Commentary Contraception

Who Decides? Delays and Barriers to Accessing Birth Control at Georgetown University

Sandra Fluke

Although Georgetown’s student health insurance doesn’t cover contraception, it does cover birth control pills when they’re prescribed for medical reasons other than preventing pregnancy. But barriers to access illustrate the consequences for women’s health when university administrators dictate which reasons for a birth control prescription are the “right” reasons.

Cross-posted with permission from the Repossess Reproductive Justice blog in partnership with #HERvotes.

See all our coverage of the 2012 Contraceptive Mandate here.

As you may have recently read in the New York Times, although Georgetown’s student health insurance doesn’t cover contraception, it does ostensibly cover birth control pills when they’re prescribed for medical reasons other than preventing pregnancy (e.g. severe acne, mood disorders, and so forth). This is called the “over-ride” process because it over-rides the usual ban on contraceptive coverage. Unfortunately, this over-ride process is terribly flawed and fails many women at Georgetown. The problems with this process illustrate the consequences for women’s health when university administrators dictate which reasons for a birth control prescription are the “right” reasons.

Because of an obsession with preventing students from fraudulently using the over-ride to get contraception coverage for the “wrong” reason (preventing pregnancy), students who attempt to use the over-ride process are sometimes subjected to questioning and accusations that they are lying about their qualifying medical needs. This is followed with long delays and bureaucratic barriers that don’t exist for any other prescription covered by Georgetown’s insurance. The Times profiled how Georgetown’s policy resulted in a medical tragedy for one woman. In response a Georgetown spokeswoman said that:

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problems like this were rare and that doctors at the health service knew how to help students get coverage for contraceptives needed for medical reasons.

If only that were true! Georgetown Law Students for Reproductive Justice actually surveyed students at the law school about this. For some students, the over-ride process works adequately, but 65 percent of students attempting to utilize the over-ride process reported being subjected to extensive questioning, inordinate clerical issues, extensive delays, or other complications because of disbelief from doctors and insurance administrators. Twenty percent either never received their medication or were never reimbursed by the insurance company. Here are the experiences of just a few students:

“I was without birth control for many months because of problems with the over-ride. I spoke with people at [the student health] clinic, the Georgetown main insurance office, the insurance company, the drug insurance company, and a pharmacy. I was put on hold multiple times and had to call some of these people multiple times. After investing at least ten hours in the process, I gave up. . . .”

“Simply because I am sexually active, the doctor assumed I was lying even though I have medical needs. I struggled with getting an over-ride because the doctor was hesitant even though I reported severe pain and mood changes that affect my functioning as a student. . . .”

“[M]y OB/GYN suspects that I have endometriosis and I took a specific pill to help control it. Endometriosis cannot be definitively diagnosed without surgery, and obtaining a waiver was stressful and time consuming. It unnecessarily distracted me from my classes. . . .”

“I have found the health care coverage ban on birth control embarrassing and potentially harmful. When scheduling a yearly gynecological exam, I was subject to a line of hostile questioning twice: once by the person scheduling the exam and once by the doctor performing the exam. The questions included queries about my sexual history, which seems appropriate for the doctor to ask about, but not the scheduler. A yearly gynecological exam is a recommended procedure and may not even be tied to a birth control prescription. Georgetown’s refusal to cover birth control creates a potential burden on a woman getting this exam at all. . . .”

Tragically, Georgetown’s policy has also created rampant misinformation regarding student insurance coverage of women’s reproductive healthcare generally, leading to some students foregoing essential medical care:

“[I] was intimidated by the [‘override’] process and thus I did forego OBGYN care for over a year. More importantly, the reputation that Georgetown has as being . . . unsupportive of women’s reproductive health prevented me from seeking out STD testing after I was sexually assaulted. (I assumed [Georgetown] would not cover my HIV/STD testing because when I was tested last year at my provider’s office . . . as part of a regular/routine exam, I paid $500 due to lack of coverage. It was not until several months after I was assaulted that I found out . . . that [Georgetown] would cover such tests. In general, there is a problematic lack of info about women’s health coverage on campus. I did not even know I could get an OBGYN exam at the law center until a friend told me my 2L year. While I support Georgetown’s Jesuit identity and am a person of faith myself, I find our school’s policy to be . . . harmful to students. . . .”

I’d say “harmful to students” is putting it lightly. That’s why we’re so thankful that the new Affordable Care Act regulations will protect vulnerable students and end these types of dangerous insurance policies!


For more information about hurdling institutional barriers to birth control, see: How to Host a Birth Control Clinic in 3 Easy Steps by Emily T. Wolf, Vice President of Fordham Law Students for Reproductive Choice.

Analysis Law and Policy

The Supreme Court Could Give Religiously Affiliated Employers Even More Room to Discriminate

Jessica Mason Pieklo

A series of cases working their way through the courts could expand which businesses get a pass for offering employees discriminatory health and retirement benefits.

