[House Hearing, 112 Congress]
[From the U.S. Government Publishing Office]

DO NEW HEALTH LAW MANDATES THREATEN CONSCIENCE RIGHTS AND ACCESS TO
CARE?

=======================================================================

HEARING

BEFORE THE

SUBCOMMITTEE ON HEALTH

OF THE

COMMITTEE ON ENERGY AND COMMERCE
HOUSE OF REPRESENTATIVES

ONE HUNDRED TWELFTH CONGRESS

FIRST SESSION

__________

NOVEMBER 2, 2011

__________

Serial No. 112-102

Printed for the use of the Committee on Energy and Commerce

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COMMITTEE ON ENERGY AND COMMERCE

FRED UPTON, Michigan
Chairman

JOE BARTON, Texas HENRY A. WAXMAN, California
Chairman Emeritus Ranking Member
CLIFF STEARNS, Florida JOHN D. DINGELL, Michigan
ED WHITFIELD, Kentucky Chairman Emeritus
JOHN SHIMKUS, Illinois EDWARD J. MARKEY, Massachusetts
JOSEPH R. PITTS, Pennsylvania EDOLPHUS TOWNS, New York
MARY BONO MACK, California FRANK PALLONE, Jr., New Jersey
GREG WALDEN, Oregon BOBBY L. RUSH, Illinois
LEE TERRY, Nebraska ANNA G. ESHOO, California
MIKE ROGERS, Michigan ELIOT L. ENGEL, New York
SUE WILKINS MYRICK, North Carolina GENE GREEN, Texas
Vice Chairman DIANA DeGETTE, Colorado
JOHN SULLIVAN, Oklahoma LOIS CAPPS, California
TIM MURPHY, Pennsylvania MICHAEL F. DOYLE, Pennsylvania
MICHAEL C. BURGESS, Texas JANICE D. SCHAKOWSKY, Illinois
MARSHA BLACKBURN, Tennessee CHARLES A. GONZALEZ, Texas
BRIAN P. BILBRAY, California JAY INSLEE, Washington
CHARLES F. BASS, New Hampshire TAMMY BALDWIN, Wisconsin
PHIL GINGREY, Georgia MIKE ROSS, Arkansas
STEVE SCALISE, Louisiana JIM MATHESON, Utah
ROBERT E. LATTA, Ohio G.K. BUTTERFIELD, North Carolina
CATHY McMORRIS RODGERS, Washington JOHN BARROW, Georgia
GREGG HARPER, Mississippi DORIS O. MATSUI, California
LEONARD LANCE, New Jersey DONNA M. CHRISTENSEN, Virgin
BILL CASSIDY, Louisiana Islands
BRETT GUTHRIE, Kentucky KATHY CASTOR, Florida
PETE OLSON, Texas
DAVID B. McKINLEY, West Virginia
CORY GARDNER, Colorado
MIKE POMPEO, Kansas
ADAM KINZINGER, Illinois
H. MORGAN GRIFFITH, Virginia

7_____

Subcommittee on Health

JOSEPH R. PITTS, Pennsylvania
Chairman
MICHAEL C. BURGESS, Texas FRANK PALLONE, Jr., New Jersey
Vice Chairman Ranking Member
ED WHITFIELD, Kentucky JOHN D. DINGELL, Michigan
JOHN SHIMKUS, Illinois EDOLPHUS TOWNS, New York
MIKE ROGERS, Michigan ELIOT L. ENGEL, New York
SUE WILKINS MYRICK, North Carolina LOIS CAPPS, California
TIM MURPHY, Pennsylvania JANICE D. SCHAKOWSKY, Illinois
MARSHA BLACKBURN, Tennessee CHARLES A. GONZALEZ, Texas
PHIL GINGREY, Georgia TAMMY BALDWIN, Wisconsin
ROBERT E. LATTA, Ohio MIKE ROSS, Arkansas
CATHY McMORRIS RODGERS, Washington JIM MATHESON, Utah
LEONARD LANCE, New Jersey HENRY A. WAXMAN, California (ex
BILL CASSIDY, Louisiana officio)
BRETT GUTHRIE, Kentucky
JOE BARTON, Texas
FRED UPTON, Michigan (ex officio)

(ii)

C O N T E N T S

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Page
Hon. Joseph R. Pitts, a Representative in Congress from the
Commonwealth of Pennsylvania, opening statement................ 1
Prepared statement............................................... 3
Hon. Phil Gingrey, a Representative in Congress from the State of
Georgia, opening statement..................................... 4
Hon. Frank Pallone, Jr., a Representative in Congress from the
State of New Jersey, opening statement......................... 4
Hon. Janice D. Schakowsky, a Representative in Congress from the
State of Illinois, opening statement........................... 5
Hon. Michael C. Burgess, a Representative in Congress from the
State of Texas, opening statement.............................. 6
Hon. Marsha Blackburn, a Representative in Congress from the
State of Tennessee, opening statement.......................... 7
Hon. Tim Murphy, a Representative in Congress from the
Commonwealth of Pennsylvania, opening statement................ 7
Hon. Henry A. Waxman, a Representative in Congress from the State
of California, opening statement............................... 11

Witnesses

David L. Stevens, Chief Executive Officer, Christian Medical
Association.................................................... 123
Prepared statement........................................... 125
Answers to submitted questions............................... 215
Mark Hathaway, Director, Obstetrics and Gynecology Outreach
Services for Women's and Infants' Services, Washington Hospital
Center......................................................... 133
Prepared statement........................................... 135
Answers to submitted questions............................... 218
Jane G. Belford, Chancellor, Archdiocese of Washington, DC....... 139
Prepared statement........................................... 141
Answers to submitted questions............................... 261
Jon O'Brien, President, Catholics for Choice..................... 150
Prepared statement........................................... 152
Answers to submitted questions............................... 264
William J. Cox, President and Chief Executive Officer, Alliance
of Catholic Health Care........................................ 163
Prepared statement........................................... 165
Answers to submitted questions............................... 266

Submitted Material

Letter, dated October 4, 2011, from Mr. Murphy to Kathleen
Sebelius, Secretary, Department of Health and Human Services,
submitted by Mr. Murphy........................................ 9
Statement, dated November 2, 2011, of Hon. Jeff Fortenberry, a
Representative in Congress from the State of Nebraska,
submitted by Mr. Pitts......................................... 13
Statement, dated November 2, 2011, of John H. Garvey, President,
The Catholic University of America............................. 18
Letter, dated November 1, 2011, from Cardinal Daniel N. DiNardo,
Chairman, Committee on Pro-Life Activities, United States
Conference of Catholic Bishops, to Mr. Pitts, submitted by Mr.
Pitts.......................................................... 22
Letter, dated November 2, 2011, from Jeanne Monahan, Director,
Center for Human Dignity, and Chris Gacek, Senior Fellow for
Regulatory Policy, Family Research Council, to Mr. Pitts,
submitted by Mr. Pitts......................................... 30
Statement, dated November 2, 2011, of Nancy Keenan, President,
NARAL Pro-Choice America, submitted by Ms. Schakowsky.......... 46
Statement, dated November 2, 2011, of the Center for Reproductive
Rights, submitted by Ms. Schakowsky............................ 53
Statement, dated November 2, 2011, of Judy Waxman, Vice President
for Health and Reproductive Rights, National Women's Law
Center, submitted by Ms. Schakowsky............................ 80
Statement, dated November 2, 2011, of Laura W. Murphy, Director,
Washington Legislative Office, and Sarah Lipton-Lubet, Policy
Counsel, American Civil Liberties Union, submitted by Ms.
Schakowsky..................................................... 83
Statement, dated November 2, 2011, of Debra Ness, President, and
Judith Lichtman, Senior Advisor, National Partnership for Women
& Families, submitted by Ms. Schakowsky........................ 98
Statement, dated November 2, 2011, of the National Health Law
Program, submitted by Ms. Schakowsky........................... 104
Statement, dated November 2, 2011, of Douglas Laube, Board Chair,
Physicians for Reproductive Choice and Health, submitted by Ms.
Schakowsky..................................................... 115
Letter, dated November 2, 2011, from Advocates for Youth, et al.,
to Mr. Upton, Mr. Waxman, Mr. Pitts, and Mr. Pallone, submitted
by Ms. Schakowsky.............................................. 120
Statement, dated October 31, 2011, of Rabbi Dennis S. Ross,
Director, Concerned Clergy for Choice, The Educational Fund of
Family Planning Advocates of New York State, submitted by Mr.
Pallone........................................................ 175
Statement, dated November 2, 2011, of Nancy K. Kaufman, Chief
Executive Officer, National Council of Jewish Women, submitted
by Mr. Pallone................................................. 176
Statement, dated November 2, 2011, of The Rev. Debra W. Haffner,
Executive Director, Religious Institute, submitted by Mr.
Pallone........................................................ 182
Statement, dated November 2, 2011, of The Rev. Lois M. Powell,
Justice and Witness Ministries, United Church of Christ,
submitted by Mr. Pallone....................................... 183
Letter, dated October 31, 2011, from Mary E. Hunt, Co-director,
Women's Alliance for Theology, Ethics, and Ritual, to committee
members, submitted by Mr. Pallone.............................. 184
Statement, dated November 2, 2011, of The Rev. Dr. Carlton W.
Veazey, President and Chief Executive Officer, Religious
Coalition for Reproductive Choice, submitted by Mr. Pallone.... 186
Letter, dated November 1, 2011, from James E. Winkler, General
Secretary, General Board of Church and Society of The United
Methodist Church, to subcommittee members, submitted by Mr.
Pallone........................................................ 189

DO NEW HEALTH LAW MANDATES THREATEN CONSCIENCE RIGHTS AND ACCESS TO
CARE?

----------

WEDNESDAY, NOVEMBER 2, 2011

House of Representatives,
Subcommittee on Health,
Committee on Energy and Commerce,
Washington, DC.
The subcommittee met, pursuant to call, at 10:05 a.m., in
room 2123 of the Rayburn House Office Building, Hon. Joseph R.
Pitts (chairman of the subcommittee) presiding.
Members present: Representatives Pitts, Burgess, Shimkus,
Murphy, Blackburn, Gingrey, Latta, McMorris Rodgers, Lance,
Cassidy, Guthrie, Pallone, Dingell, Towns, Engel, Capps,
Schakowsky, Baldwin, Matheson, Christensen, and Waxman (ex
officio).
Staff present: Carl Anderson, Counsel, Oversight; Marty
Dannenfelser, Senior Advisor, Health Policy and Coalitions;
Brenda Destro, Professional Staff Member, Health; Andy
Duberstein, Special Assistant to Chairman Upton; Paul Edattel,
Professional Staff Member, Health; Ryan Long, Chief Counsel,
Health; Nika Nour, New Media Specialist; Katie Novaria,
Legislative Clerk; John O'Shea, Professional Staff Member,
Health; Heidi Stirrup, Health Policy Coordinator; Phil Barnett,
Democratic Staff Director; Alli Corr, Democratic Policy
Analyst; Ruth Katz, Democratic Chief Public Health Counsel;
Karen Lightfoot, Democratic Communications Director and Senior
Policy Advisor; Elizabeth Letter, Democratic Assistant Press
Secretary; Anne Morris Reid, Democratic Professional Staff
Member; and Tim Westmoreland, Democratic Consulting Counsel.

OPENING STATEMENT OF HON. JOSEPH R. PITTS, A REPRESENTATIVE IN
CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA

Mr. Pitts. The subcommittee will come to order. The Chair
recognizes himself for 5 minutes for an opening statement.
On August 3, 2011, the Department of Health and Human
Services issued an interim final rule that would require nearly
all private health plans to cover contraception and
sterilization as part of their preventive services for women.
While the rule does include a religious exemption, many
entities feel that it is inadequate and violates their
conscience rights by forcing them to provide coverage for
services for which they have a moral or ethical objection.
The religious employer exemption allowed under the
preventive services rule--at the discretion of the HRSA--is
very narrow. And the definition offers no conscience protection
to individuals, schools, hospitals, or charities that hire or
serve people of all faiths in their communities.
It is ironic that the proponents of the healthcare law
talked about the need to expand access to services but the
administration issues rules that could force providers to stop
seeing patients because to do so could violate the core tenets
of their religion.
I am also concerned about the process HHS used to issue the
rule. The interim final rule was promulgated before the
proposed rulemaking and the formal comment period were
conducted by HHS. In issuing the rule, HHS acknowledged that it
bypassed the normal rulemaking procedures in order to expedite
the availability of preventive services to college students
beginning the school year in August. HHS argued that there
would be a year's delay in the receipt of the new benefit if
the public comment period delayed the issuance of HRSA guidance
for over a month.
I believe that on such a sensitive issue there should have
been a formal comment period so that all sides could weigh in
on the issue and HHS could benefit from a variety of views.
When the healthcare law was being debated last Congress, the
proponents adamantly refuted claims that this would be a
Federal Government takeover of our healthcare system.
Now, we have the Federal Department of Health and Human
Services forcing every single person in this country to pay for
services that they may morally oppose. Groups who have for
centuries cared for the sick and poor will now be forced to
violate their religious beliefs if they want to continue to
serve their communities. Whether one supports or opposes the
healthcare law, we should universally support the notion that
the Federal Government should be prohibited from taking
coercive actions to force people to abandon their religious
principles.
I look forward to hearing from our witnesses. Thank you all
for being here, and I yield the balance of my time to Dr.
Gingrey from Georgia.
[The prepared statement of Mr. Pitts follows:]

[GRAPHIC] [TIFF OMITTED] T5050.221

OPENING STATEMENT OF HON. PHIL GINGREY, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF GEORGIA

Mr. Gingrey. Well, I thank the chairman for yielding to me.
And absolutely the point that he is making in regard to
conscience clause, surely, no matter how one may feel about
Patient Protection and Affordable Care Act that was passed in
March of 2010, whether you are strongly for it, as most
Democrats on the committee were and strongly opposed to it, as
most Republicans on our committee were, it seems to me that we
should agree that conscience clauses should be protected.
Each year, one in six patients in the United States are
cared for in a Catholic hospital, and approximately 725,000
individuals work in Catholic hospitals. These hospitals take
all who are in need; it doesn't matter their religious
background or their ability to pay. Come one, come all. But
now, Obamacare would actually require with the rulemaking
Catholic hospitals to primarily serve persons who share its
religious beliefs or force them to provide benefits like
abortion drugs to employees that contradict their faith.
Let me rephrase. The White House is telling Catholic
hospitals to deny care for those of other faiths or be forced
as employers to provide coverage for services that they object
to on religious and moral grounds. Why must President Obama
insist that the price for healthcare reform be giving up the
civil liberties through an individual mandate and the religious
liberties that our Founding Fathers guaranteed us under the
Constitution. This Congress can do better than that. Obamacare
can do better than that.
And I thank the chairman for yielding and I yield back.
Mr. Pitts. The Chair thanks the gentleman and now
recognizes the ranking member of the Subcommittee on Health,
Mr. Pallone, for 5 minutes for an opening statement.

OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE
IN CONGRESS FROM THE STATE OF NEW JERSEY

Mr. Pallone. Thank you, Mr. Chairman.
Today's hearing will focus on the implementation of the
Affordable Care Act's prohibition of cost-sharing for
preventive health services, which will include prescription
birth control methods. The rule released by the Department of
Health and Human Services would permit certain religious
employers to opt out of the requirement of providing
contraception. But unfortunately, this is more than an
examination of HHS's rule and whether or not it protects
conscience rights. It is simply the latest in a series of
attacks this year on the healthcare reform and women's health.
The Federal health reform law represents unprecedented
efforts to improve women's health and women's access to
comprehensive healthcare. In fact, women will gain the most
from healthcare reform. First, we must not forget that the ACA
makes health insurance a reality for 19 million women in this
country who were uninsured.
In addition, it seeks to protect women from many insurance
abuses. In the individual insurance market, women were being
denied coverage for such preexisting conditions as pregnancy,
having had a C-section, or in some cases, breast cancer. The
ACA outlaws such a practice. Women were also often being
charged substantially higher premiums than men for the same
healthcare coverage, and the ACA outlaws these gender-rating
practices.
In many cases, women and children with insurance had not
been receiving key preventive care from mammograms to well baby
and well childcare visits to family planning services such as
birth control because they could not afford the copays. Now,
the Affordable Care Act is making groundbreaking strides in
care for women by eliminating these copays and deductibles for
preventive services.
The new preventative coverage rules announced by HHS remove
significant financial obstacles for women seeking preventive
reproductive healthcare. These provisions ensure that a woman
has access to all preventative services, regardless of who her
employer is. And this is critical because it is well known that
almost all women--99 percent in fact, including religious
devotees--will use contraception at some point during their
reproductive lives. Meanwhile, 3 recent studies have found that
lack of insurance is significantly associated with reduced use
of prescription contraceptives.
But I absolutely support an individual's right to express
their religious convictions. Today's hearing has nothing to do
with religious rights and conscience protections. In my
opinion, this hearing is about women's access to comprehensive
healthcare coverage. And whether my colleagues admit it or not,
their attempts here today are meant to turn back the clock on
the great strides the Affordable Care Act has and will continue
to make for women's health. We can't continue to allow
obstacles to prevent us from insuring the affordability of
family planning service for millions of women.
I would now like to yield 2 minutes from the time I have
left, Mr. Chairman, to the gentlewoman from Illinois, Ms.
Schakowsky.

OPENING STATEMENT OF HON. JANICE D. SCHAKOWSKY, A
REPRESENTATIVE IN CONGRESS FROM THE STATE OF ILLINOIS

Ms. Schakowsky. Thank you for yielding.
The attention this committee has focused on and continues
to focus on the private lives of women makes it clear that one
of the goals of the majority is to end access not just to
abortions but to family planning. I fought for and will
continue to fight for the guidelines adopted by the
administration.
After an exhaustive and thorough scientific review by the
Institutes of Medicine to ensure insurance coverage of
preventive services for women, it is no secret that substantial
public health benefits and cost savings emerge when preventive
services, including family planning, are accessible and
affordable.
As patients, caregivers, and as workers who still earn less
than men, women have a particular stake in ensuring insurance
coverage of prescription contraceptives and other preventive
services. The new guidelines on insurance coverage of
preventive services for women should apply to all women,
regardless of where they work.
Allowing employers to exempt themselves in providing
prescription contraceptives for their employees is
counterproductive, unfair, and paternalistic. Why should the
conscience of an employer trump a woman's conscience? Why
should an employer decide for a woman whether she can access
the healthcare services that she and her doctor decide are
necessary? Why are we talking about allowing some employers to
put up a barrier to access at a time when woman are struggling
to afford and access healthcare?
It never used to be that family planning was considered a
partisan issue and it never used to be that family planning was
equated with abortion. My, how things have changed. Today, the
full continuum of reproductive healthcare is under assault.
Believe me, these conversations are heard far and wide among
women out in the public, women of all ages and races and
parties, political parties, who understand that these kinds of
assaults on women's right to make a choice about a lot of
things, including contraceptive care, and men, too, who want to
be able to plan their families. Unacceptable.
I yield back.
Mr. Pitts. The Chair thanks the gentlelady and now
recognizes the vice chair of the Subcommittee on Health, Dr.
Burgess, for 5 minutes.

OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A REPRESENTATIVE
IN CONGRESS FROM THE STATE OF TEXAS

Mr. Burgess. I thank the chairman for the recognition. And
once again, we are here learning that those who are driving the
regulatory train are in fact making the practice of medicine
more difficult through their lack of thought. And we are left
with consequences. The decision by Health and Human Services to
issue an interim final rule, while that sounds like arcane
Washington-speak, what that means is that the transparency and
accountability of the normal Federal rulemaking process has now
been circumvented, and as a consequence, we have got a rule
being put forward that now has the force of law as if it were
legislation passed by Congress and signed by the President.
Now, we have got a rule that has the force of law that is
unworkable, yes, for faith-based facilities but also was going
to have dramatic cost implications across the board for all
Americans. A good thing or bad thing, problem is we don't know
because we never had the opportunity to explore the
possibilities.
So the administration now has singlehandedly rendered
faith-based facilities fearful of their ability to continue to
serve their patients. The lack of consideration for these
organizations has manifested in an extremely narrow and in fact
an unworkable exemption.
The interim final rule further expands the power and reach
of the Federal Government into the realm of private health
insurance without regard for conscience rights to be sure, but
also without regard to the bill that must be footed by the
taxpayer. The requirement that all, underscore ``all,''
preventive FDA-approved contraceptives must be offered at no
copay to all women was never examined for its cost or its
practical implications. This policy considers both generic and
brand name contraceptives the same, so how in the world do we
expect there to be any price sensitivity in the marketplace if
we have simply removed that obligation from the marketplace
itself?
The interim final rule does violate the conscience
protections many healthcare providers rely upon and ultimately
leads to diminished access of care--as Dr. Gingrey so
eloquently pointed out--and also importantly, a rising monthly
premium for all Americans.
I yield now to the gentlelady from Tennessee.

OPENING STATEMENT OF HON. MARSHA BLACKBURN, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF TENNESSEE

Mrs. Blackburn. Thank you, Mr. Burgess.
And I want to welcome all of our witnesses. We are so
pleased that you have taken the time to be here with us today.
President Obama came before Congress and made a statement,
``under our plan, no Federal dollars will be used to fund
abortions and Federal conscience laws will remain in place.''
Then, at Notre Dame he said, ``let us honor the conscience of
those who disagree with abortion.'' But the truth is this
administration, by its actions, calls abortion essential care.
Obamacare discriminates against hospitals, insurance plans, and
healthcare professionals who don't want to violate what they
know in their hearts to be true.
HHS has published this new rule--we have all spoken about
this--to force America's doctors and nurses to do the things
that otherwise they would not do. Maybe it should be called
coercion backed by the taxpayer dollars and that is a little
bit of a poisonous medicine to swallow. It is unconstitutional
and unethical and cheapens the civil rights of our medical
professionals.
Smuggling abortion into PPACA was destructive and it is
another big reason why I think we need to repeal Obamacare.
With that, I would like to yield the balance of the time to
Dr. Murphy.

OPENING STATEMENT OF HON. TIM MURPHY, A REPRESENTATIVE IN
CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA

Mr. Murphy. Thank you. And thank you, Chairman Pitts.
Since this rule was released, I have heard an outpouring of
concern not only from religious leaders like Bishop David Zubik
of the Diocese of Pittsburgh, but from over 1,000 individual
constituents and a range of employers from the CEOs of
multibillion dollar companies to small business owners. I have
a hard time explaining to them that the Federal Government is
forcing them to choose between their faith and providing health
insurance to their employees.
This mandate stands in stark contrast to the stated purpose
of healthcare reform expanding access to healthcare. Instead,
this mandate will strip countless Americans of their health
insurance calling into question President Obama's promise that
if you like your health insurance you can keep it. To that I
would add a question. If you like your religion, can you keep
it?
Almost exactly a month ago, I sent a letter to Secretary
Sebelius expressing my concern and that of the thousands I
represent in Congress with the blatant disregard for the
religious and moral beliefs of millions of Americans displayed
in this new ``preventative services'' mandate. I am still
waiting for Secretary Sebelius to respond.
Mr. Chairman, toward that end, I ask for unanimous consent
that my letter to Secretary Sebelius be included in the
official record. And with that, I yield back.
Mr. Pitts. Without objection, so ordered.
[The information follows:]

[GRAPHIC] [TIFF OMITTED] T5050.002

[GRAPHIC] [TIFF OMITTED] T5050.003

Mr. Pitts. The Chair recognizes the ranking member of the
full committee, Mr. Waxman, for 5 minutes for an opening
statement.

OPENING STATEMENT OF HON. HENRY A. WAXMAN, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF CALIFORNIA

Mr. Waxman. Mr. Chairman, this is not a hearing about
abortion. This is not a hearing about whether people can adhere
to their religious beliefs and follow their own individual
consciences. This is a hearing about whether the Republicans
can have the government intrude to the point where people who
buy health insurance could be denied insurance coverage for the
preventive service of family planning. Preventing conception is
what family planning is all about, and it is a legitimate
medical service. In fact, the Institute of Medicine made
recommendations to the Department for what would be covered
under preventive services, and they recommended that this be a
covered preventive service.
So the question is, if somebody doesn't want to provide
contraception because it violates their religion or their
conscience, would they be required to? Absolutely not. The
question then comes down to, what is the scope of the exception
that church-provided insurance need not cover family planning?
Well, I don't know why that should be even an exception. I
disagree with the administration in providing that exception.
But the Republicans would like to, first of all, extend that
exception to all church-related groups whether it means that
the people who are covered are of the same faith or not. But we
are going to hear from a witness who would like to have no
insurance coverage for contraceptives services because it
violates her point of view.
Now, we hear a lot from the other side of the aisle about
government intrusion in our private lives. There can be no
intrusion more significant than government telling people they
cannot get contraception, they cannot get insurance to cover
contraception, it should not be a provided service. Well, that
is part of what the Republican agenda appears to be, but it is
much more than that because what we have is a hearing today
that purports to be about the conscience protection, but it is
another attempt by the Republicans to undermine and undo the
Affordable Care Act's provisions related to women's health. And
no single piece of legislation in recent memory has done more
to advance women's health and women's access to health services
than the Affordable Care Act.
It provides coverage for millions of Americans including
19.1 million women who are uninsured. It makes health insurance
coverage more affordable through premium assistance. It stops
gender rating. It would no longer be legal to do that where
women are charged higher premiums than men for the same
insurance coverage. It will be illegal for insurance companies
to discriminate against women and others on the basis of
preexisting conditions, which by the way may even include
history of breast cancer, pregnancy, or experience of domestic
violence. And then the cost-sharing requirements under Medicare
have been eliminated for women's preventive health services
such as mammograms and well women visits. For new private
health insurance coverage that prohibition against cost-sharing
extends to breastfeeding counseling, screening, and counseling
for domestic violence. And it would include FDA-approved
contraceptives in addition to mammograms and well women
checkups.
Now, the Republicans would like to take all this away, not
just the access to contraceptive services. They would like to
repeal the Affordable Care Act. And if they succeed, newly
established health benefits and health coverage for women would
disappear. And what would they do to replace this? Nothing.
They would leave the status quo in place.
Now, let me be clear. I support policies that recognize and
protect the right of individuals to express and act on their
religious and moral convictions. If you have moral convictions,
you can keep them, just don't try to impose them on everybody
else. We cannot turn the clock back. We shouldn't let the
Republicans confuse the issue.
Deny health insurance coverage that includes contraceptive
services to millions of American women, that is wrong. Women
who don't want that service don't have to access it if it
violates their conscience. A doctor does not have to provide it
if it violates his or her conscience. But tell me less about
the conscience of the employer or the insurance company and why
that should take precedence over all the people who are to be
covered that do not share that particular point of view. The
Department's position on insurance coverage for family planning
is in keeping with this goal and should move forward without
delay.
I am going to yield back my time and express a strong
support for this preventive service which is now being used
widely by people who even are members of a church that in
theory and religious doctrine disapprove of the service.
Mr. Pitts. The Chair thanks the gentleman. That concludes
the opening statements of the members. The Chair has a UC
request to submit for the record a statement by Congressman
Jeff Fortenberry; a statement by the Catholic University of
America president, John Garvey; some letters from the U.S.
Conference of Catholic Bishops; and a letter from the Family
Research Council. These have all been provided. Without
objection, these will be entered into the record.
[The information follows:]

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Ms. Schakowsky. Mr. Chairman?
Mr. Pitts. Yes?
Ms. Schakowsky. I don't know if this is an appropriate
time, but I have some things I would like to submit for the
record.
Mr. Pitts. All right. If you would----
Ms. Schakowsky. Thank you. This is testimony from NARAL
Pro-Choice America, Center for Reproductive Rights, National
Women's Law Center, ACLU, National Partnership for Women and
Families, National Health Law Program, Physicians for
Reproductive Choice and Health, and then a letter organized by
Advocates for Youth. These have all been submitted previously
and I would appreciate if they could be part of the record.
Mr. Pitts. All right. We have received these. Without
objection, so ordered.
[The information follows:]

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Mr. Pitts. The Chair now is pleased to welcome the panel of
witnesses to our hearing today. We would ask them to please
take their seats at the witness table. And I will introduce
them at this time.
Today, our witness panel includes David Stevens, CEO of the
Christian Medical Association; Mark Hathaway, Director of OB/
GYN Outreach Services for Women's and Infants' Services at
Washington Hospital Center and Title X Medical Director at the
Unity Healthcare, Inc.; Jane Belford, Chancellor and General
Counsel of the Archdiocese of Washington; Jon O'Brien,
President of Catholics for Choice; and Bill Cox, President and
CEO of the Alliance of Catholic Health Care.
We are happy to have each of you here today and ask that
you summarize your statements in 5 minutes. We will enter your
written testimony into the record.
And at this point, we will start with Dr. Stevens. You are
recognized for 5 minutes.

