In light of Hobby Lobby’s decision to defy the Affordable Care Act and refuse to allow their insurance company to provide their female employees with emergency contraception, I have a question: when did evangelicals start caring about birth control?
I grew up in some pretty conservative church communities. I know what it’s like to not be allowed to celebrate Halloween because it’s the Devil’s holiday, and to not listen to secular music because it could “give the devil a foothold,” and to wish there was a group in town that picketed the local Planned Parenthood because I would have totally gone.
The messages and rules that I was taught by my ministers, youth pastors, and missionary leaders were countless and specific. If something was of the world, I knew I wasn’t supposed to do it. No swearing, sexing, drinking, drugging, gambling, lying, cheating, any other bad thing.
There was one thing that I never, ever heard in that list: no birth control.
I never once heard from a spiritual leader that birth control is a bad thing, or that it causes abortions, or that it damages the collective psyche of the American public–all of which I have recently read on evangelical pro-life blogs. Instead, I was taught that birth control was something married couples could use if they wanted/needed to delay having children. Sex, I was taught, was a good and wonderful thing, created by God to strengthen a marriage. It wasn’t just about procreation–sex was about pleasure as much as it was about creating children. Even a recent Christianity Today blogger explained that contraception was a saving grace in their marriage.
While I attended a Christian college with a fairly conservative student body, plenty of my friends who were waiting until marriage went on birth control pills in the months before their weddings. Let me make this clear: this wasn’t some liberal Christian university where denominational affiliation was some outdated thing that was referenced once at graduation and hidden somewhere on the school website. This was a place where I had a professor or two pray before classes. We all attended chapel three times a week. This was a university where you could get called “not a real Christian” by a peer for watching The Simpsons in the dorm lounge. A friend of mine recently told me that while she was a student there, someone confronted her about the fact that they’d heard a RUMOR that she’d been swearing! Clearly, this was a place where conservative ideas were the norm, yet I never once heard anyone question or attack someone for their decision to use birth control, whether that was the pill or condoms.
In fact, when Plan B was first becoming a talking point in the early 2000s, some of my college friends and I sought to find out whether it really caused abortions and learned that it doesn’t. RU-486, “the abortion pill,” does. That’s why RU-486 is prescribed: to cause an abortion. Although we often heard people group Plan B in with the abortion pill as equally bad, we tried our best to correct people when we heard their error. “Actually, Plan B is a contraceptive, not something that causes an abortion. It cannot harm an established pregnancy,” we’d say. RU-486 ends a pregnancy. Plan B prevents one.
I always believed that people who were staunchly opposed to Plan B simply didn’t understand how it works because of confusion on the timeline of things. For most Christians, pregnancy might begin at conception, but people need to realize that conception doesn’t necessarily happen at the moment of sex. It can happen hours and days afterward. That’s why a pill taken after sex can prevent pregnancy.
In 2010, the journal of the Catholic Health Association explained its findings that Plan B is, in fact, a contraceptive and not an abortifacient. If even Catholics argue that something doesn’t cause abortion, it probably doesn’t, you know?
There were always fringe groups, of course–people who believed rather extremely that the Pill causes abortion, or is sinful, or people who linked all birth control usage with sexual depravity. These were considered to be the weirdos, though. The outliers. They were the people that totally mainstream pastors would laugh off as ridiculous legalists.
All of this is why I have been so surprised at the vitriolic response to the Affordable Care Act’s contraception mandate.
I already have enough trouble understanding why so many Christians are against a policy that gives more people access to health care. It seems like “more health care” should be in the top tier of Christian political issues, and that anything that allows for that to happen should be celebrated and lauded by believers. Jesus was a healer–through his actions we can see that he wanted people to be made physically whole in addition to spiritually. Why on earth would we be against policies that give more people the chance to be physically whole? Does it really matter if it costs a lot of money or increases the wait times of people who already have (possibly crappy or possibly awesome) medical care?
I have even more trouble understanding the reaction against the contraception mandate, which requires insurers to categorize contraception as a preventative drug and therefore provide it without copay. I get that most Christians only want to condone birth control when it is used in the context of marriage, but why be so vitriolic against men and women who choose to use birth control outside of marriage? (Any Christian who found themselves siding with Rush Limbaugh in his rants against Sandra Fluke is guilty of this vitriol.) Isn’t using birth control the responsible to do, even if you don’t think the sex itself is morally acceptable? If Christians want to see the abortion rates drop, they should be getting behind any policy that provides birth control to people who are having sex. Providing free birth control to anyone who wants it can reduce the abortion rate by up to 80%! Why would any Christian be against that?