You may remember the Little Sisters of the Poor—that group of earnest nuns who challenged the process for accommodating religious objections to the birth control benefit in the Affordable Care Act. The Little Sisters, along with dozens of other religiously affiliated nonprofits, have continuously argued that the act of completing a form to be legally excused from complying with the law substantially burdens their religious rights.

Well, the Little Sisters remain tied up in litigation with the Obama administration over birth control, nondiscriminatory insurance coverage, and their religious objections to providing for both. But there’s more at stake here. To be clear, the Sisters are intent on doing everything they can to block comprehensive insurance coverage for their employees, and block third parties from providing it to them as well. But buried in litigation footnotes is a provision of employee benefits law that, if the Sisters and other religiously affiliated organizations get their way, will solidify another pass for discriminatory corporate practices beyond contraception coverage alone.

The Employee Retirement Income Security Act, or ERISA, is the federal law governing employee benefit plans, including retirement accounts and health insurance. Both the Department of Labor (DOL) and the Internal Revenue Service (IRS) are charged with ensuring ERISA compliance, which, as you can imagine, makes ERISA a prime target for conservatives who already hate “big government.”

Employer plans governed by ERISA have a few requirements that particularly draw conservative ire. One mandates that employer-sponsored retirement plans meet certain minimum funding levels by the employer. This is to help those plans be meaningful ways for employees to save for retirement, without putting the entire burden on those workers. Another provision forbids those plans from discriminating in benefits, such as matching a higher percentage of a male employee’s retirement contributions than a female one’s, or providing comprehensive health insurance coverage for men but not women. The ACA’s birth control benefit draws upon this theory.

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However, not all employers are required to follow ERISA. In particular, the statute exempts “church plans” from its requirements. ERISA defines church plans as those “established and maintained … for its employees … by a church or by a convention or association of churches which is exempt from tax under section 501 of the Internal Revenue Code.” Church plans also include those plans maintained by an organization “controlled by or associated with a church or by a convention or association of churches.” The rationale behind the church plan exemption is similar to the rationale behind most religious or ministerial exemptions to other nondiscrimination laws: Religious orders and institutions like churches and synagogues will generally employ people who follow the same religious tenets as they do because those organizations are engaged in spiritual outreach as part of their “business.”

That prohibition on ERISA governing “church plans” is also incorporated into the ACA.

Historically, organizations like the Little Sisters have had a regulatory pass when it came to maintaining retirement plans and insurance coverage that are either underfunded, discriminatory, or both. That’s because both the DOL and the IRS have been generous in their determination of how they interpret “controlled by or associated with a church or by a convention or association of churches.” And if those agencies determine that an organization has a “church plan,” that, in turn, means it won’t be subjected to a tax penalty for not complying with the ACA’s birth control benefit.

Given the explosion of religiously affiliated employers like hospitals and nursing homes, however, the scope of what does and does not qualify as a church plan has become an increasingly important issue. As religiously affiliated employers began to grow well beyond employing people of similar tenets, away from their ministerial core and into marketplace competition with secular, for-profit businesses, it has made less and less sense to allow those employers a pass to discriminate under ERISA.

At least that’s the argument advanced in a flurry of lawsuits challenging the scope of the church plan exemption under ERISA. Those lawsuits include one against Dignity Health Care, the Catholic-affiliated hospital system facing separate lawsuits related to failing to offer comprehensive reproductive health care at its hospitals. According to the allegations in the complaint, Dignity repeatedly underfunded its retirement plan in violation of ERISA. Dignity responded by arguing its plans were church plans and not subject to ERISA oversight.

Neither the district court nor the Ninth Circuit Court of Appeals bought Dignity’s argument, holding there was no way that when Congress created the church plan exception, it intended the exemption to stretch as far as to shield the country’s fifth-largest health-care employer from regulatory oversight.

That question presented in the Dignity case—of just how broadly that exemption extends—could end up before the U.S. Supreme Court next term. The Roberts Court is considering a pair of cases with this exact issue at their center. Both involve religiously affiliated hospitals, and both have appellate court decisions ruling that organizations like Dignity, which are not actually churches nor actually maintained by religious orders, may not qualify for the church plan exemption.

Which brings us back to the Little Sisters, on whose cases these organizations will undoubtedly base some of their own arguments. The Little Sisters do have a church plan. And it should mean that they will never have to comply with the birth control benefit anyway—which would give them no standing to challenge the ACA’s accommodation. But this is not the argument the Little Sisters and their attorneys want the courts or the public to hear. Instead, the litigation has focused on whether or not completing the form for the birth control accommodation would be a substantial burden for the nuns, despite the fact that at this point under ERISA, there is no question that the federal government could penalize the Little Sisters for refusing to comply with the contraception benefit.

However, the Little Sisters are more than just a group of nuns. They own and operate facilities that employ and serve others. The DOL and IRS have, to date, agreed that the Little Sisters benefits plan is in fact a church plan. But that is in part because without switching plan administrators, the question of whether or not their employee benefits package still qualifies for the exemption has not arisen again. If and when the Little Sisters do switch plans or administrators, the status of their benefits exemption will come up.