STATEMENTS OF DAVID L. STEVENS, CHIEF EXECUTIVE OFFICER,
CHRISTIAN MEDICAL ASSOCIATION; MARK HATHAWAY, DIRECTOR,
OBSTETRICS AND GYNECOLOGY OUTREACH SERVICES FOR WOMEN'S AND
INFANTS' SERVICES, WASHINGTON HOSPITAL CENTER; JANE G. BELFORD,
CHANCELLOR, ARCHDIOCESE OF WASHINGTON, DC.; JON O'BRIEN,
PRESIDENT, CATHOLICS FOR CHOICE; AND WILLIAM J. COX, PRESIDENT
AND CHIEF EXECUTIVE OFFICER, ALLIANCE OF CATHOLIC HEALTH CARE

STATEMENT OF DAVID L. STEVENS

Mr. Stevens. I am testifying on behalf of the over 16,000
members of the Christian Medical Association, a professional
membership organization that helps healthcare professionals to
integrate their faith and their profession. I am a diplomat of
the American Board of Family Medicine and hold a master's
degree in bioethics.
Our members include physicians who hold a range of
conscience convictions on controversial ethics and moral
issues, including contraception, healthcare reform,
participation in the death penalty, and other conscience issues
that span the political spectrum.
Virtually all medical professionals and student members we
recently surveyed say it is ``important to personally have the
freedom to practice healthcare in accordance with the dictates
of his or her conscience.'' Over 9 of 10 say they would not
prescribe FDA-approved contraceptives that might cause the
death of a developing human embryo.
Many physicians today conscientiously profess allegiance to
life-affirming ethical standards such as the Hippocratic Oath.
Pro-life patients want to retain the freedom to choose
physicians whose professional judgments reflect their own life-
affirming values.
The Health and Human Services interim final regulation
would force insurance plans nationwide to cover all Food and
Drug Administration-approved contraceptive methods and
sterilization procedures. This mandate does not exempt
controversial drugs such as Ella and the morning-after pill,
which according to the FDA have post-fertilization effects that
may inhibit implantation of a living human embryo.
The potential religious exemption in the contraception
mandate--exempting only a nano-sector of religious employers
from the guidelines--is meaningless to conscientiously
objecting healthcare professionals, insurers, and patients. The
contraception mandate can potentially trigger a decrease in
access to healthcare by patients in medically underserved
regions and populations.
The administration's policies on the exercise of conscience
in healthcare, including the gutting of the only Federal
conscience-protecting regulation, actually threaten to worsen a
growing physician shortage. A national survey of over 2,100
faith-based physicians revealed that over 9 of 10 are prepared
to leave medicine over conscience rights. Eighty-five percent
of our medical professionals and students say that the policies
that restrict the exercise of conscience in healthcare make it
less likely they will practice healthcare in the future.
The contraception mandate further contributes to an
increasingly hostile environment in which pro-life physicians,
residents, and medical students face discrimination, job loss,
and ostracism. Seventy-nine percent of our members surveyed
said the new contraception mandate will have a negative impact
on their freedom to practice medicine in accordance with the
dictates of their conscience. One out of five faith-based
medical students surveyed said they will not go into OB/GYN as
a specialty because of abortion-related pressures.
The contraception mandate creates a climate of coercion
that can prompt pro-life healthcare professionals to limit the
scope of their medical practice. Over half of the medical
professionals and students we surveyed said the new
contraception mandate might cause them to restrict their
practice of medicine.
The contraception mandate can potentially cause a decrease
in the provision of health insurance for employees of pro-life
healthcare employers who want to avoid conflicts of conscience
regarding controversial contraceptives. Sixty-five percent of
the medical professionals and students we surveyed said the
contraception mandate will make them less likely to provide
insurance for their employees.
The contraceptive mandate rule sweepingly tramples
conscience rights, which have provided a foundation for the
ethical and professional practice of medicine. The
administration should rescind this mandate entirely for the
ethical and practical reasons I have noted and also for the
constitutional and statutory reasons outlined in our official
comment letter of September 29 to HHS, which I am submitting
separately and ask to be included in the record.
We encourage Members of Congress to uphold conscience
rights by passing the Respect for Rights of Conscience Act.
Upholding a respect for conscience and our First Amendment
freedoms protects all Americans, conservatives and liberals,
capitalists and socialists, atheists and people of faith.
Thank you for your consideration of these views.
[The prepared statement of Mr. Stevens follows:]

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Mr. Pitts. The Chair thanks the gentleman and recognizes
Dr. Hathaway for 5 minutes.

STATEMENT OF MARK HATHAWAY

Mr. Hathaway. Chairman Pitts, Ranking Member Pallone, and
members of the committee, thank you for the opportunity to
testify before you today.
Good morning. My name is Dr. Mark Hathaway. I am a board-
certified OB/GYN. I am the director of OB/GYN Outreach Services
for Women's and Infants' Services at the Washington Hospital
Center. I am also the Title X director at Unity Health Care,
Washington, DC's, largest Federally qualified health center.
I work in several medical facilities here in Washington,
DC. My patients tend to be women of color, primarily African
American and Latina, and of lower socioeconomic status. Many of
the patients I see are uninsured, underinsured, and seeking
prenatal care or family planning services. Despite these
obstacles, they desire to improve their lives and to have and
raise healthy children.
I see every day how increasing women's ability to plan
their pregnancies makes a difference in their lives. And by the
same token, I also see the negative consequences of unintended
and unplanned pregnancy, late prenatal care, uncontrolled
medical problems, poor nutrition, and sometimes depression. I
see firsthand how cost can be a barrier. That is why the
Institute of Medicine's recommendation is so critically
important. Contraceptive counseling and methods should be
covered under the Affordable Care Act without cost-sharing. Any
attempts to broaden exemptions to that coverage requirement
would mean leaving in place insurmountable obstacles to
contraceptive services for far too many women.
I know from my day-to-day experience what it means for
patients who cannot afford to pay for their health services.
The cost of a birth control method is frequently prohibitive
for many of my patients. This is especially true for the more
cost-effective, long-acting reversible contraceptive methods,
also known as LARC.
Women face many challenges in using contraception
successfully. Too many women using methods like birth control
pills, condoms and even injectables will experience an
unplanned pregnancy during their first year of ``typical use.''
Long-acting reversible contraceptive methods, including
intrauterine contraceptives and implants, are the most cost-
effective methods because they have an extremely low failure
rate and are effective at preventing pregnancy for several
years. The up-front costs of these methods, however, are
several hundred dollars, placing them out of the reach of
millions of women who would otherwise use them.
Three recent studies have found that lack of insurance is
significantly associated with reduced use of prescription
contraceptives. In St. Louis, researchers at Washington
University have recently found that over 70 percent of women
will choose a longer-acting method if cost and barriers are
eliminated.
There are those who assert that unintended pregnancy is not
a health condition and therefore prevention of unintended
pregnancy is not a preventive healthcare. From my personal
practice I can say that I cannot disagree more. Just last week
I met ``Sarah.'' She is 22 years old, has 2 children under the
age of 3, one a recent newborn. She came in for a pregnancy
test. Her diabetes had gone unchecked, which would put her in a
category of a high-risk pregnancy. She was visibly shaking
waiting for her pregnancy test results. She is working over 40
hours a week at 2 different jobs and was told by her primary
care clinic that she would need to pay a copay of $40 and a
$300 fee for the intrauterine device that she so desperately
wants. She would have been devastated by a positive pregnancy
test. She was incredibly relieved to learn she was not
pregnant. She was also uninsured but we used our rapidly
shrinking safety-net resources to provide her with long-acting
contraception lasting up to 7 years.
The evidence is also conclusive regarding pregnancy
spacing. It is directly linked to improved maternal and child
health. Numerous U.S. and international studies have found a
direct causal relationship between birth intervals, low birth
weight, as well as preterm births. In other words, we need to
help women plan their pregnancies for their health as well as
their children's.
Using contraception is the most effective way to prevent
unintended pregnancy. Again, I have seen the success of
contraceptive services in my own practice, and again the
evidence on this is clear. Ninety-five percent of all
unintended pregnancies occur among women who use contraception
inconsistently or use no method at all. Indeed, couples who do
not practice contraception have an 85 percent chance of
experiencing an unintended pregnancy within the first year.
For all these reasons, the Institute of Medicine's
recommendations are groundbreaking. Finally, all women will
gain access to insurance coverage of family planning services
regardless of income. All women will be able to get the
counseling, education, and access to the most effective and
medically appropriate contraceptive for them. This breakthrough
has the potential to bring about major benefits for the health
and well-being of women and their families.
Most women will contracept for approximately 3 decades
during their reproductive years. The adoption of the IOM's
recommendations holds so much promise for millions of women who
currently lack basic resources like health insurance coverage.
All of my training and experience tells me that what we are
striving for is healthy women. We are also working to ensure
that if and when they are ready to have a child that they have
a healthy pregnancy. The best way to achieve this is to help
women and couples become as healthy as possible before
pregnancy. This includes financial health, emotional health,
and physical health. We should trust women and empower women to
make the appropriate decisions for themselves. Therefore, I
hope we can agree that guaranteeing contraceptive coverage and
removing cost barriers should be at the forefront of preventive
care so that women can achieve their own goals.
Thank you very much.
[The prepared statement of Mr. Hathaway follows:]

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Mr. Pitts. The Chair thanks the gentleman and now
recognizes Ms. Belford for 5 minutes.

STATEMENT OF JANE G. BELFORD

Ms. Belford. Mr. Chairman and distinguished members of the
subcommittee, thank you for the opportunity to testify before
you today on an issue of vital importance to religious
organizations like the one I serve.
My name is Jane Belford, and I serve as chancellor of the
Catholic Archdiocese of Washington, which includes 600,000
Catholics and includes 140 parish church communities in the
District of Columbia and portions of Maryland.
The Archdiocese is one of 195 dioceses of the Catholic
Church in the United States which represents more than 70
million Catholics. Throughout this country's history, the
Catholic Church has been one of the leading private providers
of charitable educational and medical services to the poor and
vulnerable. The Archdiocese continues that tradition of service
today through its Catholic schools, medical clinics, maternal
and pregnancy resource programs, social service agencies,
senior and low-income housing, job training programs, and a
vast number of other programs and services for persons in need
regardless of their faith or no faith, without question,
without exception.
The late former Archbishop of Washington, Cardinal Hickey,
once said, ``We serve them not because they are Catholic but
because we are Catholic. If we don't care for the sick, educate
the young, care for the homeless, then we cannot call ourselves
the Church of Jesus Christ.'' Until now, Federal law has never
prevented religious employers like the Archdiocese of
Washington from providing for the needs of their employees with
a health plan that is consistent with the Church's teachings on
life and procreation. The Archdiocese provides excellent health
benefits to its nearly 4,000 employees, consistent with
Catholic teaching, and subsidizes most of the cost.
We would lose this freedom of conscience under the mandate
from the Department of Health and Human Services that the
health plans of religious organizations like ours cover
sterilization, contraceptive services, and drugs that in some
cases act as abortifacients. This is not in line with the
policy that has governed other Federal health programs.
The HHS mandate provides a radically narrow test to be
eligible for exemption. Essentially, under this test Catholic
organizations like ours would be considered religious enough
only if we primarily served Catholics, only if we primarily
hired Catholics, and only if the whole purpose of our service
was to inculcate our religious values.
Under this analysis, organizations like ours would be only
free to follow Catholic teaching on life and procreation if we
stopped hiring and serving non-Catholics. However, as in the
parable of the Good Samaritan, Catholic organizations serve
people of all different faiths without question or condition
and without knowing their faith.
Just last year, Catholic Charities of the Archdiocese
served over 100,000 people. I could not tell you what their
faith is. Our 98 Catholic schools educate 28,000 students in
the District of Columbia and Maryland, and in some locations,
more than 80 percent of the students are non-Catholic.
HHS has drafted an exemption that is so narrow that it will
exclude virtually all Catholic hospitals; Catholic schools,
colleges, and universities; and charitable organizations, none
of which impose a litmus test on those they serve. Why does the
government want to have us do that?
In my written testimony, I allude to the vast array of
services being provided right now in the Archdiocese of
Washington--the medical care, educational services, and social
services that are made available. This narrow religious
exemption drafted as it has would burden our deeply held belief
not only in life and procreation but in the belief that God
calls us to serve our neighbors. Both those beliefs--our
beliefs in life and procreation and our belief in service--are
grounded in a fundamental teaching that upholds the dignity of
human life of whatever race, status, or creed from the
beginning of life to the end.
It is part of our central mission and religious identity to
be a witness in the world through acts of service to all who
are in need, regardless of religion or creed. When we are
fortunate enough to be able to partner with the government in
providing these services, our devotion to the cause and our
institutional resources can make each dollar of funding go
further. Unfortunately, the mandate poses a threat to our
rights of conscience in our services for our neighbors. At a
time when local, State, and Federal governments have had to
consider drastic cuts to their healthcare and social service
programs and when our citizens' need for support is so great,
it is difficult to understand why the Federal Government would
impose requirements that are designed to undermine and restrict
access to these services.
We believe in the value and dignity of all human life from
beginning to end, and we believe that we are called to serve
our neighbors, all of them. We will continue to honor these
beliefs. We have served, we serve now, and we will continue to
serve, but I urge the committee to consider our Nation's
historical commitment to religious liberty and the value and
importance of the Church's service to the poor and vulnerable
and to permit us to practice our faith consistent with the
teachings of our church.
Mr. Chairman and members of the committee, thank you for
the opportunity to address you.
[The prepared statement of Ms. Belford follows:]

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Mr. Pitts. Thank you. The Chair thanks the gentlelady,
recognizes Mr. O'Brien for 5 minutes.

