The culture wars may soon be coming to a doctor’s office near you.
Your care should be guided by the standards of medical necessity and best clinical judgment, as they have been for decades. A doctor’s duty is to apply those standards in determining your treatment. The insurance company may second-guess that judgment or look for a cheaper alternative, but the guiding principle is clear — what kind of care is “medically necessary” and do you need it for sound clinical reasons?
Insurance reimbursement for your medically necessary care is a business transaction. The only value judgment should be faith in the medical profession’s ability to assess which treatments are effective and in your physician’s decision as to which ones to use. Personal value preferences have no place in this financial relationship — at least they have not had a place until now.
On Oct. 6, the Trump administration announced broad new exceptions to rules under the Affordable Care Act that require coverage without cost sharing for approved forms of preventive care. The exceptions apply to only one kind of care, contraception, and only to coverage arranged by an employer for its workers or a university for its students, but the implications could be far-reaching.
The exemptions inject your employer’s values into the business of health insurance. They let the organization you work for shape your coverage according to values that have nothing to do with medical necessity or clinical judgment. And they pay no regard to whether you or your physician shares those values. This is new ground for the health-care system.
Acknowledging the difficult position that contraceptive coverage could pose for some religious congregations, the Obama administration exempted them from the rule. It also crafted an accommodation for religiously affiliated organizations, like universities and hospitals, that took the organization out of the equation and let an insurer provide coverage directly to employees. The Supreme Court ruled in 2014 that the government must accommodate similar requests by small family-owned for-profit companies.
But the new exceptions go well beyond anything the Obama administration or the Supreme Court contemplated. Any organization, whether nonprofit or for-profit, and including publicly traded companies, can automatically qualify for an exception to mandated contraceptive coverage based on religious objections. And any organization, except publicly traded corporations, can automatically qualify for an exemption based on a much broader standard of having “moral” qualms.
This raises some fundamental concerns.
How, exactly, does a for-profit corporation adopt a religious belief? It is a business entity with a primary obligation to make money for its shareholders. It fills its coffers with revenue from customers and funding from investors. If it were to adopt a religion, who would decide which one to choose — management, employees, shareholders? They all play essential roles. Religious beliefs are personal, not the province of a profit-making machine composed of multiple constituencies and interests.
A corporation may sell religious items or services, but if it chooses to operate on a for-profit basis, it has selected that as its overriding imperative. Worshiping money is not a religious or moral doctrine; it is a figure of speech and should remain that way.
Almost as incomprehensible is the exemption’s limitation to contraceptive coverage. While contraception is objectionable to some religious traditions, other traditions may object to different medical practices, such as vaccination, blood transfusions, and some forms of end-of-life care. For the government to accommodate the religious qualms of some traditions but not of others is to play favorites among values. That is hardly an expression of the respect for sincerely held beliefs the exemptions purport to embody. If exemption requests for different kinds of coverage were to arise, would the government draw a line, and if so, how?
Conflicts between religious beliefs and medical practices are nothing new — they go back centuries. America has always shown great deference to religion, and properly so. But first and foremost, that deference should respect the religious and moral beliefs of patients, as advised by their physicians, not those of businesses whose primary mission is to generate profits. And if deference means special exemptions from legal requirements, the government must grant them or deny them for all religious and moral beliefs equally, without favor for those it decides are worthy.
Culture wars don’t belong in the examining room.
Robert I. Field, a professor of law and health management and policy at Drexel University, is the editor for commentaries at philly.com/healthcents.” firstname.lastname@example.org