I’m very uncomfortable with the number of Christians I see arguing against the contraception mandate. It’s one thing to think it’s because it covers abortion–we can simply prove that it doesn’t and move on. But more than that, I see them making a judgment call. I see anger toward women who choose to use birth control regardless of whether or not they are married. I understand that Christians tend to view sex as best between a married couple only, but why should that make us hateful toward people who don’t value the same thing? Why, when we realize that our health insurance premiums are covering someone else’s birth control, should we say, “I don’t want to pay so you can have sex!” We don’t say that about anything else that our premiums cover. Can you imagine someone saying, “I don’t want to pay so you can treat your asthma when you have an attack from being around something you’re allergic to!” “I don’t want to pay so that you can treat your carpal tunnel syndrome! Stop typing so much!”
No one says those things. Or if they do, they need to fund their own healthcare altogether so that they’re not chipping in toward anyone else’s care with their premiums.
There are a few things I wish I could fix here.
- I wish I could show people that emergency contraception does not cause abortion. It prevents ovulation. Without ovulation, there is no pregnancy or embryo to abort! The whole “maybe it prevents implantation of a fertilized zygote” is still a problematic point of view because there is no real evidence that that’s what it actually does.
- I wish some Christians weren’t so blinded by their fear and hatred of Barack Obama that they reject anything proposed by his administration, even if it guarantees that the abortion rate will be lowered.
- I wish we wouldn’t phrase this as an issue of religious liberty because the ACA “requires businesses to pay for abortion-causing drugs,” even though we’ve already demonstrated that: a) the ACA contraception mandate does not cover any abortion-causing drugs, and b) the insurance companies are the ones providing medical care, not the employers.
So, when DID evangelicals make this switch to getting worked up over contraception? In an attempt to combat the Affordable Care Act, they seem to have been willing to pick up an issue that has simply never been important to them before. It feels really disingenuous to me. One of the things that I usually say the church has going for it is being genuine and honest in its intentions. Usually I can say, “Well, at least they mean what they say.” This time, not so much.
By clinging to this political issue despite the fact that it doesn’t make sense scientifically, theologically, or historically, it really makes the church look bad, and that is pretty painful.
Tagged: abortion, ACA, birth control, college, contraception, feminism, Plan B, politics, sexism
The religious objections to the contraceptive mandate aside, the mandate makes no sense economically. I have written a blog post about this already, and so that I don’t have to re-type what I’ve written I ask that you kindly read what I wrote at https://thenullspace.wordpress.com/2012/03/05/on-health-insurance-mandates/.
A few comments about some of your specific points:
“I already have enough trouble understanding why so many Christians are against a policy that gives more people access to health care.”
The policy does not give anyone more access to health care. Employer-paid health insurance (which is itself merely insurance, not health care) is part of an employee’s total compensation (which includes the employee’s paycheck plus all benefits like health insurance). By mandating that employers include contraceptives as part of an employee’s health insurance, the health insurance premium increases to cover the insurance company’s cost of providing “free” contraceptives, which means the employer must spend more on health insurance. But the employer has an incentive to attempt to keep the employee’s total compensation the same (or even lower) so the employer will simply reduce the employee’s paycheck to compensate for the extra expense for health insurance (this reduction may not happen immediately for current employees, but can occur by, for example, reduced pay raises). In short, you are trading “cold hard cash” (the paycheck) for “free” contraceptives which you may not even need. Worse, since the contraceptives are “free” people have an incentive to over-utilize contraceptives (in an economic sense) which tends to drive up the price of contraceptives (higher demand leads to higher prices).
“Does it really matter if it costs a lot of money or increases the wait times of people who already have (possibly crappy or possibly awesome) medical care?”
Yes, it does, since there is a finite amount of money and time in the world. Spending “a lot of money” on contraceptives allocates money away from other things we might want to spend it on, and I can think of plenty of things higher up on my priority list to spend money on than contraceptives (provision of food and water, shelter, emergency health care, surgery, etc.). Time allocation has the same problem.
“Isn’t using birth control the responsible to do, even if you don’t think the sex itself is morally acceptable?”