STATEMENT OF JON O'BRIEN

Mr. O'Brien. Mr. Chairman, Member Pallone, and members of
the subcommittee, thank you for this opportunity to present
testimony on this important question of conscience rights and
access to comprehensive healthcare.
For nearly 40 years, Catholics for Choice has served as a
voice for Catholics who believe that Catholic teaching means
that every individual must follow his or her own conscience and
respect the rights of others to do the same. This hearing seeks
to answer the question: Do new health law mandates threaten
conscience rights and access to care? I firmly believe the
requirements under the Affordable Care Act and the slate of
regulations being created to implement it infringe on no one's
conscience, demand no one change his or her religious beliefs,
discriminate against no man or woman, put no additional
economic burden on the poor, interfere with no one's medical
decisions, compromise no one's health--that is, if you consider
the law without refusal clauses.
When the question is asked in light of these unbalanced and
ever-expanding clauses, the answer becomes yes, it would do all
those things. When burdened by such refusal clauses, the new
health law absolutely threatens the conscience rights of every
patient seeking care for these restricted services and of every
provider who wishes to provide comprehensive healthcare to
patients. These restrictions go far beyond their intent of
protecting conscience rights for all by eliminating access to
essential healthcare for many, if not most patients, especially
in the area of reproductive health services. This will make it
harder for many working Americans to get the healthcare they
need at a cost they can afford.
Like many Catholics, I accept that conscience has a role to
play in providing healthcare services, but recent moves to
expand conscience protections beyond the simple right for
individual healthcare providers to refuse to provide services
to which they personally object to go too far. It is incredible
to suggest that a hospital or an insurance plan has a
conscience. Granting institutions--or entities like these--
legal protection for the rights of conscience that properly
belong to individuals is an affront to our ideals of conscience
and religious freedom.
Respect for individual conscience is at the core of
Catholic teaching. Catholicism also requires deference to the
conscience of others in making one's own decisions. Our faith
compels us to listen to our consciences in matters of moral
decision-making and to respect the rights of others to do the
same. Our intellectual tradition emphasizes that conscience can
be guided, but not forced, in any direction. This deference for
the primacy of conscience extends to all men and women and
their personal decisions about moral issues.
Today, the 98 percent of sexually active Catholic women in
the United States who have used a form of contraceptive banned
by the Vatican have exercised their religious freedom and
followed their consciences in making the decision to use
contraception. Thus, they are in line with the totality of
Catholic teaching if not with the views of the hierarchy.
Having failed to convince Catholics in the pews, the United
States Conference of Catholic Bishops and other conservative
Catholic organizations are now attempting to impose their
personal beliefs on all people by seeking special protection
for their conscience rights. They claim to represent all
Catholics when in truth theirs is a minority view. The majority
of Catholics support equal access to contraceptive services and
oppose policies that impede upon that access.
Two-thirds of Catholics, 65 percent, believe that clinics
and hospitals that take taxpayer money should not be allowed to
refuse to provide procedures or medications based on religious
belief. A similar number, 63 percent, also believes that all
health insurance, whether private or government-run, should
cover contraception. Sweeping refusal clauses and exemptions
allow a few to dictate what services many others may access.
They disrespect the individual capacities of women to act upon
their individual conscience-based decision. They impede the
rights of women and men to make their own decisions about what
is best for them, their health and their families.
Lawmakers of all political hues can come together to
support a balanced approach to individual conscience rights and
access to comprehensive healthcare. It makes sense for all
those who want to provide more options to women seeking to
decide when and whether to have a child. It makes sense for
those who want to keep the government's involvement in
healthcare to a minimum. Above all, it makes sense for a
society that believes in freedom of religion, a right one can't
claim for oneself without extending it to one's neighbor.
The bottom line is that protecting conscience rights and
preserving access to care shouldn't just be about protecting
those who seek to dictate what care is and is not available,
nor should it be for those who would dismiss the conscience of
others by imposing their view of which consciences are worth
protecting. Protecting individual conscience and ensuring
access to affordable, quality care is not just an ideal, it is
a basic tenet of our society and it is the right thing to do.
I thank the subcommittee for inviting me today.
[The prepared statement of Mr. O'Brien follows:]

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Mr. Pitts. The Chair thanks the gentleman and recognizes
Mr. Cox for 5 minutes for an opening statement.

STATEMENT OF WILLIAM J. COX

Mr. Cox. Good morning, Mr. Chairman and members of the
committee, and thank you for convening a hearing on this
critically important matter. My name is Bill Cox and I am
president and CEO of the Alliance of Catholic Health Care,
which is based in Sacramento, California. We represent 4
Catholic systems in California that operate 54 hospitals.
My testimony focuses on the exceedingly narrow definition
of religious employer in HHS's interim final rule.
You have a copy of my extended remarks, so I will summarize
them by making four brief points about the definition and the
mandate.
First, in order to benefit from the definition, a religious
institution must primarily employ and serve its coreligionists
and it must proselytize. As an essential element of the
religious missions Catholic hospitals, universities, and social
services hire and provide services to a broad array of people
and they do not proselytize those they serve. Thus, the
definition, together with the mandate, will require Catholic
hospitals, universities, and social service agencies to cover
in their health insurance plans contraceptives, abortifacients,
and sterilizations in direct violation of their religious
beliefs.
Mr. Chairman, Catholics have been providing healthcare
services in California since 1854 when eight Sisters of Mercy
arrived in San Francisco from Ireland. The following year, a
cholera epidemic broke out and the Sisters went to work in the
county hospital. According to San Francisco's ``The San
Francisco Daily News'' of that time, ``the Sisters of Mercy did
not stop to inquire whether the poor sufferers of cholera were
Protestant or Catholic, American or foreigners, but with the
noblest devotion, applied themselves to their relief.''
Mr. Chairman, had HHS's definition of religious employer
been in effect in 1854, the ministry of the Sisters of Mercy in
San Francisco would not have been considered by the Federal
Government to be a religious ministry.
Second, I think it is very important to emphasize this
morning that neither the propriety nor the wisdom of nor the
government's authority to impose a contraceptive mandate on all
employers is at issue here. The question is actually a very
narrow one related to the First Amendment, and that is whether
the HHS definition of religious employer contravenes the First
Amendment by putting the Federal Government in the position of
determining what parts of a bona fide religious organization
are religious and what parts are secular.
In particular, it allows the government to make such
distinctions in order to infringe the religious freedom of that
portion of the organization the government declares to be
secular. This is exactly what the founders of this country
sought to avoid by adopting the First Amendment to the
Constitution.
Third, the definition is discriminatory in that it tracks
identical language first enacted in a California statute that
was deliberately designed to contravene the religious conduct
of religious organizations such as Catholic hospitals,
universities, and social services. At the time, one of the
principal proponents of that definition of religious liberty
said our purpose and intent here is to close the Catholic gap.
That is, we want to compel these religious institutions by
force of law to provide these services regardless of what they
may think of them in terms of their religious belief.
Fourth, there is no escape from the HHS mandate. Unlike
most State contraceptive mandates that have a similar
definition of religious employer, religious employers cannot
avoid the HHS mandate by either dropping coverage of
prescription drugs or by self-insuring through an ERISA plan.
In conclusion, I would just like to note that Catholic
hospitals provide a broad array of services not always
available in other institutions. For example, in California 86
percent of our hospitals have palliative care programs compared
to only 43 percent of all California hospitals. Our palliative
care programs address the physical, emotional, and spiritual
needs of chronically ill and dying patients and their families.
Moreover, a recent Thomson Reuters study found that on 8
key metrics Catholic healthcare systems in the United States
were significantly more likely to outperform their nonprofit
and investor-owned counterparts on quality, efficiency, and
patient satisfaction. It would be a great loss to the Nation
and the communities we serve if our hospitals were compelled by
Federal law to forgo their religious mission and consciences in
order to comply with the HHS contraceptive mandate.
I would be happy to answer any questions.
[The prepared statement of Mr. Cox follows:]

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Mr. Pitts. The Chair thanks the gentleman and thanks all
the witnesses for their opening statements.
I will now begin the questioning and recognize myself for 5
minutes for that purpose.
Mr. Cox, the Church amendment which became part of the
Public Health Service Act in 1973 declares that hospitals' or
individuals' receipt of Federal funds in various health
programs will not require them to participate in abortion and
sterilization procedures if they object based on moral or
religious convictions. Also, no State in the country except
Vermont requires insurance coverage of sterilization. How is
the interim final rule on preventive services issued by HHS
subsequent to passage of the healthcare law different in
respect to conscience protections and sterilization mandates?
And what are the implications for Catholic healthcare
providers?
Mr. Cox. Well, these are requirements that would force
Catholic healthcare providers, Catholic universities, and
social service agencies to include contraceptive services,
sterilization, and other things in their health insurance plans
in violation of their religious beliefs. And that is how it
would affect them.
Under most State laws there are options that we have
available to us. One, if for instance in California a religious
employer can drop prescription drug benefits entirely in their
health insurance plan and get out from under California's
contraceptive mandate. We have chosen not to do that because
that would make absolutely everyone else worse off in our
employ. But what we have done is moved to ERISA plans in order
to self-insure and get out from under the mandate.
Now, under the HHS mandate and definition of religious
employer, as I said in my testimony, there is no escape. ERISA
plans will be covered. All employers are required, regardless
of religious views, to cover these services.
Mr. Pitts. The supporters of the interim final rule on
preventive benefits argue the substance of the rule is similar
to contraceptive mandates imposed by States on health plans
operating within their State. Just as you said, the question
was do State contraceptive mandates apply to self-insured plans
governed under ERISA? And does the HHS rule differ in this
respect? You spoke to that.
Do State contraceptive mandates typically require coverage
of sterilization procedures?
Mr. Cox. They do not. I think Vermont is the only State
that does.
Mr. Pitts. Do State contraceptive mandates force plans to
cover such products even if they do not provide coverage for
prescriptive drugs generally?
Mr. Cox. I think the laws in the various States differ with
respect to that, and many of the States that have a
contraceptive mandate also have pretty strong and effective
conscience legislation that allows religious employers and
providers with a moral perspective on this to opt out of the
mandates.
Mr. Pitts. Thank you.
Let me go to Dr. Stevens. You said that the contraceptive
mandate ``violates the religion and free speech clauses of the
First Amendment of the Constitution by coercing faith-based
healthcare ministries to not only violate their very faith-
based tenets that have motivated patient care for millennia but
also to pay for that violation. Such conscience-violating
mandates will ultimately reduce patients' access to faith-based
medical care, especially depriving the poor and medically
underserved population of such care.'' Do you believe that the
particular mandate could contribute to faith-based providers
leaving the medical profession, reducing access to medical
care, and are you concerned that faith-based providers might
leave certain areas of medical care?
Mr. Stevens. We are seeing a pattern from this
administration to restrict conscience rights, including
stripping regulations, deregulation. We actually surveyed our
membership and 88 percent of them say the problem is getting
much worse. The issues we are talking about today I never
talked about during my training. And we are also seeing people
coming under increasing discrimination in the workplace.
One of my staff member's wife, a family practice doc,
worked in Texas. She did not distribute contraceptives to
single women, referred them across the hallway to another
physician, and it wasn't even an inconvenience for them, and
she was told she was going to lose her job and she had to go
find other employment within a week. We have seen this with
anesthesiologists; we have seen this with the family practice
docs. Just this week, 12 nurses in New Jersey have been forced
to participate in abortion in the workplace and there is a suit
being brought at the medical school there. This is a pattern
that concerns all of us because we have 16,000 members. They
have over 125,000 doctors that we are in regular communication
with. They are very concerned about this and it could affect
healthcare in this country.
Mr. Pitts. Thank you. My time has expired.
The Chair recognizes the ranking member, Mr. Pallone, for 5
minutes for questions.
Mr. Pallone. Thank you, Mr. Chairman.
I would ask unanimous consent to insert in the record
statements from the following organizations: Concerned Clergy
for Choice; National Council of Jewish Women; Religious
Institute; United Church of Christ--Justice and Witness
Ministries; Women's Alliance for Theology, Ethics, and Ritual,
or WATER; Physicians for Reproductive Choice; Religious
Coalition for Reproductive Choice; General Board of Church and
Society of the United Methodist Church. I believe you have all
these.
Mr. Pitts. Without objection, so ordered.
[The information follows:]

