Clinical Review
UPDATE: CONTRACEPTION
Unpredictable bleeding with progestin-only contraceptives can lead to dissatisfaction and discontinuation. The authors scrutinize the reported...
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When I last wrote about the Affordable Care Act (ACA), in May 2014, I focused on the contraception issue. Since then, the US Supreme Court ruled, in Burwell v. Hobby Lobby, that closely held, for-profit companies with religious objections to covering birth control can opt out of the requirement to provide contraceptive coverage to their employees.
In this article, I explore that decision and what it means for women’s health. I also present data on the uninsured rate in the United States, which has dropped significantly since enactment of the ACA, and I discuss one increasingly common barrier to access to care—the use of narrow networks by insurers.
A corporation now can hold a religious belief
The Supreme Court’s majority 5-4 ruling recognized, for the first time, that a for-profit corporation can hold a religious belief, but the Court limited this claim to closely held corporations. The Court also decided that the ACA placed a substantial burden on the corporations’ religious beliefs and concluded that there are less burdensome ways to accomplish the law’s intent, rendering the contraceptive coverage provision in the ACA in violation of the Religious Freedom Restoration Act (RFRA). The Court limited its ruling to the contraceptive coverage requirement, essentially turning the requirement into an option for many employers.
Are contraceptives abortifacients?
The religious belief at the center of Burwell v. Hobby Lobby was that life begins at conception, which the Green family—the owners of Hobby Lobby—equate to fertilization. Hobby Lobby’s attorneys also asserted that four contraceptives approved by the US Food and Drug Administration and included in the ACA mandate may prevent implantation of a fertilized egg, thereby constituting abortion.
Although there is no scientific answer as to when life begins, ACOG and the medical community agree that pregnancy begins at implantation. In its amicus brief to the US Supreme Court, ACOG asserted the medical community’s consensus that the four contraceptives prevent pregnancy rather than end it, and are not abortifacients:
- emergency contraceptive pills: levonorgestrel (Plan B) and its generic equivalents and ulipristal acetate (ella)
- the copper IUD (ParaGard)
- levonorgestrel-releasing intrauterine systems (Mirena, Skyla).
What is a closely held corporation?
In general, according to the Pew Research Center, a closely held corporation is a private company (not publicly traded) with a limited number of shareholders. The Internal Revenue Service (IRS), an important source, defines a closely held corporation as one in which more than half of the stock is owned (directly or indirectly) by five or fewer individuals at any time in the second half of the year.
“S” corporations are also considered closely held. These are corporations with 100 or fewer shareholders, with all members of the same family counted as one shareholder. “S” corporations don’t pay income tax; their shareholders pay tax on their personal returns, based on the corporations’ profits and losses.
Hobby Lobby is organized as an “S” corporation. According to the IRS, in 2011, there were 4,158,572 “S” corporations, 99.4% of them with 10 or fewer shareholders.1
The US Census Bureau estimates that, in 2012, about 2.9 million “S” corporations employed more than 29 million people. Many closely held corporations are quite large.2 According to the Pew Research Center, family-owned Cargill employs 140,000 people and had $136.7 billion in revenue in fiscal 2013. Hobby Lobby has estimated revenues of $3.3 billion and 23,000 employees.2
What’s next?
ACOG helped secure coverage of contraceptives in the ACA and is working with the US Congress and our women’s health partners to restore this important care. Days after the Supreme Court decision, Senator Patty Murray (D-WA) introduced the Protect Women’s Health from Corporate Interference Act, S. 2578, with 46 cosponsors as of this writing. ACOG fully supports this bill, also known as the “Not My Boss’ Business Bill,” which would reestablish the contraceptive coverage mandate as well as other care required by federal law. This bill still maintains the exemption from contraceptive coverage for houses of worship and the accommodation for religious nonprofits.
In introducing her bill, Senator Murray pointed out that “the contraceptive coverage requirement has already made a tremendous difference in women’s lives—24 million more prescriptions for oral contraceptives were filled with no copay in 2013 than in 2012, and women have saved $483 million in out-of-pocket costs for oral contraceptives.”3
Uninsured rate is declining
The Commonwealth Fund shows that, from July–September 2013 to April–June 2014, the nation’s uninsured rate fell from 20% to 15%, resulting in 9.5 million fewer uninsured adults.4 The biggest drop occurred among young adults, with the uninsured rate falling from 28% to 18%, and in states that adopted the Medicaid expansion, where uninsured rates fell from 28% to 17%.4
