The birth-control wars return to the Supreme Court Wednesday, and it is likely that the five-justice conservative majority will make it more difficult for women to get birth control if they work for religiously affiliated institutions like hospitals, charities and universities.
At issue in the case is a Trump administration rule that significantly cuts back on access to birth control under the Affordable Care Act. Obamacare, the massive overhaul of the health care system, sought to equalize preventive health care coverage for women and men by requiring employers to include free birth control in their health care plans.
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Houses of worship like churches and synagogues were automatically exempted from the provision, but religiously affiliated nonprofits like universities, charities and hospitals were not. Such organizations employ millions of people, many of whom want access to birth control for themselves and their family members. But many of these institutions say they have a religious objection to providing birth control for employees.
For these nonprofits, the Obama administration enacted rules providing a work-around to accommodate employers' religious objections. The workaround was that an employer was to notify the government, or the insurance company, or the plan administrator, that, for religious reasons, it would not be providing birth-control coverage to its employees. Then, the insurance company could provide free birth-control options to individual employees separately from the employer's plan.
But some religiously affiliated groups still objected, saying the work-around was not good enough, and sued. They contended that signing an opt-out form amounted to authorizing the use of their plan for birth control. Among those objectors was the Little Sisters of the Poor, an order of Catholic nuns that runs homes for the elderly poor.
The Supreme Court punted in 2016
The Little Sisters sued, and their case first reached the Supreme Court in 2016. At the time, Sister Constance Viet explained why she refused to sign any opt-out form, saying that "the religious burden is what that signifies and the fact that the government would ... be inserting services that we object into our plan. And it would still carry our name."
Back then, when the Little Sisters' case got to the Supreme Court, the justices basically punted, telling the government and the sisters to work together to try to reach a compromise that would still provide "seamless birth control" coverage for employees who want it, without burdening the Sisters' religious beliefs. Although the Little Sisters did eventually get relief from the lower courts, the fight over the accommodations rules continued right up to the end of the Obama administration.
But when President Trump came into office, the administration issued new rules that would give broad exemptions to nonprofits and some for-profit companies that have objections to providing birth-control coverage for their employees. And the new rules expanded the category of employers who would be exempt from the birth-control mandate to include not just those with religious objections, but those with moral objections, too.
New rules
Those new rules, currently blocked by lower courts, are what is at issue Wednesday in the Supreme Court.
"Many states are suing and none of them can find a single actual woman who claims she's been harmed," says Mark Reinezi, president of the Becket Fund for Religious Liberty, which is defending the Trump rules against challenges brought by Pennsylvania and other states.
And, he adds, "there are many other ways to provide contraceptive coverage to people if they happen to work for religious objectors."
Rienzi says that employees who work for birth-control objectors can get coverage from their spouse's insurance plan, or by switching to a different insurance plan on an Obamacare exchange. And he says that birth control is also available under a program known as Title X, which gives money to state and local governments to provide health care for women.
But Brigitte Amiri, the deputy director the of ACLU's Reproductive Freedom project, says the idea that Title X could make up for the lost coverage is "a joke." Amiri notes that the Title X program has been underfunded for years, and the Trump administration has issued new regulations that in her words "decimated the program."
According to Amiri, "the Trump administration and Vice President [Mike] Pence have long wanted to ... take away coverage for contraception. They want to block access to birth control. They want to block access to abortion ... so this is all part and parcel of the overall attack on access to reproductive health care."
Potential consequences
She maintains that if the expanded Trump rules are upheld for religious objectors, hundreds of thousands of women across the country will lose their contraceptive coverage. Ultimately, Amiri says, there just is no way to maintain birth-control coverage for employees who work for religiously affiliated institutions unless that employer, as she puts it, is willing to "raise their hand" to opt out.
A break in birth-control coverage that big could have serious consequences, say say birth-control advocates. They note that the National Academy of Medicine, a health policy nonprofit, recommended the original rules because birth control is prescribed not just to avoid pregnancy but also to treat various female medical conditions. In fact, it is the most frequently taken drug for women ages 15-60. And it is expensive, $30 a month and more for pills, and as much as $1,000 for buying and having an IUD inserted.
Birth-control advocates say that's the very reason that a broad requirement to cover birth control in insurance was included in Obamacare. They say the new Trump rule improperly undermines that mandate.
But selling that argument to the Supreme Court will be hard. When the court last considered this issue in 2016, its makeup was far less conservative than it is now. Since then, two Trump appointees have been added to the court. And both of those appointees — Neil Gorsuch and Brett Kavanaugh — have already indicated strong support for the notion that religious rights may often trump other rights.
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