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Mr. Pallone. Thank you.
I am going to start with Mr. O'Brien. Your testimony
discusses use of contraceptive services among both Catholic and
non-Catholic women. Is it your understanding that surveys and
studies have shown virtually all Catholic women have used
contraceptive services at some point in their lifetimes?
Mr. O'Brien. Yes, Congressman, that is correct.
Mr. Pallone. Thank you. Is it true that the use of
contraceptive services among Catholic women mirrors that of
non-Catholics?
Mr. O'Brien. It is.
Mr. Pallone. And I am going to go to Dr. Hathaway. I saw a
recent poll of registered voters about their views on
contraceptive services. I want to ask you a few questions about
public support for contraception. Do the vast majority of
Americans support access to contraceptive services?
Mr. Hathaway. Yes.
Mr. Pallone. And is this same view also held by people who
are opposed to abortion?
Mr. Hathaway. Yes, indeed.
Mr. Pallone. And back to Mr. O'Brien, if you would chime
in. Does research indicate that the majority of Catholics
support access to contraceptive services?
Mr. O'Brien. Yes, during the health insurance reform
debate, Catholics were surveyed, and 6 in 10 Catholics believe
that contraception should be covered as part of health
insurance.
Mr. Pallone. Thank you. For both gentlemen, your answers
underscore an important point, and that is that improved access
to contraceptive services is supported by the majority of
Americans, and I certainly agree with some of the comments made
by my colleagues and the witnesses about ensuring that
individual health providers not be compelled to act against
their conscience, but the subject of today's hearing is
regulations that address what plans are required to do. Given
what we have heard today, I think we should support coverage
for contraceptive services and make these services available to
the millions of women who would benefit from it.
Now, I want to go to Dr. Hathaway again. In your testimony,
you discuss the importance of making sure that women have
access to contraceptive services and information that will help
them better plan and space their pregnancies. Can you briefly
describe the benefits of using contraceptive services?
Mr. Hathaway. Briefly would be difficult. There are
multiple, multiple benefits towards contraception. A woman's
ability to maintain and get herself healthy before pregnancy is
incredibly important--taking folate to reduce anomalies,
getting her medical conditions under control. Many women have
multiple medical conditions that are out of control before they
get pregnant.
Mr. Pallone. What about in terms of babies' health?
Mr. Hathaway. Also. Birth spacing is incredibly important.
We know from research that birth spacing, the shorter the
interval, the greater likelihood of low weight births as well
as preterm births, an incredible burden to both the family as
well as society and the health industry.
Mr. Pallone. Well, you know there are over 60 million women
of reproductive age in the country but there are many women who
do not use contraception regularly or at all. Could you
elaborate on the extent to which cost is a barrier to the use
of contraceptive services?
Mr. Hathaway. It is an incredible barrier. Many women have
to jump hoops to get contraceptives. If they have some
insurance, perhaps it doesn't cover all of their contraceptive
methods. And as I pointed out in my testimony, the longer-
acting methods are the most cost-effective and yet the most
cost-prohibitive up front and those are the methods that we
ought to be turning towards to provide better contraception in
our country.
Mr. Pallone. And what about when you have insurance
coverage for contraception? I mean does that impact the ability
of women to access those health services?
Mr. Hathaway. In many cases, yes. Even insurance there are
restrictions regarding copays, as well as additional fees for
these, as I said, most effective methods.
Mr. Pallone. And based on your clinical experience, do you
believe that elimination of out-of-pocket costs for birth
control pills and other forms of contraception would increase
their use?
Mr. Hathaway. Most definitely. Most definitely.
Mr. Pallone. All right. I just want to thank you, Dr.
Hathaway. I mean it is clear from your testimony and responses
that there are compelling policy reasons why we should promote
access to contraception and also limit cost-sharing associated
with those services.
Thank you and thank you to Mr. O'Brien.
I yield back, Mr. Chairman.
Mr. Pitts. The Chair thanks the gentleman and recognizes
the vice chair of the subcommittee, Dr. Burgess, for 5 minutes.
Mr. Burgess. Thank you, Mr. Chairman.
Dr. Hathaway, along the lines as Mr. Pallone was just
exploring, they said that there are valid policy reasons to
consider providing contraception, but you also allude to the
fact that in your world cost is a consideration. Is that
correct?
Mr. Hathaway. I am not sure I understand the question. Cost
as a consideration for an individual patient?
Mr. Burgess. You talk about the individual in your clinic
who wanted a long-term method of contraception but it nearly
exhausted your safety net dollars----
Mr. Hathaway. Right.
Mr. Burgess [continuing]. And cost is an issue whether we
like it or not. Money has got to come from somewhere, has it
not?
Mr. Hathaway. Indeed. And yet if you look at a lot of the
research, including Guttmacher Institute's research on cost
savings for contraception overwhelmingly----
Mr. Burgess. Yes, let us hold that. We will get to that in
a minute because I am not quite sure we have delivered on the
promise of the cost savings. And of course, we are Members of
the House of Representatives. We live under the rule of the
Congressional Budget Office and as all of us on both sides of
the dais know, we are not allowed to score savings. We can only
talk about cost. That is an important point; I do want to get
to it.
But here is my beef with this thing. I mean it came to us
as an interim final rule. There was obviously a rush. There
were some calendar considerations. We have got to get it done
within some certain time constraints, but it didn't really
allow for the proper input and transparency of the normal
Federal agency process. The Affordable Care Act is a lot of
pages of very densely worded instructions to Federal agencies,
and whether you agree with or not, going through the process at
the Federal agency, there is a reason that it does that because
it allows the public to comment. Before the rule is put
forward, it allows for the people to weigh in on it.
But in an interim final rule, that is kind of a different
world because although it sounds like, well, it is only
interim. Either you come back and do--you really can't. I mean
this thing comes out of the agency with the force of law and
you see right now in this environment how difficult it is for
Congress, the House and Senate to get together and pass any law
that the President will sign, but this thing can come out with
the force of law in a relatively condensed period of time with
maybe public input but maybe it ignores public input.
Now, I worked my residency with Parkland Hospitals--a long
time ago I grant you--but we provided a lot of healthcare to
women who were very, very poor and I never wrote a prescription
for an oral contraceptive except Ortho-Novum 1/50 for 4 years'
time because that was the formulary that Parkland Hospital
used. In order to provide the services for the vast numbers of
people that they had to serve, they got a deal with the
contraceptive manufacturer, and that was the birth control
pill. It was a learning experience for me to be out in private
practice and see all of the choices that were out there.
But those choices come with a cost, don't they?
Mr. Hathaway. Yes. Yes, indeed.
Mr. Burgess. Can you give us an idea of what kind of the
range of cost? Let us just stick with oral contraceptives for
right now. I know you are interested in long-term
contraception, but just for oral contraceptives right now,
there is a pretty wide variation of cost, is there not?
Mr. Hathaway. Yes, the brand name contraceptives probably
run in the neighborhood of upwards of $50 per month.
The generics have probably in the neighborhood of 30 or
somewhere in that neighborhood.
Mr. Burgess. Well, through the miracle of the iPad and
Leslie's List, I can tell you that there is a cost differential
of about $20 a month for a generic Ortho-Novum 1/35, Necon--
funny name for that pill--and there is another one called
Seasonique that is, according to research done by my staff,
$1,364 a year, so about $110 a month. So that is a pretty wide
discrepancy, isn't it?
Mr. Hathaway. Indeed, and yet if we were able to help a
woman with a longer-acting method for that year, you would
save----
Mr. Burgess. Let us not go there just yet because----
Mr. Hathaway [continuing]. A lot of dollars right there----
Mr. Burgess [continuing]. The Institute of Medicine and the
interim final rule says without regard to cost, we have to
provide all methods now across the board. And this is the
problem with having an interim final rule. I didn't get to go
to the Federal agency and say you know what? This is a pretty
wide cost discrepancy here. You can provide 5 women with the
same type of oral contraceptive protection that one woman gets
for Seasonique. And there are reasons that patients want to
take that. I get that. Perhaps it should be available with a
copay or paying a little extra for that premium contraceptive
coverage. This would be something that I think would have been
useful to the Federal agency. But unfortunately, we didn't get
to have input on that because it was promulgated as an interim
final rule.
Mr. Chairman, you have been generous with my time. If we
have time for a second round, I do want to talk about the cost-
benefit stuff.
Mr. Pitts. The Chair thanks the gentleman and now
recognizes the ranking member emeritus, Mr. Dingell, for 5
minutes.
Mr. Dingell. And the questions here I direct at Mr.
O'Brien, and I hope that the answers will be by yes or no.
The interim rule issued by HHS on August 3, 2011, regarding
coverage of preventive services under ACA included language
that exempted certain religious employers from covering
contraceptive services without cost sharing. A religious
employer is defined by one that has religious values as the
purpose of the organization, primarily employs and serves
persons who share the religious tenets of the organization, and
is a nonprofit organization. Isn't it true that this definition
of religious employer is set forth by HRSA and the interim rule
is not wholly a new definition of a religious employer? Yes or
no?
Mr. O'Brien. Yes, Congressman.
Mr. Dingell. Now, isn't it also true that the 20 States
that exempt certain religious employers from having to cover
contraceptives that they allow them to be exempt from providing
contraceptive services, and at least half of these States use a
definition of a religious employer similar to that in the
definition used by HRSA in the interim final rule? Yes or no?
Mr. O'Brien. Yes.
Mr. Dingell. Isn't it also true that 2 State Supreme Courts
in California and New York upheld a definition of religious
employer similar to the definition of a religious employer in
the legislation as constitutional? Yes or no?
Mr. O'Brien. Yes.
Mr. Dingell. So I think everybody in this room should agree
that individuals have the right to decline to provide certain
medical treatment if they conscientiously object to their
religious beliefs. That is not interfered with under the
regulations, is it?
Mr. O'Brien. Yes.
Mr. Dingell. The answer is it is not interfered with.
Mr. O'Brien. No.
Mr. Dingell. Thank you. And under current healthcare
professionals who conscientiously object to providing certain
medical services or procedures due to their religious beliefs
are allowed to again not to provide those services, is that
right?
Mr. O'Brien. That is right.
Mr. Dingell. But isn't it true that the broadening
definition of a religious employer would allow an employer, say
a hospital or health insurer, to deny coverage for
contraceptives or other preventive services based on their
religious beliefs? Yes or no?
Mr. O'Brien. Yes.
Mr. Dingell. Now, isn't it also true that the broadening of
the religious exemption would limit access to contraceptives to
nearly 1 million people and their dependents who work at
religious hospitals and nearly 2 million students and workers
at universities with a religious affiliation? Yes or no?
Mr. O'Brien. Yes.
Mr. Dingell. One of the ways the Affordable Care Act works
to address the need of lowering costs in our health system is
by putting renewed emphasis on prevention and wellness programs
to help American families to live healthier lives and reduce
the need for more costly treatments later in life. The
Affordable Care Act does this by eliminating copays and cost-
sharing for preventive service. Is that correct?
Mr. O'Brien. Yes. Yes.
Mr. Dingell. And he doesn't have a nod button so you have
got to answer yes or no. HHS has asked the Institute of
Medicine, an independent organization who is convening a panel
of experts to make recommendations about what preventive
services for women would qualify for no cost-sharing. The
Institute of Medicine identified 8 preventive services as being
necessary to improving women's health and well being, including
all FDA-approved contraceptive methods and patient education
counseling, amongst other benefits. HHS adopted these
recommendations in full, is that correct?
Mr. O'Brien. Yes.
Mr. Dingell. Now, wouldn't you agree that--by the way, is
that yes or no?
Mr. O'Brien. Yes.
Mr. Dingell. Wouldn't you agree that broadening the
religious exemption would limit or prevent access to critical
preventive services that are intended to improve the health and
well being of women? Yes or no?
Mr. O'Brien. Yes, absolutely.
Mr. Dingell. Now, wouldn't you also agree that the limiting
or preventing of access to critical preventive services is
counter to the goal of the Affordable Care Act to help make
prevention affordable and accessible to all Americans? Yes or
no?
Mr. O'Brien. Yes, that is true.
Mr. Dingell. Now, I note in the testimony that I have heard
this morning, I have heard no complaints that what we have done
here is to expand the right to abortion or to change the basic
language of the legislation in the Affordable Care Act on that
point. Am I correct in that understanding?
Mr. O'Brien. You are correct.
Mr. Dingell. Thank you.
Mr. Chairman, I note I yield back 2 seconds.
Mr. Pitts. The Chair thanks the gentleman and recognizes
the gentleman, Mr. Shimkus, for 5 minutes for questions.
Mr. Shimkus. Thank you, Mr. Chairman.
About a year ago, we had some theologians here on climate
change and I quoted some scripture, got myself in trouble, made
myself a name. But I mean if we are going to go down the right
and talk about safe--and especially for Christians, God's word
is the final arbiter of truth. Jeremiah 1:5, ``before I formed
you in the womb, I knew you.'' Psalm 71:6, ``you brought me
forth from my mother's womb.'' Those are just a few of numerous
scripture references on the pro-life debate for confessional
Christians, and this is where I really appreciate my fellow
Christians in the Catholic Church. I am Lutheran by faith
tradition, so hold a really distinct close bond. But there is a
strong position on the right to life.
And what we have done in the national healthcare law has
attacked the very providers of healthcare and social services
for the poor in this country, which are church, faith-based
institutions. And Mr. O'Brien, what we are doing is we are
depriving them of their choice. That is what we are doing. And
Illinois as aside has just done this in the adoption realm
where now the Catholic Church is suing the State of Illinois
because of now the Illinois legislation that grants same-sex
couples under the State law all the rights of married couples.
So when a faith-based institution like a Christian
denomination--and in this case, Catholic charity does 20
percent of all adoptions in the State of Illinois--you take the
other faith-based, I think it is up to 33 percent, they now
have to make a moral decision of whether they are going to
continue adoption services or comply with their faith-based
teachings. So that is going on in Illinois. That is exactly
what is going on here with the healthcare law. So I will follow
up with these questions.
To Ms. Belford, Mr. Cox, Mr. Stevens, should individuals or
institutions lose their rights to follow their moral and
religious beliefs once they decide to enter a healthcare
profession? Ms. Belford?
Ms. Belford. No, they should not lose that right.
Mr. Shimkus. Mr. Cox?
Mr. Cox. Absolutely not.
Mr. Shimkus. Mr. Stevens?
Mr. Stevens. We shouldn't be asking our medical schools to
ethically neuter healthcare professionals based upon only what
the State decides is right.
Mr. Shimkus. To the same three, should we compel providers
to act in violation of their conscience?
Mr. Cox. Absolutely not. It is a violation of the First
Amendment to the Constitution.
Mr. Shimkus. OK. That was Mr. Cox. Ms. Belford?
Ms. Belford. No. No, we shouldn't. That is a right
enshrined in our history, in our Constitution, in our laws the
right not to violate our firmly held, sincerely held religious
beliefs.
Mr. Shimkus. And Dr. Stevens?
Mr. Stevens. I agree. We cannot ask people to take
professional license and lay aside their personal morality.
Mr. Shimkus. Another question. When a provider makes a
conscious objection, is there anything that prevents a patient
from going to another willing healthcare provider for service?
Dr. Stevens?
Mr. Stevens. Absolutely not.
Mr. Shimkus. Ms. Belford?
Ms. Belford. No.
Mr. Shimkus. Mr. Cox?
Mr. Cox. No.
Mr. Shimkus. Ms. Belford, in order to qualify for the
religious employer exemption to HHS's interim final rule on
preventive services, an employer would have to meet all 4
criteria delineated in the rule, including that it primarily
serves persons who share its religious tenets. What would be
the impact on sick and needy people in the Archdiocese in
Washington if the Archdiocese organizations had to limit the
provision of their services in such a manner?
Ms. Belford. Well, Congressman, let me just say right at
the outset we have served, we are serving, and we will continue
to serve the people who need help. We would hope that our
government would recognize the value of those services and the
