Analysis Contraception

Self-Certification and the Contraceptive Coverage Rule: What Does it Mean for an Institution to “Hold Itself Out as Religious?”

Bridgette Dunlap

Some religiously-affiliated institutions characterize themselves as "secular" when recruiting or seeking public funding but "church-controlled" when demanding exemptions from the law, such as the birth control benefit. Potential employees, students, and patients—as well as taxpayers generally—deserve to know who they are dealing with.

The Obama administration is accepting comments from the public until April 8th on the Notice of Proposed Rule-Making for the birth control benefit or contraceptive coverage rule. The proposed rule amends the exemption for houses of worship and their affiliates and adds an accommodation for other non-exempt non-profits opposed to birth control.

The accommodation requires that insurance companies offer separate contraceptive coverage directly to the employees of objecting organizations at no additional cost. To take advantage of the accommodation, an organization need only self-certify to its health insurer or plan administrator that it is a non-profit opposed to some of the required contraceptive services and that it “hold[s] itself out as a religious organization.”

It is not enough for an institution seeking special treatment to simply assert that it holds itself out as religious. I expect the Obama administration is loathe to define what it means to be a religious organization or police whether an institution is in fact holding itself out as such, and rightly so.  Nevertheless, the institution should have to make a statement describing how it holds itself out as religious and what that religiousness entails. This statement should be made easily available to the public and organizations should have give to notice of it to those with whom it seeks to contract, such as employees, students, patients, and funders.

This is necessary due to a pattern of religiously-affiliated institutions characterizing themselves one way when recruiting or seeking public funding and another when demanding to be exempt from laws that govern secular institutions. The trend in First Amendment Establishment Clause jurisprudence has permitted increasing public funding for religious organizations. This means we need whatever protections the free market can provide individuals from the imposition of religion by institutions active in the public sphere. We can only avoid involvement with institutions that will discriminate on the basis of religious control if we know which institutions those are.

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To understand some particularly flagrant examples of religiously-affiliated institutions trying to have it both ways, we turn to a bit of state constitutional law. Over 37 state constitutions contain explicit prohibitions on the use of public money for religious institutions or instruction. New York is among them and its Constitution prohibits public funding of any educational institution “wholly or in part under the control or direction of any religious denomination.”

In the mid-60s many private universities throughout the country were in dire financial straits. New York sought to rescue its private universities with taxpayer funding through a program known as “Bundy aid.” However, giving public funds to religiously-controlled universities was clearly unconstitutional. So religious universities, particularly Catholic ones, underwent re-organizations to separate themselves from the control of their founding religious orders and other church authorities and endeavored to become more suitable places for people of any or no faith to work and study. By becoming non-sectarian, while maintaining only a religious affilation, they qualified for public funding.  The motivation behind secularization was not exclusively financial, but part of a larger attempt by Catholic universities to strengthen their academic and intellectual legitimacy.

By accepting funds each year, a New York college makes a representation to the state that it is an independent institution free from religious control. Despite this, a number of universities receiving Bundy aid, have asserted that they are church-controlled in order to be free from various generally applicable laws.

In 2010, adjunct professors at Manhattan College sought to unionize. To block them, Manhattan College claimed it was not subject to the jurisdiction of the National Labor Review Board because it is “church-operated.” Among the evidence on which the NLRB board relied in rejecting the claim Manhattan College holds itself out as a religious institution was the fact that Manhattan College deliberately eliminated church control to get Bundy aid and continues to claims to be non-sectarian by accepting it.

In 2009, St. John’s University argued it was exempt from the Americans with Disabilities Act because it is “controlled by a religious organization.” Prior to that, St. John’s successfully argued it was eligible for an exemption from New York’s Human Rights Law for the same reason. In agreeing that St. John’s is controlled by a religious organization, the Court did not take notice of the fact that St. John’s represents to the state that it is not controlled, even in part, by a religious organization in order to get taxpayer funding each year.

Multiple universities that receive Bundy aid have health policies that are controlled by the U.S. Conference of Catholic Bishops through the USCCB’s Ethical and Religious Directives for Catholic Health Care Services.  The Directives are 43 pages long and as detailed as a statute. These schools tend to be less than forthcoming as to how the Directives are implemented in school policy, and some fail to give notice that the Directives control at all.