If you honestly cannot afford birth control (which is relatively cheap compared to other expenses like food and housing) then you certainly cannot afford a pregnancy and child, which is a risk whenever you have sex (even when on birth control, though of course the risk is lowered). In that case the responsible thing to do not to use birth control but rather to avoid sex altogether (or do it in ways which cannot result in pregnancy).
“Why, when we realize that our health insurance premiums are covering someone else’s birth control, should we say, “I don’t want to pay so you can have sex!” We don’t say that about anything else that our premiums cover. Can you imagine someone saying, “I don’t want to pay so you can treat your asthma when you have an attack from being around something you’re allergic to!” “I don’t want to pay so that you can treat your carpal tunnel syndrome! Stop typing so much!”
No one says those things. Or if they do, they need to fund their own healthcare altogether so that they’re not chipping in toward anyone else’s care with their premiums.”
You are conflating health insurance with health care. They are not the same thing. Health insurance pays for certain expenses associated with health care. Insurance is properly designed to pay for unexpected and catastrophic expenses like emergency surgeries and hospitalization, not predictable and mundane expenses like contraceptives, long-term asthma treatment, etc. It is less costly to eliminate the insurance middleman for such mundane and predictable health care expenses (I cover this in my blog post above) and since contraceptives are mundane and predictable expenses it is foolish for the mandate require insurance companies to pay for them.
I can’t agree with you that insurance is for catastrophic events only, not long-term or preventative care. If we have good preventative care, not only does our health improve, but our costs go down because we catch things early and in time to prevent them from turning into far more expensive conditions that are catastrophic.
First of all, it is possible to just get catastrophic insurance. Perhaps if you view insurance in this way, that would be the best path for you. However, what you’re describing is simply not how health insurance works, even if that’s how you think it *should* work. You have some really well-stated points on your blog about what you imagine as an ideal approach to health insurance, but it doesn’t match how Americans approach this issue. At all.
Health insurance, however, is a system operating to cover things that are routine and general. Not just catastrophic. Even if it was designed to only cover catastrophic risks, it now exists and functions to cover the day-to-day care. This is partly because it is now next to impossible to cover medical costs for standard, routine illnesses without insurance.
It’s a bit ironic that you use long-term asthma care as your example of something that shouldn’t really be covered by insurance. I used it in my example specifically because my family is influenced on a daily basis by the financial and logistical costs of long-term asthma care. It currently costs us $10k/year to cover premiums and pulmonary care in our family. Are you suggesting that medical care for things like asthma, sleep apnea, GERD, hypertension, etc. shouldn’t be covered, because individuals with those things should suck it up and budget ahead of time?
Perhaps you are not aware of what it costs to monitor “standard” long-term care.
In other words, it seems like you are saying that people who have the bad luck to be sick with a few common things are out of luck and should never be able to buy a house, go on a vacation, have kids they can afford, pay cash for a car, etc. Just because they happen to be sick?
That’s a pretty ugly leap, if you ask me, and it’s one I’m specifically uncomfortable with as a religious person who puts a lot of stake into the idea that everyone should have equal access to healthcare, no matter their income level or their “lifestyle choices.”
Here’s the thing: Without insurance covering long-term asthma care, my husband would be dead from an asthma attack or spending at least $40k a year to keep himself out of the hospital.
” Insurance is properly designed to pay for unexpected and catastrophic expenses like emergency surgeries and hospitalization, not predictable and mundane expenses like contraceptives, long-term asthma treatment, etc.”
I really wish you didn’t list a respiratory disease as predictable and mundane. Would you group heart disease into this list as well? Do you have asthma? Have you lived around someone with moderate to severe asthma?
Gosh, Chalupa. Way to win the “Be Far More Concise Than Liz” Award. AGAIN.
I would consider my depression to be pretty catastrophic, and it requires long-term care in the form of medication.
Hi, chronic disability here. I’ve been working full-time with health insurance coverage since I was 19 (now in my 40s) and was diagnosed with a painful chronic auto-immune disorder about 5 years ago. The cost of my medications is shockingly high, and there is no cure for my condition. Now how, exactly, should I budget for long-term healthcare costs if health insurance “should not’ cover those expenses? I’ve been paying in to a system all of these years with the understanding that my health insurance will defray the cost of care for whatever health issues arise. I don’t understand how the ‘system’ would work if we pay into our employer health insurance plans only to find that preventative care and ‘predictable and mundane’ expenses like the shots and pain medications which I will need for the rest of my life are not covered?