importance of those services and the right that has been
granted to us under the Constitution and the laws of this
country to be able to provide those services without violating
our religious beliefs. But we will serve. We have been here for
hundreds of years in this country serving. One of our oldest
agencies in the Archdiocese is St. Ann's Infant and Maternity
Home. It was chartered by President Lincoln and it is still
here serving. We will be here.
Mr. Shimkus. And let me personally thank you for your
service.
And I yield back.
Mr. Pitts. The Chair thanks the gentleman and recognizes
the gentlelady from Illinois, Ms. Schakowsky, for 5 minutes for
questions.
Ms. Schakowsky. I just wanted to note the number of
religious organizations that Mr. Pallone inserted testimony
into the record, and I note that one of them was the National
Council of Jewish Women, which I am a proud member of.
So let me understand from Dr. Stevens and Ms. Belford and
Mr. Cox. We are not talking about--as my colleague from
Illinois was saying--individual healthcare providers. You are
talking about healthcare systems, am I right? Institutions and
networks of institutions that would be exempted from having to
provide contraception, is that true, Dr. Stevens?
Mr. Stevens. Yes.
Ms. Schakowsky. Ms. Belford?
Ms. Belford. In the case of the Archdiocese of Washington,
we conduct our ministries through separate organizations, but
in addition to what we as church do----
Ms. Schakowsky. In your testimony are you asking to expand
it?
Ms. Belford. Excuse me?
Ms. Schakowsky. In your testimony are you saying that the
narrow exemption should be broadened if not dropped and to
include systems as well and broader----
Ms. Belford. It should include religious organizations that
operate in accordance with their teachings and beliefs, yes.
Ms. Schakowsky. And Mr. Cox, hospital systems as well and
hospitals?
Mr. Cox. The definition puts HHS in the position of
trolling through the religious beliefs and practices of
religious organizations----
Ms. Schakowsky. So that would include institutions?
Mr. Cox [continuing]. And determining, Congresswoman, which
ones it agrees with and which ones it doesn't agree with, and
if it doesn't agree with them, then it uses the force of law to
compel that organization to follow its beliefs.
Ms. Schakowsky. And let me ask the three of you, then, if
this regulation were not changed, would you drop your health
insurance coverage? Dr. Stevens?
Mr. Stevens. I think it would be something we would have to
consider because it is a problem when you are dispensing an
abortifacient and paying for it. It is called moral complicity.
Ms. Schakowsky. OK. Ms. Belford?
Ms. Belford. It is unthinkable that we would drop our
health insurance coverage but we would not provide coverage for
contraception and sterilization as required by this law.
Ms. Schakowsky. Mr. Cox?
Mr. Cox. We will have to challenge it in court if it isn't
dropped.
Ms. Schakowsky. OK. So I just want to make sure that the
word goes forth into the country that this is about depriving
women of contraception by large hospital systems, smaller
organizations, and potentially even all healthcare coverage for
the employees of those organizations despite the fact, as it
was pointed out, that all but perhaps 5 percent of Catholic
women also use contraception, that virtually all Americans in
recent surveys--women--use contraception.
Mr. O'Brien, this issue of conscience is so important
because I perceive that as an individual right of conscience,
can you elaborate on the difference between individuals and
institutions and the right of conscience that you mentioned
before?
Mr. O'Brien. You are absolutely correct, Congresswoman.
I think one of the things that is interesting about this is
the Catholic Church is not actually asking for an exemption.
The Catholic Church is all of the people in the Church, which
includes the 98 percent of Catholic women who use a
contraceptive. The consciences of these women, of the people in
the Church, are absolutely essential. The Catholic hierarchy,
the United States Conference of Catholic Bishops, represents
about 350 bishops. It is the bishops and the people involved in
the Catholic healthcare industry who are asking for these
exemptions. The conscience of an individual within Catholicism
and St. Thomas Aquinas told us very clearly that it is a mortal
sin not to follow your conscience, your individual conscience,
even if you have to go against church teaching. I think that
Catholics do that every day on an individual basis. The idea
that an institution or a health insurance plan in some way has
a conscience and there is no tradition of that and the reality
is that conscience is applied to real people and individuals.
Ms. Schakowsky. And since we are getting into very personal
and private matters dealing with women, I am just curious from
Dr. Stevens, Ms. Belford, and Mr. Cox, do you have any problem
with the insurance companies providing prescription drugs for
erectile dysfunction, Cialis or Viagra? Just curious.
Mr. Stevens. I don't have any problem at all. I also don't
have any trouble with contraceptives, most of them, but that
doesn't mean I am going to prescribe all of them or that my
Catholic brothers and sisters should not have the right to
decide they are not going to pay for them.
Mr. Cox. Our plans don't cover those services.
Ms. Belford. I think as I indicated, Congresswoman, in my
testimony, our plan does not cover contraceptive coverage,
sterilization, and the drugs that are mandated here.
And if I would just add I recognize that the teachings of
the Catholic Church on procreation and life may not be the
majority view and may not be popular, but I also understand
from all the testimony that I have just heard this morning that
contraception is widely available and universally used. So the
issue here is not whether or not women are using it or have
access to it. The issue for me and why I came here today is
because the Catholic Church has a teaching about procreation
and life and we are talking about whether us as an employer,
the Archdiocese of Washington, would be required to provide
coverage for something that we teach is morally wrong. I know
not everyone----
Ms. Schakowsky. And I hope you would inform all of your
women employees of that policy. Thank you.
Mr. Pitts. The Chair thanks the gentlelady and recognizes
the gentleman from Pennsylvania, Dr. Murphy, for 5 minutes.
Mr. Murphy. Thank you, Mr. Chairman.
Dr. Hathaway, in your testimony you spoke of your many
uninsured patients and the cost they face to excess
contraceptives, just to be clear, because this interim final
rule is directed at those providing insurance, nothing in this
rule would actually change your uninsured patients' ability to
access contraceptives, is that correct?
Mr. Hathaway. I am not a legal scholar and I can't truly
point to that, but I do know----
Mr. Murphy. They would still have access to that?
Mr. Hathaway. Access and copays and coverage for some of
the most effective methods are prohibitive for many, many, many
insured and uninsured women in our country. It is----
Mr. Murphy. I am asking under this interim rule, would
nothing that would change the uninsured patient's ability to
access contraceptives in this?
Mr. Hathaway. I think it would.
Mr. Murphy. Excuse me. Now, there are many business owners
in my district guided by their faith who are struggling with
whether or not they can continue to provide health insurance to
their employees in light of this new rule. Do you honestly
think that thousands of individuals and families in my district
who could lose their health insurance altogether are really
better off as a result of this rule?
Mr. Hathaway. I feel that this rule, in the Institute of
Medicine's evidence-based looking into this issue is pretty
clear that removing copays, removing cost barriers will have a
dramatic positive impact on reducing unintended----
Mr. Murphy. And the issue before us here is also one of
people's ability to practice their faith, that the government
is not saying that people cannot access these at all, but the
question really before us is whether or not government has the
right to force faith-based hospitals or clinics or providers or
employers certain services that violate their church teachings.
And the question is whether the Secretary of HHS can act
unilaterally to force employers, medical providers, hospitals,
clinics, and others to act in ways that violate their faith and
conscience.
And to that, Mr. O'Brien, I strongly disagree with your
analysis of the Catholic Church. Conscience is at the core of
Catholic teaching, you said, but slavery was not left to
personal decisions and conscience, thank goodness.
Conscience, according to Father Anthony Fisher, tells us
that ``it is the inner core of human beings whereby, compelled
to seek the truth, they recognize there is an objective
standard of moral conduct and they make a practical judgment of
what is to be done here and now in applying those standards.''
That and I think, too, it teaches us the moral character of
actions is determined by objective criteria not merely by the
sincerity of intentions or the goodness of motives. And the
church of the modern world and all people are called to form
their conscience accordingly and to fit with it as opposed to
rewrite their image of the church and of the Lord's teachings.
It is not--I repeat--it is not our duty as Catholics to tell
God what he should do or the image that he should adhere to or
what he should think, but it is up to us to shape our
conscience to conform with the teachings he has given us.
When Moses came down with the 10 Commandments, he didn't
put it up for a vote or ask for a referendum or say to people,
so what do you think, folks? Our life is spent in continuous
struggle to learn that which is good and conscience is not
merely to declare it in terms of humanism and then form some
image of God based upon some desires. Conscience, sir, is not
convenience.
Father Fisher goes on to say that ``deep within their
conscience, human persons discover a law which they have not
themselves made but which they must obey. Conscience goes
astray through ignorance and the key here is to shape our
conscience to conform to the laws of God, not to practicality
or solecism.'' ``Conscience,'' he goes on to say, ``is formed
through prayer, attention to the sacred, and adhering to
certain teachings of the church and the authority of Christ
teachings in the church.'' Conscience is not that which
described by Shakespeare when he says in Hamlet ``nothing is
either good or bad but thinking makes it so.''
So asking a group in a survey whether or not they have ever
acted or thought of acting a certain way that runs counter to
the church's teachings is no more a moral code than asking
people if they ever drove over the speed limit as a foundation
for eliminating all traffic laws.
With that, I end with a quote from John Adams, which he
said in 1776 when he was writing our Declaration of
Independence of the United States. He said, ``it is the duty of
all men in society, publicly and at stated seasons, to worship
the Supreme Being, the Creator and Preserver of the universe,
and no subject shall be hurt, molested, or restrained in his
person, liberty, or estate for worshipping God in the manner
most agreeable to the dictates of his own conscience or for his
religious profession, or sentiments provided he doth not
disturb the public peace or obstruct others in their religious
worship.'' The foundation of our Nation is not to impose laws
which restrict a person's ability to practice their faith, sir.
With that, I yield back.
Mr. Pitts. The Chair thanks the gentleman and recognizes
the gentlelady from California, Ms. Capps, for 5 minutes.
Mrs. Capps. Thank you, Mr. Chairman.
One thing that does trouble me in today's testimony is some
confusion about what the preventive service rule applies to and
what it doesn't. I would like to set the record straight as I
understand it. The rule we are discussing today is whether or
not an employer--as in a hospital or university system--can ban
the coverage of a medical service but it would not mandate that
any individual prescriber's control or that any woman or man
take birth control. Period. Today's hearing is yet another
example of how out of touch the majority side is with the
American people. My constituents tell me that we should be
spending our time here considering jobs and the economy, not
blocking women's access to contraceptive services. But instead
here we are again poised to attack another important piece of
the healthcare law to rile up an extremist constituency at
women's expense.
The Institute of Medicine report illustrates the strong
evidence and sound science that proper birth spacing and
planning of pregnancies does improve the health of a woman and
her future children. The HHS rule then translates the science
into provisions to give women options to choose if, when, and
how to space their pregnancies, something they should be
discussing with their medical provider, not with their boss. As
we have heard, especially in these tough economic times, women
are sometimes forced to choose between paying for their birth
control prescription or paying for other necessities. These
economic concerns are the threat to public health we should be
discussing, not whether or not your boss' conscience is more
important than your own.
Now, Mr. Cox, I want to praise the good work of your
institutions in California because many of them are serving my
constituents in my congressional district----
Mr. Cox. Thank you.
Mrs. Capps [continuing]. On the central coast. In your
testimony you say that you represent Catholic healthcare
organizations in California, including 54 hospitals. Is that
correct?
Mr. Cox. That is correct.
Mrs. Capps. So to be clear, you are not speaking for or
representing the views of all Catholic hospitals or nursing
homes in the United States?
Mr. Cox. No, but I would believe that my views would be
consistent----
Mrs. Capps. Right, but you do not represent any other than
the ones in California.
Mr. Cox. That is correct.
Mrs. Capps. As I understand it, California has a
requirement for coverage of contraception that is very much
like the one that HHS has now proposed, and that includes the
religious exemption that you are now saying is too narrow. I
also understand that this coverage requirement has been
reviewed by the California Supreme Court and found not to be
religious discrimination and that the United States Supreme
Court refused to review that decision. So my question to you, I
assume that your hospitals in their role as employers comply
with the California law and do provide insurance coverage for
your employees for contraceptive services. Is that correct?
Mr. Cox. Most of our members have moved or are moving
towards self-insurance under ERISA, which would be denied to us
by the HHS rule.
Mrs. Capps. But they do now?
Mr. Cox. Pardon?
Mrs. Capps. They do now?
Mr. Cox. Yes, they either have or are moving towards----
Mrs. Capps. But they do now use it?
Mr. Cox [continuing]. Self-insured ERISA plans in order to
get out from under----
Mrs. Capps. But they do provide insurance coverage now as
required?
Mr. Cox. Yes, of course, we do.
Mrs. Capps. OK. I wondered if you would tell us all have
any of your hospitals closed as the result of this requirement?
Yes or no, please.
Mr. Cox. We have other options.
Mrs. Capps. So they have not.
Mr. Cox. They have not.
Mrs. Capps. Have any of your hospitals dropped insurance
coverage for its employees as a result of this requirement?
Mr. Cox. No.
Mrs. Capps. Have any of the Catholic bishops severed ties
with your hospitals over this requirement?
Mr. Cox. No.
Mrs. Capps. Thank you.
Now, I would like to address Mr. Hathaway. I only have a
few seconds left, but if there was an expansion of refusal
provisions for employers, in some estimates that would affect
over a million employees and their families. Where would these
women go for their care?
Mr. Hathaway. My guess is they would end up in a safety net
system somehow and struggle to make ends meet.
Mrs. Capps. Like a Title X?
Mr. Hathaway. Right.
Mrs. Capps. And a clinic like the one you describe with
certain patients that you serve gets Title X funding to provide
these services for women who can afford them?
Mr. Hathaway. Correct.
Mrs. Capps. Thank you.
Mr. Hathaway. I think it should be pointed out that the
areas of the United States where there is less access to
healthcare are also the areas where there is higher epidemic
rates of unintended pregnancies, and those are the population--
if I am here representing anyone, I am representing the
thousands of women that I have seen daily that just don't have
access to good healthcare. And I truly hope we can move forward
on this Preventive Care Act.
Mrs. Capps. That is exactly what I wanted to allow you the
opportunity to say because as a former public health nurse in a
school system I see those faces before me every single day as I
serve here in Congress. Thank you very much.
Mr. Hathaway. Thank you.
Mrs. Capps. I yield back.
Mr. Pitts. The Chair thanks the gentlelady and recognizes
the gentlelady from Tennessee, Ms. Blackburn, for 5 minutes.
Mrs. Blackburn. Thank you, Mr. Chairman, and thank the
panel for their time.
Dr. Stevens, I want to talk with you for a couple of
minutes, but before I do, the gentlelady from California
mentioned that we should be talking about jobs. I would like to
say that straightening out this Obamacare bill is a way for
us--to repeal it, to replace it is a way to deal with jobs
because we heard from CBO that passage of this bill would cost
us about 800,000 jobs. So I appreciate that we are looking at
the dynamic that this has.
But Dr. Stevens, I want to talk with you. Since you are
from Tennessee and you are familiar with the impact that
TennCare program had on Tennesseans, I want to look at this
access-to-care issue because as I have told my colleagues here
in this committee many times over the past few years that what
we saw happen in Tennessee was individuals had access to the
queue but they didn't have access to the care. And there is an
enormous difference that is there. On the contraceptive
mandate, I want to be certain that I am quoting you right. And
your quote was, ``it violates the religion and free speech
clauses of the First Amendment of the Constitution by coercing
faith-based healthcare ministries to not only violate the very
