42]

Framing the issue[edit]

See also: War on Women

Some people see the matter as primarily one of women's health, such as the National Women's Law Center.[43] Others see it as a matter of religious freedom.

Certain consumers of mandatory health insurance, such as students matriculated at colleges of further education, have criticized what they perceive to be discrimination in provision or in practice: employer-provided plans that cover University faculty and staff may be subject to legal mandates whereas plans that cover the student body may not. Sandra Fluke was invited to present oral arguments on behalf of certain female student consumers dissatisfied with restrictions attached to registration for undergraduate and graduate attendance at Georgetown University School of Law.[44] No contraceptive mandate applies to private parties entering into an association for commercial gain.[citation needed] Students are required to purchase the University's plan if they are not covered elsewhere, for example under a family members' (parents, spouse) plan, or are able to demonstrate their ability to self-insure at equivalent policy limits for certain levels of medical care.[citation needed]

See also[edit]


  1. ^ "The Pregnancy Discrimination Act of 1978". The U.S. Equal Employment Opportunity Commission. 1978-10-31. Retrieved 2014-01-25. 
  2. ^ a b "Commission Decision on Coverage of Contraception". The U.S. Equal Employment Opportunity Commission. 2000-12-14. Retrieved 2014-01-25. 
  3. ^ "Contraceptive Coverage in the New Health Care Law: Frequently Asked Questions". 2011-11-01. Retrieved 2014-01-25.  "The official start date is August 1, 2012, but since most plan changes take effect at the beginning of a new plan year, the requirements will be in effect for most plans on January 1, 2013. School health plans, which often begin their health plan years around the beginning of the school year, will see the benefits of the August 1st start date."
  4. ^ "Prescription Drug Costs and Health Reform: FAQ". 2013-05-04. Retrieved 2014-01-25. 
  5. ^ "Contraceptive Coverage in the New Health Care Law: Frequently Asked Questions". 2011-11-01. Retrieved 2014-01-25.  "These changes include cutting benefits significantly; increasing co-insurance, co-payments, or deductibles or out-of-pocket limits by certain amounts; decreasing premium contributions by more than 5%; or adding or lowering annual limits."
  6. ^ "Contraceptive Coverage in the New Health Care Law: Frequently Asked Questions". 2011-11-01. Retrieved 2014-01-25.  "Non-grandfathered plans are group health plans created after the health care reform law was signed by the President or individual health plans purchased after that date."
  7. ^ Sonfield, Adam (2013). "Implementing the Federal Contraceptive Coverage Guarantee: Progress and Prospects". Guttmacher Policy Review 16 (4). Retrieved 2014-01-25. 
  8. ^ a b James Trussell, Anjana Lalla, Quan Doan, Eileen Reyes, Lionel Pinto, Joseph Gricar (2009). "Cost effectiveness of contraceptives in the United States". Contraception 79 (1): 5–14. doi:10.1016/j.contraception.2008.08.003. PMC 3638200. PMID 19041435. 
  9. ^ a b c d Cleland K, Peipert JF, Westhoff C, Spear S, Trussell J (May 2011). "Family planning as a cost-saving preventive health service". N. Engl. J. Med. 364 (18): e37. doi:10.1056/NEJMp1104373. PMID 21506736. 
  10. ^ Benson, Judy (January 12, 2012). "Clinic at New London High School to offer students contraceptives". The Day (New London, Connecticut). Retrieved May 2, 2014. 
  11. ^ "Bookmarkable URL intermediate page". Retrieved 2015-03-11. 
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  14. ^ Nick Baumann (February 8, 2012). "Most of Obama's "Controversial" Birth Control Rule Was Law During Bush Years". Mother Jones. Retrieved May 26, 2012. 
  15. ^ "Read the Law |". Retrieved 2015-03-11. 
  16. ^ Committee on Preventive Services for Women; Institute of Medicine (July 19, 2011). Clinical Preventive Services for Women: Closing the Gaps. Washington, D.C.: The National Academies Press. ISBN 978-0-309-21538-1. 
    U.S. Department of Health & Human Services (August 1, 2011). "Affordable Care Act Ensures Women Receive Preventive Services at No Additional Cost (news release)". Washington, D.C.: U.S. Department of Health & Human Services. 
    U.S. Department of Health & Human Services (January 20, 2012). "A statement by U.S. Department of Health and Human Services Secretary Kathleen Sebelius (news release)". Washington, D.C.: U.S. Department of Health & Human Services. In August 2011, the Department of Health and Human Services issued an interim final rule that will require most health insurance plans to cover preventive services for women including recommended contraceptive services without charging a co-pay, co-insurance or a deductible. The rule allows certain non-profit religious employers that offer insurance to their employees the choice of whether or not to cover contraceptive services. Today the department is announcing that the final rule on preventive health services will ensure that women with health insurance coverage will have access to the full range of the Institute of Medicine’s recommended preventive services, including all FDA-approved forms of contraception. 
    U.S. Department of Health & Human Services (July 2, 2013). "Coverage of Certain Preventive Services Under the Affordable Care Act; Final Rules". Federal Register 28 (127): 39870–39899.  p. 39870:
    On August 1, 2011, HRSA adopted and released guidelines for women’s preventive health services (HRSA Guidelines) based on recommendations of the independent Institute of Medicine.
    As relevant here, the HRSA Guidelines include all Food and Drug Administration (FDA)-approved contraceptive methods, sterilization procedures, and patient education and counseling for women with reproductive capacity, as prescribed by a health care provider (collectively, contraceptive services).1
    1 The HRSA Guidelines exclude services relating to a man’s reproductive capacity, such as vasectomies and condoms.
  17. ^ Dept. Health and Human Services (February 10, 2012). "Group Health Plans and Health Insurance Issuers Relating to Coverage of Preventive Services Under the Patient Protection and Affordable Care Act – Final Rules" (77 FR 8725). Federal Register, GPO. Retrieved February 15, 2012. Summary: These regulations finalize, without change, interim final regulations authorizing the exemption of group health plans and group health insurance coverage sponsored by certain religious employers from having to cover certain preventive health services under provisions of the Patient Protection and Affordable Care Act. 
  18. ^ Liptak, Adam. "Contraception and Insurance Coverage (Religious Exemption Debate)". The New York Times. Retrieved 16 July 2012. 
  19. ^ "Women’s Health vs. Religious Freedom: House Leaders Debate Birth Control Mandate - ABC News". 2012-03-01. Retrieved 2015-03-11. 
  20. ^ "Senate Blocks Blunt’s Repeal of Contraception Mandate - ABC News". 2012-03-01. Retrieved 2015-03-11. 
  21. ^ Denise Grady (January 29, 2012). "Ruling on Contraception Draws Battle Lines at Catholic Colleges". The New York Times. Retrieved February 12, 2012. 
  22. ^ Laurie Goodstein (February 11, 2012). "Bishops Reject White House's New Plan on Contraception". The New York Times. Retrieved February 12, 2012. 
  23. ^ "U.S. Bishops Vow To Fight HHS Edict". United States Conference of Catholic Bishops. January 20, 2012. Retrieved February 8, 2012. 
  24. ^ Erik Eckholm (February 15, 2012). "Both Sides Eager to Take Birth Control Coverage Issue to Voters". The New York Times. Retrieved February 16, 2012. Is it about religious liberty or women's health? 
  25. ^ a b Parsons, Christi, Kathleen Hennessey and Noam Levey (February 10, 2012). "Obama's birth-control compromise wins some support". The Baltimore Sun. Retrieved February 12, 2012. 
  26. ^ Robert Pear (March 16, 2012). "U.S. Clarifies Policy on Birth Control for Religious Groups". The New York Times. Retrieved March 17, 2012. 
  27. ^ N.C. Aizenman (March 16, 2012). "Birth control rule won’t apply to all student plans at colleges, White House says". The Washington Post. Retrieved March 17, 2012. 
  28. ^ Joan Frawley Desmond (June 18, 2012). "Course Correction: Sister Carol Keehan Now Opposes Obama 'Accommodation' for HHS Mandate". National Catholic Register. Retrieved July 2, 2012. 
  29. ^ Laurie Goodstein (February 14, 2012). "Obama Shift on Providing Contraception Splits Critics". The New York Times. Retrieved February 15, 2012. 
  30. ^ Jonathan Cohn (February 8, 2012). "Religious Institutions Matter. So Do Their Employees.". The New Republic. 
    Jonathan Cohn (February 10, 2012). "Obama’s Deal on Birth Control Coverage". The New Republic. 
  31. ^ Wyatt, Kristen (Associated Press) (June 27, 2013). "Hobby Lobby won't have to pay millions in fines as it challenges Obamacare birth control mandate". Huffington Post. Retrieved January 2, 2014. 
  32. ^ Smith, Mailee R. (February 19, 2013). "Amicus Curiae Brief of Association of American Physicians & Surgeons, American Association of Pro-Life Obstetricians & Gynecologists, Christian Medical Association, Catholic Medical Association, National Catholic Bioethics Center, Physicians for Life, and National Association of Pro Life Nurses". Washington, D.C.: Americans United for Life. Retrieved January 2, 2014. 
  33. ^ "Document - Conestoga Wood Specialties Corp. v. Sec'y HHS, 724 F.3d 377, 121 FEP Cases 66 (3d Cir. 2013), Court Opinion". Bloomberg Law. Retrieved 2015-03-11. 
  34. ^ "Conestoga Wood Specialties Corp. v. Burwell". SCOTUSblog. Retrieved 2015-03-11. 
  35. ^ "Burwell v. Hobby Lobby Stores, Inc.". SCOTUSblog. Retrieved 2015-03-11. 
  36. ^ "Autocam Corp. v. Burwell". SCOTUSblog. Retrieved 2015-03-11. 
  37. ^ "State Policies in Brief: Insurance Coverage of Contraceptives". 2014-01-01. Retrieved 2014-01-25.  "28 states require insurers that cover prescription drugs to provide coverage of the full range of FDA-approved contraceptive drugs and devices; 17 of these states also cover require coverage of related outpatient services."
  38. ^ "Supreme Court of the United States : Syllabus : BURWELL, SECRETARY OF HEALTH AND HUMAN SERVICES, ET AL. v. HOBBY LOBBY STORES, INC., ET AL." (PDF). Retrieved 2015-03-11. 
  39. ^ Geiger, Kim. "Before now, GOP backed contraceptive mandates | The Seattle Times". Retrieved 2015-03-11. 
  40. ^ "Obama Birth Control Mandate Divides Democrats". Retrieved 2015-03-11. 
  41. ^ "Home | Committee on Oversight & Government Reform". Retrieved 2015-03-11. 
  42. ^ "House Democrats Walk Out Of One-Sided Hearing On Contraception, Calling It An 'Autocratic Regime'". 2012-02-16. Retrieved 2015-03-11. 
  43. ^ [1][dead link]
  44. ^ Fluke, Sandra Kay (2012-02-23). "Sandra Fluke testimony to US Congress (2012 February 23)". Retrieved 2014-01-25.