No healthcare policy has been as controversial in recent years as the Affordable Care Act, and one of its most contentious aspects is the “contraception mandate,” requiring employers to provide no-cost birth control to employees. Employers with a religious or moral objection to contraception have claimed it is a violation of their religious freedom to force them to cover certain contraceptive methods in their insurance plans—an objection that was vindicated by the Supreme Court in the controversial Hobby Lobby decision.
Central to the debate was the claim that the mandate didn’t just violate the rights of religious employers, but also of religious individuals by forcing them to take part in insurance plans that covered contraceptives. “Never before has the federal government forced individuals and organizations to go into the marketplace and buy a product that violates their conscience,” charged the New York Archbishop, Timothy Dolan, who spoke for the Catholic Church at the time as the head of the U.S. bishops’ conference.
The Catholic Church was first out of the gate in criticizing the mandate, claiming that it was an affront to Catholics because of the church’s official prohibition on contraception. This charge was echoed by Catholic pundits, which helped stoke the controversy and the widespread perception that Catholics opposed the measure. Within months, leaders of conservative-leaning Christian groups like the National Association of Evangelicals also joined in the criticism, pressing for faith-based institutions like hospitals and universities to be exempted from the mandate, like houses of worship already were.
But what about religiously affiliated women? Where were their voices in all of this? And what did they think about the mandate? This was the question that intrigued Elizabeth Patton, an OB/GYN and health-services researcher at the University of Michigan. “There was a lot of media framing around religious opposition to the mandate and we tend to hear from certain religious and political leaders, but the voices of religious women aren’t really well-represented,” she said. “We wanted to see what women who self-identify with a religious affiliation think.”
Patton and colleagues conducted the first study to look specifically at the views of religiously affiliated women aged 18 to 55 (reproductive age and just beyond)—those who are most affected by access to birth control—on the contraception mandate. And what they found is surprising. Catholic women, the group most frequently singled out in the policy debate, were among the most supportive of employer-provided contraception coverage.
Sixty-three percent of Catholic women said that employers should provide no-cost contraception for employees, making them second only to mainline Protestant women, at 66 percent, in their support. Both groups supported the mandate at greater rates than the general population—according to the Public Religion Research Institute, 61 percent of Americans think public corporations should have to provide health insurance that offers free contraception, and 57 percent think the same for private corporations. “Catholics are often portrayed as the group that is opposed to the mandate, but these women had some of the highest rates of support,” Patton noted. “This shows that the narrative that we hear isn’t reflecting what women are thinking.”
It’s the religious affiliation of the women who were least supportive of the mandate that hints at the political alliance that formed around opposition to it. The women who were most likely to say they opposed the mandate were from conservative-leaning denominations, such as Baptists, non-denominational Christians, Pentecostals, and Mormons. Fewer than 50 percent of these women supported the mandate. This suggests that it’s largely the leadership of the Catholic and conservative Christian denominations, as well as rank-and-file Christians who belong to these denominations, who oppose the mandate, not Catholics themselves. (It turns out that the political leanings of the women surveyed had very little effect on their support for the mandate, once researchers controlled for other factors.) “Sometimes we are hearing from religious leaders but this doesn’t that reflect what attendees really feel,” Patton said.
Understanding the views of religiously affiliated women is important because the question is far from settled. Just last week, the Supreme Court sent a bellwether case involving the University of Notre Dame back to the lower court. It centered on the so-called accommodation for religious nonprofits that the Obama administration created in an attempt to assuage their concerns. Faith-based institutions object to the accommodation, which requires nonprofits that don't want to provide contraception to notify the Department of Health and Human Services, which then tells the employers’ insurer to cover contraceptives, because they say it still renders them complicit. “It violates Notre Dame’s religious beliefs to hire or maintain a relationship with any third party that will provide contraceptive coverage to its plan beneficiaries,” the Catholic university said in its petition to the Supreme Court.
With other high-profile cases, such as that of the Little Sisters of the Poor order of nuns, still pending, many are predicting that the nonprofit accommodation will end up in the Supreme Court. If the court rules against the accommodation, women who work for religious nonprofits, which include many large hospital and university systems, could lose contraception coverage.
Patton’s study found that support for allowing religiously affiliated hospitals and colleges to opt out of the mandate was low. Only 23 percent of Catholic women supported allowing religious nonprofits to opt out, as did 29 percent of Baptist women and women from other conservative denominations; support was lowest among non-Christian religious women (Jews, Buddhists, Muslims) and the religiously non-affiliated.
Patton and her colleagues also delved into a key contention of Notre Dame and other litigants—the charge that some forms of contraception included in the mandate, such as emergency contraceptives and the IUD, are abortifacients and, therefore, particularly objectionable. “We knew that the ACA doesn’t cover abortion, but there has been some linking of some types of contraception to abortion. We were curious to see if women’s view of abortion affected their view of contraception,” she said.
So although the ACA doesn’t cover abortion outside rape, incest, or when the life of the woman is at stake, they asked women if “employers should provide health plans that cover abortion.” They found support for abortion coverage was significantly lower than support for the mandate. Both Catholic women and mainline Protestant women supported abortion coverage at a rate of about 25 percent. “What this tells us is that women are able to distinguish between the two,” Patton said.
Overall, the factor that best predicted how women viewed employer-provided reproductive healthcare was how often they went to church. Women who attended services weekly or more often were less likely to think that employers should pay for contraceptives. “People who go to church more often are more likely to be conservative,” Patton said. But she notes that when they controlled for other factors like income and education, even the effect of church attendance was minimal and that nearly half of “highly religious” women still supported employer-provided coverage. “It’s really a complicated mix of sociodemographic factors,” she said. “People tend to view this as very black and white, but this conversation is more complicated and nuanced.”
In the end, Patton said, “These debates about religion and reproductive healthcare aren’t going away and 80 percent of women have a religious affiliation, according to Pew Research Center data. That’s why we need to understand the complexity of their views—because if we don't, we aren’t going to have policies that are meaningful for women.”
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