faith-based tenets that have motivated patient care for
millennia but also to pay for that violation. Such conscience-
violating mandates will ultimately reduce patients' access to
faith-based medical care, especially depriving the poor and
medically underserved populations of such care.''
Mr. Stevens. That is very much the case. You know, the
intention may be to expand coverage, but actually what this is
going to do I believe if it is carried forward will reduce care
as faith-based professionals, because they are forced into a
situation, begin not providing those services or not providing
insurance for the staff that are working with them. So that is
a great concern because the bottom line is we want to take care
of the poor, we want to provide good services, but we cannot
violate our conscience.
Mrs. Blackburn. OK. And you also noted a national survey at
FreedomToCare.org of over 2,100 faith-based physicians revealed
that 9 of 10 are prepared to leave the practice of medicine if
pressured to compromise their ethical and moral commitments. So
do you believe that this particular mandate could contribute to
more faith-based providers leaving the medical profession and
thereby reducing patients' access to medical care? And are you
concerned that faith-based providers might leave certain or
particular areas of medical care in especially large numbers?
Mr. Stevens. I know that is happening. We work on 222
medical and dental campuses across the country where we have
student chapters and I remember meeting with 5 students down at
the University of Texas, 5 girls, and I said what are you guys
interested in? And they all said OB/GYN. How many of you are
going into it? Only one. Why not? Because of right-of-
conscience issues, because of pressures in residency, coercion
to participate in abortions or do things that violate their
conscience. So we are already beginning to change the face of
healthcare. The sad thing, Congresswoman, is that I think that
is what some people want.
I was debating a Planned Parenthood lawyer on National
Public Radio on right of conscience; he said you have no
business being in healthcare if you are not willing to provide
legal services. And I think there are some that would love to
see faith-based people out of the whole healthcare equation.
Mrs. Blackburn. OK. Let me go to Mr. Cox and Dr. Stevens
and Ms. Belford with this one. And Dr. Stevens, starting with
you and working across. Let me just ask you--this is a yes or
no--and then you can explain if you would choose. We only have
a minute and 45 seconds left. Does this preventive services
rule adequately protect freedom of conscience?
Mr. Stevens. Absolutely not. It is the most constrictive
thing we have had in Federal law in history.
Mrs. Blackburn. So the fears of the students would be
realized under that?
Mr. Stevens. Absolutely.
Mrs. Blackburn. OK. Ms. Belford?
Ms. Belford. I agree.
Mrs. Blackburn. OK.
Mr. Cox. Completely agree.
Mrs. Blackburn. Thank you. Thank you very much.
And with that, I will yield back my time so that we can
move through the rest of the panel.
Mr. Pitts. The Chair thanks the gentlelady, recognizes the
gentleman, Mr. Towns, for 5 minutes for questions.
Mr. Towns. Thank you very much, Mr. Chairman. Let me thank
you and the ranking member for holding this hearing.
The Supreme Court and lower courts throughout this land
have repeatedly ruled that a law that is applied generally is
enforceable even if some religious groups oppose the action or
the inaction that it requires. Let me give you a few examples.
The Quakers must pay taxes that support wars. Native Americans
may not use traditional drugs. Mormon men may not have multiple
wives. Some courts have ruled that the Muslim women must remove
their veils for photo identification cards and et cetera, et
cetera, going on and on and on.
The question for the court is whether the government is
pursuing a legitimate goal. Family planning is a legitimate
goal. We have reams of data and medical consensus that family
planning improves health outcomes for mother and child. We have
shelves of studies that show that unintended pregnancies are
likely to result in worse health and are much more likely to
result in abortion. The government, of course, cannot require
individuals to use family planning, it cannot require
individuals to provide family planning, but it can require
employers to pay for insurance that covers family planning, and
it should.
Let me go to you, I guess, Dr. O'Brien. I fully respect the
rights of an individual provider to exercise his or her
conscience. However, I believe that this right must be
carefully balanced by the rights of patients' access to safe,
legal healthcare. We must be certain that any right of refusal
provided is solely granted to an individual and not to an
institution to ensure that we strike the right balance.
Dr. O'Brien, do you believe that the Affordable Care Act
refusal clauses have the potential to compromise the health of
women?
Mr. O'Brien. I believe the Affordable Care Act is an
absolutely marvelous initiative that would greatly improve the
lives and the healthcare of women, men, and families. I think
the difficulty really comes about when what we are hearing all
the time is trying to bestow conscience rights on institutions.
I fully agree with you that with regards to doctors, nurses,
pharmacists, individuals have a right of conscience. They have
a right to refuse to provide services.
If they find themselves in that situation, obviously the
onus is to ensure that somebody can access those services.
Because in Catholicism--and also I believe within fair play in
the United States of America--the idea that someone cannot
access services, there is something wrong with that. I think
there is a real difficulty that we didn't hear a lot today from
some members about the conscience rights of those individuals
who would be denied service. What these refusal clauses are
really intending to do would be to have the State sanction
discrimination against individual workers just because they
happen to work in an institution that is a Catholic
institution. The idea that an employer can decide what services
you do or do not get, I think there is something very wrong
with that, something very un-American about it.
Mr. Towns. Right. Thank you very much. I much admit that I
agree.
Dr. Hathaway, why do you as a medical professional support
the ACA preventative coverage provision? As a doctor who
specializes in women's health, could you please explain why
unintended pregnancies are considered by doctors a health
condition? And I only have a few seconds left because I want to
make a statement in reference to I know we keep using the word
Obamacare. I am going to suggest for this committee, which is
the Health Committee, refer to it as President Obamacare. Thank
you.
Mr. Hathaway. Yes. Thank you, Chairman.
Mr. Towns. Thank you.
Mr. Hathaway. After I had been practicing in a public
health clinic for several years, I took some time to go to
public health school and it was for the exact reason as we are
speaking about today that I found many, many, many women, my
patients, coming in with unplanned, unintended pregnancies. And
I felt as though we need to be doing something about that. And
when this recommendation came out from the Institute of
Medicine, many of my colleagues throughout the country, OB/
GYNs, family, nurse practitioners, midwives, family medicine
doctors, pediatricians all to my knowledge are overwhelmingly
supportive of this recommendation that preventive healthcare
should include contraception care, family planning care, as
well as the multitude, 7 or 8 other points that they recommend.
Public health is an incredibly important issue for our country
and preventive health is paramount.
Mr. Towns. I yield back.
Mr. Pitts. The Chair thanks the gentleman and recognizes
the gentleman from Georgia, Dr. Gingrey, for 5 minutes.
Mr. Gingrey. Mr. Chairman, thank you for yielding, and I
thank our witnesses. I want them to know if they don't already
know that prior to Congress I spent 26 years practicing
obstetrics and gynecology in Marietta, Georgia, my hometown.
I am going to address my first questions to Dr. Stevens,
Ms. Belford, and Mr. Cox, and I will get each of you to quickly
answer these questions. They are pretty straightforward yes or
no.
Are you aware that President Obama promised every American
that they could ``keep what they have if they liked it'' when
referring to health insurance?
Mr. Stevens. Yes.
Ms. Belford. Yes.
Mr. Cox. Yes.
Mr. Gingrey. And the second question for the same three, I
referenced the Catholic hospitals in my opening statement. Does
this interim rule in your opinion support President Obama's
promise that workers, including the 750,000 of the Catholic
Hospital Association, could keep what they have if they like
it?
Mr. Stevens. No.
Ms. Belford. No.
Mr. Cox. No.
Mr. Gingrey. Thank you. The next question I want to address
to Mr. O'Brien. Mr. O'Brien, you stated that you believe in
choice and Mr. Waxman referenced in his statement the need for
employees to have the choice to access services. I am glad to
hear that because I basically agree with the two of you. I also
believe that choice is a two-way street, both to do and not to
do.
In 2014, according to supporters of the new health law,
President Obamacare, every single person will have numerous
choices in the health plans through these exchanges. So instead
of forcing every person to pay for a service they may have a
moral conscience objection to, Mr. O'Brien, don't you agree it
would be better to allow them to choose whether they want these
services and if they want to pay for them?
Mr. O'Brien. I think that there is a lot of people in the
United States of America who have problems with taxes, problems
paying taxes, the amount of taxes they pay. But we don't get to
pick and choose what we pay and what we don't pay for. Some
people disagree with the wars, some people disagree with the
incarceration system in the United States. Other people feel
that as regards to welfare that they don't feel like paying for
it. But we do. As a society, this is an important way for
society to be constructed so that it can actually operate. So
we don't always get to pick and choose.
I think the idea that one religious group would receive a
free pass, I think that that is very unfair and I don't think
that that is right.
Mr. Gingrey. Well, I am going to interrupt you because I
think that your answer is no. And no matter how long you talk,
the answer is going to be no. It seems to me quite honestly the
only choice you believe people should have are choices that fit
with your own philosophical views. The views that you espouse
are not choices but rather imposing of those views on people
regardless of their moral or religious views or convictions.
Quite honestly, Mr. O'Brien, that doesn't sound very American
to me.
I am going to go back to Dr. Stevens and Ms. Belford and
Mr. Cox in the remaining time that I have. In looking at this
interim rule, I guess that Catholic hospitals and providers
could limit their hires to Catholics and of course only deliver
care to Catholics. Is that the healthcare system that we
ultimately want, one in which Catholics treat Catholics,
Protestants treat Protestants, Muslims treat Muslims, or should
this government instead encourage hospitals and providers, the
doctors, to treat all patients?
Mr. Stevens. Should encourage to treat all patients.
Ms. Belford. That is a fundamental tenet of our faith, that
we care for our neighbor and love our neighbor as ourselves. So
yes, we should care for all.
Mr. Cox. It would be inconsistent with our religious
mission to limit our services only to Catholics.
Mr. Gingrey. Well, I thank the three of you. I certainly
agree with that.
Mr. Cox, I am going to conclude with you in the half-minute
I have left. Going back to previous questions, can you explain
the difference between California's law on benefits and the
impending HHS rule that we are discussing here today?
Mr. Cox. They are very similar and particularly with
respect to the definition of religious employers. HHS borrowed
or utilized the definition that was first developed by
California in its contraceptive mandate statute. They differ in
this regard: that you can get out from under the mandate in
California if you decide not to cover those prescription drug
benefits in your health insurance plan, and our members are
also able to self-insure under ERISA. They have been able to up
until now self-insure under ERISA and get out from under the
mandate. Also, the California statute does not cover
sterilization, which the HHS rule does and will compel us to
cover in our health insurance plans.
Mr. Gingrey. Thank you, Mr. Cox.
Mr. Chairman, I yield back. Thank you for your patience.
Mr. Pitts. The Chair thanks the gentleman and recognizes
the gentlelady from Wisconsin, Ms. Baldwin, for 5 minutes for
questions.
Ms. Baldwin. Thank you, Mr. Chairman.
I have a few questions for our witnesses but I would like
to first point out that here we are again, once again in the
middle of what has been described as the Republican war on
women. At a time when our committee and our Congress should be
coming together to put America back to work, putting partisan
divisions aside in the interest of the people, once again our
committee is advancing issues that divide Americans, and in
this case, issues that infringe on women's rights.
Today, the majority is focusing on yet another effort to
limit women's access to essential and medically necessary
treatment options. And in particular, my colleagues would like
to limit the number of new group or individual health insurance
plans that will be required to provide preventative services
for women without cost-sharing requirements. The Affordable
Care Act makes significant strides in expanding access and
making healthcare affordable for women. Thanks to this law,
being a woman can no longer be considered a preexisting
condition, and thanks to a provision in the Affordable Care Act
that we are discussing today, women will now have access to
preventative services that have been too costly for so many up
until now. That is unless Republicans succeed in their efforts
to limit the number of health plans that are required to cover
such preventative services.
I would like to explore this issue further and ask our
witnesses some questions. Dr. Stevens, Mr. Cox, and Ms.
Belford, as you know, I believe Congressman Fortenberry has
introduced a bill, H.R. 1179, the Respect for Rights of
Conscience Act. This bill would amend the Affordable Care Act
such that health plans would not be required to provide
coverage or pay for coverage for any service that is ``contrary
to the religious or moral convictions of the sponsor or issuer
or the plan.'' Just so the record is clear--and this question
is for each of you--do you support this legislation? Dr.
Stevens?
Mr. Stevens. I do support that legislation.
Ms. Baldwin. Mr. Cox?
Mr. Cox. We support it.
Ms. Baldwin. Ms. Belford?
Ms. Belford. Yes.
Ms. Baldwin. Thank you. Now, Ms. Belford, as the attorney
on the panel, I want to ask you some questions related to the
provision of H.R. 1179. As I read it, an employer can exclude
from its insurance coverage for its employees coverage of any
service that is contrary to the religious or moral convictions
of that employer. So if you can answer the following with a yes
or no, that would be greatly appreciated with our time
constraints. Under this language that I quoted, could a plan
exclude coverage for certain infertility services because the
plan sponsor has a religious objection to such services?
Ms. Belford. I can only speak to what our plan provides and
what our----
Ms. Baldwin. No, the quoted provision of Mr. Fortenberry's
bill if it were to be passed into law, I am wondering if under
that language I quoted could a plan exclude coverage for
certain infertility services because the plan's sponsor has a
religious objection to such services?
Ms. Belford. Hypothetically, I think it probably could.
Ms. Baldwin. Thank you. Under that language, could a plan
exclude coverage for alcohol and drug addiction services
because a plan's sponsor believes that use of alcohol or drugs
is sinful?
Ms. Belford. I honestly don't know the answer to that
question because these are all services that we provide under
our health plan.
Ms. Baldwin. But under the language of the Fortenberry
bill, health plans would not be required to provide coverage or
pay for coverage of any service that is contrary to the
religious or moral convictions of the sponsor or issuer. So
under that language could a plan exclude coverage for alcohol
and drug addiction because the plan's sponsor believes that the
use of alcohol or drugs is sinful?
Ms. Belford. Theoretically. I am not aware of religions
that do and I guess I would have to look with reference to what
our Federal laws and constitutional cases have indicated with
regard to what our moral and religious----
Ms. Baldwin. So you don't know the answer to that question.
Ms. Belford. I really don't.
Ms. Baldwin. OK. Under the language I quoted, could a plan
exclude coverage for HIV and AIDS patients because the plan's
sponsor expresses moral objections to homosexuality?
Ms. Belford. This is a hypothetical question but I just
have to say in our church we care for all people and we don't--
--
Ms. Baldwin. That is not the question.
Ms. Belford. We don't decline services----
Ms. Baldwin. We are considering legislation that will have
impacts if passed. Mr. Chairman, would I be able to be granted
an additional 30 seconds?
Mr. Pitts. Without objection.
Ms. Baldwin. Under the language that I quoted could a plan
exclude coverage for blood transfusions because the plan's
sponsor is religiously opposed to this medical service even in
an emergency situation?
Ms. Belford. I don't know the answer to that.
Ms. Baldwin. Under this language could a plan exclude
coverage for unmarried pregnant women because the plan's
sponsor has a religious objection to premarital sex?
Ms. Belford. We don't exclude such coverage so I don't----
Ms. Baldwin. I am not asking about your plan.
Ms. Belford [continuing]. Know whether that would be the
case.
Ms. Baldwin. Well, I hope that you see the point that I am
trying to make here. The scope of H.R. 1179 is broad enough to
exclude anything to which an employer decides it is religiously
or morally opposed. There is absolutely no standard, no