For a further example of conflicting self-characterizations, we now turn to the permissibility of funding under the federal Constitution. In 2000, the University of Notre Dame received a $500,000 federal grant that funded a program that included training teachers to work in parochial schools. Taxpayers sued the federal government, alleging the grant violated the First Amendment’s prohibition of government establishment of religion. Notre Dame intervened in the case as a defendant to defend its interest in the funds. Inherent to Notre Dame’s argument that the funding did not violate the First Amendment, is the fact that Notre Dame engages in many secular activities. In fact, just by applying for the grant, for which the “[u]se of funds for religion” was explicitly prohibited, Notre Dame represented to the government that despite its religious affiliation, not everything it does is an exercise of religion.

In court papers, Notre Dame detailed how it segregated and tracked the use of the taxpayer funds to ensure they were not used for religious purposes. Among those expenses Notre Dame categorized as “secular” were “director’s and associate director’s salaries and benefits.” Those benefits presumably include medical benefits. Compare that to Notre Dame’s lawsuit challenging the contraceptive coverage mandate, in which Notre Dame claims offering particular health plans is an exercise of its religious belief.  (See page 38 here.) Health plans are “secular” when the University seeks taxpayer money, but an “exercise of religion” when it doesn’t want to adhere to generally applicable law.

In defending its federal funding, Notre Dame cited a number of cases for the proposition that government aid to universities does not necessarily violate the Establishment Clause. In so holding, courts rely on the fact that universities are not intrinsically sectarian places where government funds will be used for indoctrination, distinguishing them from religious primary schools. For example, in Tilton v. Richardson, the Supreme Court explained, “[t]here are generally significant differences between the religious aspects of church-related institutions of higher learning and parochial elementary and secondary schools.” Those differences in secularity and the feasibility of separating religious from non-religious activities, makes direct funding of religiously-affiliated universities constitutional while funding religious primary schools generally is not. Despite its prior reliance on these cases, Notre Dame is now claiming to be a “person” under the Religious Freedom Restoration Act whose every policy or action is apparently an exercise of religion.

If these universities are making conflicting statement about whether or not they are religiously controlled to courts and government agencies, imagine the incomplete information they are giving prospective students and employees. Institutions that believe they are entitled to exemptions to the law or to use religion as a post hoc defense to discrimination claims should have to say so up front.  No institution should be able to claim the contraceptive coverage accommodation or any other without making a statement of their religious affiliation that is available to the public.

Fuller disclosure of religious control is especially necessary in the case of religiously-affiliated hospitals. Any hospital that is providing its employees with a substandard healthcare plan because it adheres to Directives promulgated by the bishops rather than generally accepted health care standards, likely has similarly problematic patient care. That would make it somewhere I do not want to be treated. It would also make it a place many health care professionals wouldn’t want to work and risk having to compromise their own ethical and medical judgments due to the control of a religious authority. However, many hospitals are not making it clear what their religious affiliation means and, where religious hospitals merge with secular ones or change their names, it may be unclear they have a religious affiliation at all.

A friend of mine is doctor who has worked at two different Catholic hospitals, neither of which provided him with a copy of the bishops’ Directives prior to his employment. He first learned how his current hospital’s Catholic control affects patient care in the middle of helping a family navigate end of life care for his comatose patient. When the family decided it was time to let the patient go, they wished to donate his organs. Only then, did their doctor learn the patient would have to be transferred to another hospital to do so. The family did not want to endure transferring the patient, so they had to let him die at the Catholic hospital without the potentially life-saving donation they believed he would have wanted.

At another Catholic hospital, that family might not have been able to withdraw care at all. There is disagreement among hospital ethicists about whether foregoing intravenous food and water is permissible according to decrees by Pope John Paul II and the bishops. Confusion among doctors about the rules at Catholic hospitals is apparently common. I asked my friend how his hospital’s Catholic affiliation affected obstetric care and he had no idea.

Nonstandard medical practices should not be a surprise. A publicly available statement of what an institution’s religious affiliation means won’t help you if you are miscarrying and the ambulance takes you to the nearest hospital, but it would provide vital information to those in a position to choose where to seek treatment or work.

