In light of the growing number of uninsured and underinsured patients reaffirming the need for better healthcare systems, it is troubling to witness the rising trend of healthcare institutions—hospitals, HMOs and others—opting out of providing certain medical services due to so-called “moral” or “religious” objections.
How can an institution—a hospital, an HMO or a healthcare system—impose its religious doctrine on naive employees and their unaware patients? In many cases, state law, often referred to as a “conscience clause” or “refusal clause,” protects these institutions from being required to provide those services. Currently, there are 43 states that allow healthcare institutions to refuse to provide abortion services.1
Institutional Refusal Clause: A Definition
An institutional refusal clause, also referred to as institutional restrictions on reproductive healthcare, involves service limitations based on the religious position or ideology of an institution. Examples of these restrictions include, but are not limited to, forbidding contraceptive counseling (including emergency contraception for survivors of sexual assault) or assisted reproductive technologies within religious hospitals, refusing insurance coverage for family planning services, forbidding physicians affiliated with religious hospitals to perform sterilizations within their private offices and denying contraception to students at religiously-affiliated colleges or universities.
How Institutional Restrictions Thrive
• Catholic Hospitals
According to the Catholic Health Association of the United States, as of 2006, 12% of U.S. hospitals—or 615 hospitals—were Catholic, receiving 88 million outpatient visits.2 Often, these Catholic hospitals are in rural areas, where they are the only healthcare facilities available to the surrounding community. Catholic healthcare systems and facilities are present in all 50 states, where one in six people in the U.S. is cared for in a Catholic hospital.3
• Catholic HMOs
According to a 2000 survey by Catholics for a Free Choice (CFFC), 48 Catholic healthcare plans exist nationally, with approximately 2.5 million customers enrolled in their plans. Like all other Catholic healthcare institutions, Catholic HMOs follow the Ethical and Religious Directives for Catholic Health Care Services (the Directives), guidelines issued by the United States Conference of Catholic Bishops. The Directives outline the principles these healthcare institutions and systems are required to follow in providing healthcare services for their patients. The Directives specifically prohibit sterilization procedures (including tubal ligation), in vitro fertilization, abortion and prescribing and dispensing contraception.
Given the Catholic healthcare’s commitment to serving the underserved, one would expect to see full participation in Medicaid programs by Catholic health plans. However, the CFFC study found that only 15 out of the 48 plans were participating in Medicaid, serving approximately 770,700 people.4
The problem doesn’t end there. Patients who try accessing certain reproductive healthcare services through a Catholic HMO often face unexpected barriers and delays in service. Physicians trying to provide necessary reproductive health services may not be appropriately reimbursed.
• Abstinence-Only Programs
Sexuality education in schools is another site of contention between proponents of abstinence-only-until-marriage programs and those of comprehensive sexuality education. Currently, there are three government programs that fund federal abstinence-only programs: the Adolescent Family Life Act, the Personal Responsibility and Work Opportunity Reconciliation Act, and the Marriage and Healthy Family Development Initiative. In 2005, $168 million was earmarked for abstinence-only programs, with a proposed increase to $206 million in the 2006 budget.5
The funding of abstinence-only-until-marriage programs is a compelling example of politics trumping science. No scientific research has proven that abstinence-only programs work to achieve their intended goal of lowering teen pregnancy rates. Yet millions of dollars in federal funding is funneled into promoting this ideologically-driven concept of education for adolescents.
• Federal Refusal Clause
The Weldon Amendment, also known as the federal refusal clause, was signed into law in 2004 as part of the Departments of Labor, Health and Human Services and Education and Related Agencies Appropriations Act 2005 spending bill. Since then, it has continued to be included in the Appropriations bill for the Departments of Labor, HHS and Education and Related Agencies. As of September of 2006, the Weldon Amendment continues to be part of the Appropriation bill. Because this changes annually, for more up-to-date information, contact email@example.com.
The Weldon Amendment prohibits federal agencies and programs, and state and local governments, from discriminating against healthcare entities because they do not refer and/or provide coverage for abortion. The Amendment covers a diverse group of healthcare entities, including physicians and other healthcare providers, hospitals, provider-sponsored organizations, HMOs, insurance plans or “any kind of healthcare facility, organization or plan.” Any law or regulation instructing these entities to require such action would be considered discriminatory and institution could be at risk of losing federal funding under the Labor-HHS-Education bill.
The Weldon Amendment directly conflicts with the federal regulation of Title X-funded family planning clinics that are required to provide referrals for abortion services if requested by a patient. The impact of the Weldon Amendment is not yet known.
• State Refusal Clause
Nearly all states explicitly allow a healthcare institution to opt out of providing abortion services. As of 2006, 43 states allow healthcare institutions to refuse to provide abortion services.6 Each legislative session brings new attempts to expand the current refusal clause beyond medical institutions to HMOs and other healthcare entities.
As physicians, you can be affected and effective.
As physicians working as part of a larger healthcare system, you and your patients can be unexpectedly affected by institutional restrictions. If you have questions or would like more information, please contact Physicians for Reproductive Choice and Health at 646-366-1890 or firstname.lastname@example.org.
1 Guttmacher Institute. State Policies in Brief: Refusing to Provide Health Services. Accessed October 4, 2006.
2 The Catholic Health Association. Fast Facts: Care Provided by Catholic Facilities. Available at: http://www.chausa.org/Pub/TopNav/Newsroom/FastFacts/. Accessed October 5, 2006.
4 Miller, P, and Chelala, C. Catholic HMOs and Reproductive Health Care. Catholics for a Free Choice. 2000:28.
5 NARAL Pro-Choice America. Abstinence-Only Programs: Ideology Over Science. Available at http://www.prochoiceamerica.org/assets/files/Sex-Ed-Ab-Only-Ideology.pdf. Accessed February 24, 2006.
6 The Guttmacher Institute. State Policies in Brief: Refusing to Provide Health Services. Available at http://www.guttmacher.org/statecenter/spibs/spib_RPHS.pdf. Accessed October 4, 2006.