guidelines in place for making such a decision. This bill would
also undo State law and it would completely undermine the
Affordable Care Act.
Mr. Gingrey. Would the gentlelady yield to me when she has
a little time?
Mr. Cassidy. I would point out she is way over 30 seconds.
Mr. Pitts. The gentlelady's time has expired.
Ms. Baldwin. Thank you, Mr. Chairman.
Mr. Pitts. The Chair thanks the gentlelady, recognizes Dr.
Cassidy for 5 minutes for questions.
Mr. Cassidy. Folks, I got 5 minutes so if I interrupt you,
it is not to be rude. It is just because I have 5 minutes.
Now, Mr. O'Brien, Dr. Stevens raised an interesting point
of moral complicity, but it appears and frankly if we view the
employer as merely an extension of the State, we can take
Representative Baldwin's point and extend it to terrible things
where the State might demand something terrible and the
employer is merely an extension, a puppet being dictated by a
law who would have to comply. So I think this cuts both ways,
but I gather that you feel as if moral complicity is not an
issue if an employer is mandated to cover a service which he
particularly finds objectionable.
Mr. O'Brien. We think Catholicism and we think----
Mr. Cassidy. No, no, no, just in general.
Mr. O'Brien. In general fairness I think that a properly
formed conscience requires us to have respect for the
consciences of others. So I think that----
Mr. Cassidy. That said, we also are responsible for
ourselves, so if the employer finds something objectionable,
again, if you say that it is incredible to suggest that a
healthcare plan has a conscience, but it is not really the
healthcare plan; it is the purchaser of the healthcare plan
that has a conscience. I gather that you think it is incredible
that the purchaser of that healthcare plan would manifest her
conscience through the benefits covered. Is that correct?
Mr. O'Brien. I believe that due deference to the
consciences of others is an essential element----
Mr. Cassidy. No, but is it correct that you would find it
incredible that the purchaser of a healthcare plan would
manifest her conscience as regards with services she would
elect to cover for employees?
Mr. O'Brien. I think if you are talking about individuals,
I believe in the right of individual conscience.
Mr. Cassidy. So I am thinking of a small business owner,
she has got 35 employees and she is making a decision as to
what benefits to cover. It is she that is making it, she is an
individual, and you find it I gather incredible that she would
reflect her values through the services provided.
Mr. O'Brien. I think an employer, a company, an
institution, I think that the job of an institution is to give
due deference to the consciences of all----
Mr. Cassidy. So she is also filing as an S corp. so she is
actually taking income from the business as her own income. If
you will there is an identity that is respected in other
aspects of the law that is recognized by the IRS and others.
But again, you seem to find it incredible--I am not quite
getting the yes or no. In fact let me do what Ms. Baldwin did
or Mr. Pitts, which is a yes or no.
Do you find it incredible that that small business owner--
--
Mr. O'Brien. No.
Mr. Cassidy [continuing]. Would attempt to reflect her
values in the services she covers.
Mr. O'Brien. I don't think that an employer has a right to
insist that their values--for example, if an employer----
Mr. Cassidy. OK. That is fine. You know, you have made your
point. You don't think so. Again, I have only 5 minutes.
Mr. O'Brien. Sorry.
Mr. Cassidy. So at that point, the employer's conscience
merely becomes an extension of what the majority party is able
to put through without an open hearing through HHS. Ultimately,
that is it, correct? Yes, no?
Mr. O'Brien. I believe that it is the job of the
institution to facilitate the consciences of all people.
Mr. Cassidy. So again all people is interesting because we
are not really facilitating the conscience of that small
business owner who would like her values to be reflected in the
benefits she provides. And you also reject moral complicity. So
if that small business owner puts out a product, somehow you
have divorced her from the actions of her company. So if she
puts out a product which is harmful, there is no moral
complicity there?
Mr. O'Brien. I don't think that it is speaking to what the
actual issue is.
Mr. Cassidy. No, the question is----
Mr. O'Brien. The issue is whether----
Mr. Cassidy. I only have 5 minutes.
Mr. O'Brien. OK.
Mr. Cassidy. And so again if we are going to take a
holistic viewpoint of what this small business owner is doing,
if she put out something which was known to be harmful, we
would call that--in terms of a product--we would call that
morally reprehensible and we would ask her conscience to be
sharper. But then we can turn around and say she has no right
to judge what products should be covered by her insurance that
she provides for her employees. That is a cognitive dissonance.
That said, let us also make the point, Dr. Hathaway, that
this is really not about access for preventive services for
those who are poor. They are currently covered through Medicaid
and SCHIP, that I have been told IUDs can be placed right after
delivery, which is a long-term form of birth control. I am not
an OB/GYN; I am a gastroenterologist, you know, so whatever
that is worth. But that said, this is not about access for the
poor, and for those who have coverage, I see that the generic
birth control pill can cost $14 a month through 340(b) pricing.
If we are going to say through legislation that everything has
to be covered equally, then really we are saying to people
don't choose the $14-a-month pill; choose the $100-a-month
pill, which is also bad social policy. We just run out of money
at some point in our good will.
I yield back. Thank you.
Mr. Pitts. The Chair thanks the gentleman and we have----
Mr. Gingrey. Mr. Chairman?
Mr. Pitts [continuing]. Unanimous consent request from Dr.
Gingrey for 1 minute to respond since our friend, Ms. Baldwin,
went 1 minute over, so without objection.
Mr. Gingrey. And I thank my colleagues for allowing me the
minute because Ms. Baldwin was going down a line of
hypotheticals in regard to objection to blood transfusions,
objection to treating AIDS patients, and I want to make sure
and I want to particularly direct this to the 3 panelists that
I asked questions of before in regard to the Catholic principle
that the intimate relationship between husband and wife is for
the purpose of procreation of children and not simply
recreation as a number one principle. And the second principle,
even more important, the Catholic principle is that life begins
at conception and should never be deliberately terminated. I
would think that this is the reason that the three of you are
opposed to this interim rule and I just want to get your
response on that because this is a very narrow area in which
you would be opposed to sterilization, you would be opposed to
abortion, you would be opposed to your hospital prescribing
birth control pills or abortifacients. Is that not the crux of
this problem? Very quickly yes or no.
Mr. Stevens. Yes.
Ms. Belford. Yes.
Mr. Cox. Yes, we have not been covering those services in
our health insurance plans for a very, very, very long time. It
is only now that the government comes forward and says we are
going to require you to abandon that practice and violate your
conscience.
Mr. Gingrey. Thank you all very much.
And Mr. Chairman, thank you for----
Mr. Pitts. The Chair thanks the gentleman. That concludes
the first round of questioning. We will go to one follow-up per
side. Dr. Burgess for 5 minutes.
Mr. Burgess. Yes, Dr. Hathaway, if I could--and I won't use
the entire 5 minutes to question. What I am going to ask is
likely going to require a longer response, and if you wish to
respond in writing, that is perfectly acceptable.
But first let me ask you, you talked a little bit in your
testimony about the amount of money that is spent. Can you tell
us between Title X, Medicaid, and temporary assistance for
needy families how much money is spent on family planning by
the Federal Government every year?
Mr. Hathaway. I don't know that number.
Mr. Burgess. But it is a lot, right?
Mr. Hathaway. I presume so. I don't know that number.
Mr. Burgess. Yes, I don't either. That is why I am asking
you but it is likely to be well in excess of a billion dollars.
In fact it may be a multiple of that. And you referenced----
Mr. Hathaway. Pardon me, Chairman. I think also we need to
recognize that what this Institute of Medicine's recommendation
has to do with is insurers would cover contraceptive family
planning methods. We are not talking exclusively about public
assistance programs. We are talking about insurers throughout
the board. So we are now paying a tremendous amount of money,
those of us that have private insurance----
Mr. Burgess. Correct.
Mr. Hathaway [continuing]. For coverage and we are not
talking about an incredibly----
Mr. Burgess. Reclaiming my time. And we are going to pay
more under the IOM's guidelines. Dr. Cassidy is a
gastroenterologist. He doesn't prescribe birth control pills,
but I would submit that if the IOM were to require that
everyone who comes into his clinic be able to get whatever
proton pump inhibitor that they want, regardless of cost,
nobody is going to buy the generic Wal-Mart $4-a-month
prescription, which is available for the generics of Tagamet
and Zantac and some of the earlier products. Everyone is going
to get NEXIUM because that is the best and why wouldn't you
want to best? But the cost differential is substantial between
$4 a month to $100 a month. That is going to have the effect of
driving up the cost of the product for everyone, whether they
be on public assistance or not. Everyone who is on employer-
sponsored insurance is going to bear the brunt of that cost.
That is the way insurance works, is it not?
Mr. Hathaway. My understanding is that insurers, insurance
systems have formularies for just that reason, to reduce----
Mr. Burgess. Correct. And that is a good point because that
is the point I was trying to make with my experience at
Parkland Hospital. But under the interim final rule, my read of
the Federal Register is you don't get to use a formulary. You
get to have any product that is marketed as being used for
that, and that is the reason for the comparison between Necon
and Seasonique. There is a vast difference in the price
differential of those 2 compounds.
Mr. Hathaway. So can I interrupt?
Mr. Burgess. Yes.
Mr. Hathaway. Let me put it this way. It is interesting
sitting here----
Mr. Burgess. Well, let me just ask you the question. I have
Aetna health savings account.
Mr. Hathaway. Um-hum.
Mr. Burgess. I use a formulary with them. I only go to
their Web site and buy the products they tell me I can buy. But
as I understand it, under the IOM guidelines, there would be no
such prohibition. There would be no allowance for a formulary
for contraception, is that correct?
Mr. Hathaway. I am not aware of that. I don't know that.
Mr. Burgess. Well, that is my read of the Federal Register.
Now, again, this is the problem with an interim final rule.
We didn't get to talk about any of that, we didn't get any
transparency, and, you know, forgive me if I make the leap of
faith and say the reason for the interim final rule was
precisely for these conscience protections that are getting so
much discussion this morning. There was a reason that they
followed that trajectory. There is a reason that they went
there, say, we can't wait past August because we have got this
to get out there. Well, that is nonsense. This argument is
going to be going on for a long time and just so you could get
this year's student population covered under these rules to me
was not a valid assertion unless you have a political
calculation that may be geared for November 2012. And that may
very well have been the case with this, but in the meantime,
the individuals who claim that their conscience provisions are
going to be violated--and I think they are exactly right with
that--they are the ones who are suffering as a consequence of
what is very bad policy and a very bad way of going about that.
Let me ask you, though, you mentioned that child spacing
and that there is a societal benefit and I don't disagree with
that. I am an OB/GYN myself. I agree with what you are saying
but I am certainly interested with the billions that we are
spending on family planning through all areas of the Federal
Government, what is our return on investment for that? Now, we
already know, for example, that many of the people who are
counted as uninsured actually have access to SCHIP, Medicaid,
maybe even a COBRA program that they don't avail themselves of.
And if you really scrutinize emergency room populations, you
will come across those folks. So what is the evidence that
providing these dollars in the family planning area gives us
that benefit in child spacing?
Mr. Hathaway. Lots and lots of evidence. For every dollar
spent on family planning services, there is about $4 or $5
saved----
Mr. Burgess. And I would appreciate it very much because we
are out of time if you could provide me references for those, I
would be anxious to look at that.
Mr. Hathaway. I would be delighted. Thank you so much.
Thank you.
Mr. Burgess. Thank you very much.
I will yield back, Mr. Chairman.
Mr. Pitts. The Chair thanks the gentleman and recognizes
the gentleman, Mr. Engel, for 5 minutes for the follow-up.
Mr. Engel. Thank you very much, Mr. Chairman.
First of all, I want to say that I respect people's
consciences. This is a sensitive issue, and it is sensitive all
the way around, and while I don't think anyone should be forced
to provide services that morally they feel that they cannot do,
I think conversely it works the other way as well. I think that
people who make their own choices and their own decisions
should not be impeded from getting the services that they want
and they need. I think this is an important hearing to discuss
this very important issue of coverage for preventive services.
And I believe there have been many significant advances that
the Affordable Care Act made in access to quality and
affordable care for women.
I am sorry we have another hearing which seems designed to
attack the significant advances that the Affordable Care Act
made for women. HHS's final interim rule is a significant step
in the right direction of providing women access to coverage to
a whole range of healthcare needs that are very specific to
women, and I applaud their efforts. I am just concerned once
again we are undermining or attempting to undermine these
benefits that women have. The cost that is placed on women in
order to get access to all their healthcare needs is something
that we ought to be concerned with.
And again with respect to the religious exemptions, I would
say that the Department of Health and Human Services has made a
significant effort to allow religious organizations to opt out
of the requirements, to provide coverage for contraception. I
support that. I don't think anyone should be forced to do it,
but I think that works again both ways. I mean you need to be
sensitive both ways.
So my first question is for Dr. Hathaway. HHS's interim
final rule has already accounted for the concern of providing
coverage for contraception. In your testimony, you mention that
cost is a barrier for many women who cannot afford access to
quality medical information. In your opinion, Doctor, what will
be some of the most significant benefits for women who can now
have access to coverage for preventive services?
Mr. Hathaway. You know, I am sitting here thinking some
days I feel as though I am pretty passionate about this. There
are other days that I wish I could be more passionate, and the
only way I think I could do that is if I were a woman or a
woman of color or a woman of lower social economic strata. And
since I can't do that, I have to hope that I can present the
voice that I try to do as best I can. Preventive healthcare,
contraception care, family planning services are incredibly
important for multitudes of women in our country, and I think
we are fooling ourselves if we are not looking at the cost
savings and the amount of despair we have put women into for
years and years and years. We have moved to a whole different
era of contraception. You know, this is a 50th anniversary of
oral contraceptive pills and yet they have saved and helped
many, many women for years throughout our country as well as
many other countries, and yet we are in a different era. If I
were to ask any of us in this room how easy it is to take a
pill every day, most of us would say it is pretty darn
difficult. Most women would say they would like to wait at
least a year or more to avoid the next pregnancy or a pregnancy
at all. And therefore, we ought to be able to help them.
Whether it is private insurance or no insurance, we need to be
able to help those women space and prevent the pregnancies when
they want to.
Mr. Engel. So let me just follow up with that because you
mention in your testimony--which is consistent with what you
just said--that access to coverage for counseling, education,
and contraception is very important for women of all
socioeconomic backgrounds, but specifically, the women who
cannot afford access. So what impact would efforts to roll back
this interim rule have on women's health and what would a
continued cost barrier mean for women who cannot afford the
access to care?
Mr. Hathaway. Detrimental. I feel as though, you know, the
women who are currently not using the most effective methods or
have no access to any method at all are still going to struggle
without this moving forward. I think the Institute of
Medicine's recommendations are very, very strong and I applaud
them. I think it is a wonderful move for our country.
Mr. Engel. Thank you, Dr. Hathaway.
Thank you, Mr. Chairman, and I yield back.
Mr. Pitts. The Chair thanks the gentleman.
That concludes the final round of questioning. I would like
to thank the witnesses for your testimony today and this
concludes today's hearing.
I remind members that they have 10 business days to submit
questions for the record, and I ask that the witnesses please
agree to respond promptly to these questions.
With that, thank you. The subcommittee is adjourned.
[Whereupon, at 12:21 p.m., the subcommittee was adjourned.]
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