In the context of the contraceptive coverage regulation, organizations claiming the accommodation should also have to identify who has determined that the religion bars providing contraceptive coverage and why. The situation at Boston College is the latest example of why this is necessary.  Responding to administrators’ threats of discipline for students distributing condoms and health information in their dorm rooms, students and alumni have sounded a familiar refrain:

“we chose to go to a Catholic university, not the Catholic Church. We were never warned that students who advocate for basic health-care access would be silenced and undermined at every turn. In every tour and orientation, student guides proclaim that BC is a welcoming campus for people from diverse backgrounds and perspectives.”

At Boston College (as at Notre Dame, Fordham, Georgetown and likely many other universities facing escalating pressure from off campus) vague references to the mission are being used to justify policies students didn’t expect with little explanation as to how permitting access to sexual health services and information violates Catholic teaching, nor discussion of the extent to which university policy is controlled by Catholic doctrine.

Organizations controlled by and affiliated with religious authorities increasingly demand public funding with few conditions. Courts are reluctant to inquire into how religious an organization is or engage in line drawing as to whether an activity is or is not religious exercise. The harder it becomes to restrict taxpayer money for religious use, the more we must rely on avoiding institutions, to the extent that is possible, that will deprive us of legal protections for religious reasons. Given that institutions sometimes find it in their interests to keep things vague in order to say different things to different audiences, the law should require, at the very least, that an institution seeking either public funding or any religious accommodation make an explicit and comprehensive statement about its own religiousness and accept whatever consequences result.

Commentary Contraception

For Students at Religious Universities, Contraception Coverage Isn’t an Academic Debate

Alison Tanner

When the U.S. Supreme Court sent a case about faith-based objections to the Affordable Care Act's contraceptive mandate back to lower courts, it left students at religious colleges and universities with continuing uncertainty about getting essential health care. And that's not what religious freedom is about.

Read more of our articles on challenges to the Affordable Care Act’s birth control benefit here.

Students choose which university to attend for a variety of reasons: the programs offered, the proximity of campus to home, the institution’s reputation, the financial assistance available, and so on. But young people may need to ask whether their school is likely to discriminate in the provision of health insurance, including contraceptive coverage.

In Zubik v. Burwell, a group of cases sent back to the lower courts by the U.S. Supreme Court in May, a handful of religiously affiliated universities sought the right to deny their students, faculty, and staff access to health insurance coverage for contraception.

This isn’t just a legal debate for me. It’s personal. The private university where I attend law school, Georgetown University in Washington, D.C., currently complies with provisions in the Affordable Care Act that make it possible for a third-party insurer to provide contraceptive access to those who want it. But some hope that these legal challenges to the ACA’s birth control rule will reverse that.

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Georgetown University Law Center refused to provide insurance coverage for contraception before the accommodation was created in 2012. Without a real decision by the Supreme Court, my access to contraception insurance will continue to be at risk while I’m in school.

I’m not alone. Approximately 1.9 million students attend religiously affiliated universities in the United States, according to the Council for Christian Colleges and Universities. We students chose to attend these institutions for lots of reasons, many of which having nothing to do with religion. I decided to attend Georgetown University Law Center because I felt it was the right school for me to pursue my academic and professional goals, it’s in a great city, it has an excellent faculty, and it has a vibrant public-interest law community.

Like many of my fellow students, I am not Catholic and do not share my university’s views on contraception and abortion. Although I was aware of Georgetown’s history of denying students’ essential health-care benefits, I did not think I should have to sacrifice the opportunity to attend an elite law school because I am a woman of reproductive age.

That’s why, as a former law clerk for Americans United for Separation of Church and State, I helped to organize a brief before the high court on behalf of 240 students, faculty, and staff at religiously affiliated universities including Fordham, Georgetown, Loyola Marymount, and the University of Notre Dame.

Our brief defended the sensible accommodation crafted by the Obama administration. That compromise relieves religiously affiliated nonprofit organizations of any obligation to pay for or otherwise provide contraception coverage; in fact, they don’t have to pay a dime for it. Once the university informs the government that it does not want to pay for birth control, a third-party insurer steps in and provides coverage to the students, faculty, and staff who want it.

Remarkably, officials at the religious colleges still challenging the Affordable Care Act say this deal is not good enough. They’re arguing that the mere act of informing the government that they do not want to do something makes them “complicit” in the private decisions of others.