At some point during oral arguments in March in Zubik v. Burwell, the conglomerate of cases challenging the accommodation process to the birth control benefit, the fact that the Little Sisters had a church plan and would never be subject to having to comply with the benefit did come up. Paul Clement, who represented the nuns, skillfully dodged the question of whether there was a church plan issue for the Little Sisters. Instead of acknowledging that fact—one even established in the record as an assumption the Tenth Circuit Court of Appeals was making earlier in the litigation to move the case along—Clement assured the justices the church plan wasn’t really something the Court needed to concern itself with at the moment.

Maybe that’s because Clement and the nuns were hoping that if nobody noticed the pass given Little Sisters in their challenge to the birth control benefit, nobody would notice when hospitals and nursing homes also argue for the right to provide discriminatory retirement benefits and cite Zubik for their authority to do so. Maybe they didn’t know about the fight brewing in the appellate courts over which enormous corporate entities are shielded from regulatory nondiscrimination laws like provisions in ERISA and the ACA.

That seems unlikely, though, doesn’t it?

While it may be dry as toast, the church plan exemption under ERISA is critically important. As we’ve seen throughout the nonprofit challenges to the birth control benefit, when employers are allowed to opt out, the effect disproportionately falls on poor women and women of color. And the wages offered to hospital and nursing home workers? They hardly are the kind to lift a person up to more stable financial footing. Which is all another way to say that conservatives’ assertions that institutions like Dignity Health fulfill some spiritual mission and should therefore be treated like a church are all smoke and bluster. Instead, these institutions want cover for ongoing attempts to nickel-and-dime their own workers and to discriminate, based on religious beliefs, when it comes to how and whom these institutions serve. And they’re hoping the Roberts Court will give it to them this next term.

News Politics

Congresswoman Pushes Intersectionality at Democratic National Convention

Christine Grimaldi

Rep. Bonnie Watson Coleman (D-NJ) charges that reproductive health-care restrictions have a disproportionate impact on the poor, the urban, the rural, and people of color.

Read more of our coverage of the Democratic National Convention here.

The members of Congress who flocked to the Democratic National Convention in Philadelphia this week included a vocal advocate for the intersection of racial and reproductive justice: Rep. Bonnie Watson Coleman (D-NJ).

Watson Coleman’s longstanding work in these areas “represented the intersection of who I am,” she said during a discussion in Philadelphia sponsored by the Center for Reproductive Rights and Cosmopolitan. Reproductive health-care restrictions, she stressed, have a disproportionate effect on the poor, the urban, the rural, and people of color.

“These decisions impact these communities even more so [than others],” she told Rewire in an interview. “We don’t have the alternatives that middle-class, suburban, white women have. And we’d rather they have them.”

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Watson Coleman has brought that context to her work in Congress. In less than two years on Capitol Hill, she co-founded the Congressional Caucus on Black Women and Girls and serves on the so-called Select Investigative Panel on Infant Lives, a GOP-led, $1.2 million investigation that she and her fellow Democrats have called an anti-choice “witch hunt.”

Coleman said she’s largely found support and encouragement among her fellow lawmakers during her first term as a woman of color and outspoken advocate for reproductive rights.

“What I’ve gotten from my Republican colleagues who are so adamantly against a woman’s right to choose—I don’t think it has anything to do with my being a woman or an African American, it has to do with the issue,” she said.

House Republicans have increasingly pushed anti-choice policies in advance of the ongoing August recess and November’s presidential election. The House this month passed the Conscience Protection Act, which would give health-care providers a private right of action to seek civil damages in court, should they face supposed coercion to provide abortion care or discrimination stemming from their refusal to assist in such care.

Speaker Paul Ryan (R-WI) lauded passage of the bill and the House’s thus-far unsuccessful effort to prove that Planned Parenthood profited from fetal tissue donations—allegations based on widely discredited videos published by the Center for Medical Progress, an anti-choice front group that has worked closely with GOP legislators to attack funding for Planned Parenthood.

On the other side of the aisle, Watson Coleman joined 118 other House Democrats to co-sponsor the Equal Access to Abortion Coverage in Health Insurance Act (HR 2972). Known as the EACH Woman Act, the legislation would overturn the Hyde Amendment and ensure that every woman has access to insurance coverage of abortion care.

The Hyde Amendment’s restriction of federal funding for abortion care represents a particularly significant barrier for people with low incomes and people of color.

The Democratic Party platform, for the first time, calls for repealing the Hyde Amendment, though the process for undoing a yearly federal appropriations rider remains unclear.

For Watson Coleman, the path forward on getting rid of the Hyde Amendment is clear on at least one point: The next president can’t go it alone.

“The president will have to have a willing Congress,” she said. She called on the electorate to “recognize that this is not a personality contest” and “remove some of those people who have just been obstructionists without having the proper evidence.”

In the meantime, what does a “willing Congress” look like for legislation with anti-choice roadblocks? A majority voting bloc helps, Watson Coleman said. But that’s not everything.

“There are lots of bills that Republicans will vote for if their leadership would simply bring them up,” she said.

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