The Institute of Medicine (IOM), the health policy arm of the National Academy of Sciences, has issued its long-awaited report making recommendations to the U.S. Department of Health and Human Services (HHS) on mandatory insurance coverage of preventive services for women’s health care.
The mandatory coverage of certain preventive services was required by an amendment to the Patient Protection and Affordable Care Act (PPACA), known colloquially as Obamacare. The central feature of PPACA is a mandate that every American purchase a health insurance policy. The IOM report is thus rightly seen as envisioning a mandate within a mandate.
The IOM recommendations on preventive medicine not only would include a “full range” of contraceptives but would also stipulate that the contraceptives be offered without co-pays and exempt from deductibles—preferential treatment not accorded other procedures or prescription drugs. The term contraceptive is impressively flexible, including sterilization and devices and drugs that are known to have a mode of action that includes causing an abortion early in pregnancy. Among the latter is a new drug called ulipristal, or Ella, which is characterized as a morning-after pill, but it can actually work days after conception by “preventing attachment to the uterus,” as a promotional video from the manufacturer describes it.
If HHS follows the IOM’s recommendations, the burdens of the new mandate on individual and institutional conscience, in addition to the assault on sound health care policy, will be immense. Consider just the following impositions:
- Insured individuals (single men and women, people of non-reproductive age, and others who have no desire or reason to avail themselves of contraceptives) will lose the ability to purchase plans that do not include this coverage with its exceptional status.
- Religious entities and nonprofit groups may lose their ability to limit the scope of the health insurance plans they offer and to exclude practices to which they have religious, moral, and/or practical objections. The contraceptive coverage mandate would put added pressure on colleges and other institutions to submit to attempts by the Equal Employment Opportunity Commission to require them to cover drugs and procedures they find morally objectionable.
- Through the inclusion of ulipristal—and, arguably, other drugs or devices that operate at least intermittently in an abortifacient manner—taxpayers may lose another portion of the conscience protections included in PPACA that were indispensable to its passage. While one provision of PPACA allows states to opt out of including in their new exchanges any insurance plan that covers abortion (and several states have already exercised that option), a new mandate to include abortifacient preventive services will conflict with that provision. Certainly the spirit of PPACA’s conscience protections—which are meant to secure the freedom of insurers, providers, and purchasers of insurance alike—would be violated by the mandate.
- Finally, the ability of all participants in the health insurance market to purchase plans that meet their needs and reflect their values and priorities will be compromised by adoption of the IOM recommendations. The absence of co-pays and deductibles for one class of drugs or services by no means makes them “free”—it merely shifts all rather than some of their cost to other plan members, an extraordinary situation rendered even more offensive because, for many members, participation in the plan will be wholly or completely involuntary.
HHS Secretary Kathleen Sebelius has stated that she welcomes the IOM report, which she requested under the law, and that her department will issue its formal “preventive services” list soon. Both sexual activity and use of contraceptives are voluntary behaviors in areas where sensitivity to individual conscience is especially warranted. HHS should not compound the policy errors present in Obamacare by trampling on conscience in the name of medicine.