Such an argument stands religious freedom on its head in an attempt to impose one group’s theological beliefs on others by vetoing the third-party insurance providers’ distribution of essential health coverage to students, faculty, and staff.

This should not be viewed as some academic debate confined to legal textbooks and court chambers. It affects real people—most of them women. Studies by the Guttmacher Institute and other groups that study human sexuality have shown that use of artificial forms of birth control is nearly universal among sexually active women of childbearing years. That includes Catholic women, who use birth control at the same rate as non-Catholics.

Indeed, contraception is essential health care, especially for students. An overwhelming number of young people’s pregnancies are unplanned, and having children while in college or a graduate program typically delays graduation, increases the likelihood that the parent will drop out, and may affect their future professional paths.

Additionally, many menstrual disorders make it difficult to focus in class; contraception alleviates the symptoms of a variety of illnesses, and it can help women actually preserve their long-term fertility. For example, one of the students who signed our brief told the Court that, “Without birth control, I experience menstrual cycles that make it hard to function in everyday life and do things like attend class.” Another woman who signed the brief told the Court, “I have a history of ovarian cysts and twice have required surgery, at ages 8 and 14. After my second surgery, the doctor informed me that I should take contraceptives, because if it happened again, I might be infertile.”

For these and many other reasons, women want and need convenient access to safe, affordable contraceptives. It is time for religiously affiliated institutions—and the Supreme Court—to acknowledge this reality.

Because we still don’t have an ultimate decision from the Supreme Court, incoming students cannot consider ease of access to contraception in deciding where to attend college, and they may risk committing to attend an university that will be legally allowed to discriminate against them. A religiously affiliated university may be in all other regards a perfect fit for a young woman. It’s unfair that she should face have to risk access to essential health care to pursue academic opportunity.

Religious liberty is an important right—and that’s why it should not be misinterpreted. Historically, religious freedom has been defined as the right to make decisions for yourself, not others. Religious freedom gives you have the right to determine where, how, and if you will engage in religious activities.

It does not, nor should it ever, give one person or institution the power to meddle in the personal medical decisions of others.

Roundups Law and Policy

Gavel Drop: Ruth Bader Ginsburg Hints at More Supreme Court Retirements

Imani Gandy & Jessica Mason Pieklo

In a recent interview, Supreme Court Justice Ruth Bader Ginsburg dishes on the last Supreme Court term and hints the next president may have more than one justice to appoint.

Welcome to Gavel Drop, our roundup of legal news, headlines, and head-shaking moments in the courts.

Ruth Bader Ginsburg suggests the next president is going to have a couple of U.S. Supreme Court nominations to make, which means the Court could be effectively up for grabs depending on this election’s outcome.

This summer, the Supreme Court ordered the Obama administration and religiously affiliated nonprofits who object to providing contraception to try and find some kind of compromise. While they hammer one out, a University of Notre Dame student has asked a federal appeals court to let her join in the litigation, to fight the university’s stance of trying to deny access to contraception coverage.

Anti-choice protesters will be descending on Wichita, Kansas, this week to commemorate the 25th anniversary of the Summer of Mercy clinic sieges.

A state judge dismissed a lawsuit filed by Kentucky Gov. Matt Bevin (R) against Planned Parenthood of Indiana and Kentucky for purportedly performing abortions without license.

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Florida officials have not yet appealed a federal district court ruling blocking a law that would have prevented Medicaid funds from going to Planned Parenthood reproductive health care centers. The law would also mandate a state regulator review of patient records from half of the approximately 70,000 abortions in the state each year.

An Ohio appeals court ruled a Cleveland abortion clinic can move forward with its lawsuit challenging requirements that prohibit public hospitals from entering into transfer agreements with clinics, along with another requirement that mandates providers to check for a fetal heartbeat before performing an abortion.

Attorneys from the American Civil Liberties Union (ACLU) sued to block an Indiana law requiring that a patient getting an abortion must have an ultrasound 18 hours before the procedure.

Meanwhile, abortion rights supporters in Wisconsin are urging lawmakers to repeal the state’s admitting privileges requirement.

Anti-choice lawmakers in Texas plan to try to require aborted fetuses to be buried or cremated in an attempt to add additional emotional burden and administrative expense to the procedure.

Free speech for whom, exactly? The man who posted the video of the police killing of Alton Sterling has been reportedly arrested on charges of assault and battery.