Also, for all of those companies which feel that they should be able to dictate whether or not birth control is covered: surely they will also require that any man who requests coverage for viagra prove that they are married and intend to use that prescription to conceive children? If the morals of the company will dictate what their insurance will cover, why would they stop at birth control?
You wrote:
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“You are conflating health insurance with health care. They are not the same thing. Health insurance pays for certain expenses associated with health care. Insurance is properly designed to pay for unexpected and catastrophic expenses like emergency surgeries and hospitalization, not predictable and mundane expenses like contraceptives, long-term asthma treatment, etc. It is less costly to eliminate the insurance middleman for such mundane and predictable health care expenses (I cover this in my blog post above) and since contraceptives are mundane and predictable expenses it is foolish for the mandate require insurance companies to pay for them.”
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No, she isn’t conflating health insurance with health care. You, however, are conflating comprehensive health insurance with catastrophic health insurance. They are not the same. Catastrophic health insurance makes little sense from an economic point of view once we decide that everybody should be covered, because there are far more catastrophes. It makes sense if you only cover people for a short period of time, and then hope they drop before anything happens, because you make money off of that short time. If everybody is covered, though, not taking care of the mundane things increases the number of hugely expensive catastrophes.
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Besides this, your argument is short-sighted and…foolish. Not according to me, but according to economists. Here’s an article that breaks it down (your specific argument and why it is short-sighted): http://business.time.com/2012/02/14/why-free-birth-control-will-not-hike-the-cost-of-your-insurance/#ixzz2HhBH8HKW
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But if you don’t have time to read it, here is a quick quote that sums it up pretty smoothly: “The truth is that both insurers and employers who self-insure save money in the long run by covering contraception. So much money is saved that it makes financial sense to waive co-pays and deductibles. A 2000 study by the National Business Group on Health estimates that not providing contraceptive coverage in employee health plans winds up costing employers 15% to 17% more than providing such coverage.”
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(The National Business Group on Health, by the way, is a non-profit that is devoted to representing the perspectives of large businesses – they are certainly not biased against businesses).
Thank you to everyone for sharing their stories, and for Susan for being able to explain the differences so succinctly!
“If you honestly cannot afford birth control (which is relatively cheap compared to other expenses like food and housing) then you certainly cannot afford a pregnancy and child, which is a risk whenever you have sex (even when on birth control, though of course the risk is lowered). In that case the responsible thing to do not to use birth control but rather to avoid sex altogether (or do it in ways which cannot result in pregnancy).”
Birth control isn’t just one generic type of medication that works the same for all women. It’s not like every woman on birth control goes to the pharmacy to pick up their Birth Control. In the world of birth control, there are so many medications to choose from, some more expensive than others. I have unsuccessfuly tried three birth controls myself and had to stop each time due to horrible side effects. Not every woman is the same, and therefore, not every birth control medication is the same. So this horribly wrong misconception that birth control is this cheap thing that all womenz can go get shows how little you know about birth control. You know what offsets the cost of birth control? Health insurance.
On top of that, not every woman takes birth control just for family planning. They take it because their monthly period is horribly debilitating and they want that one week of their life back. Birth control for some women, who aren’t currently in relationships (and therefore, not for family planning), is a valid medication.
Learn more about birth control before you make other sweeping generalizations.
Lara, you are absolutely right, and I don’t understand how that point has been missed. I get that men aren’t generally too involved in the birth control decisions made by the women in their lives, but surely there is an awareness that there are different types of every medication, and that not every medication works for every person. That’s pretty common knowledge, right?
Several years ago, I was switched from a name-brand pill to a generic pill due to some rules my provider had to follow. I was told it would be exactly the same, but it wasn’t. I was sick for the full three months I was on that generic pill. It was awful. I was constantly on the verge of passing out at work, and I was miserable. I suffered through the full prescription because I didn’t have the money to buy something else at the time.
I can think of another friend who had a very negative reaction to the Paragard IUD. It cost her a bunch of money to begin with–IUDs can be quite expensive–but what was she supposed to do? Have it removed and then give Mirena a try? Only to find that it, too, might not work?
I don’t recall what she decided to do, but it definitely confirmed for me that birth control is not simple, and there are ways it can quickly go from cheap to expensive.
I have never understood the whole not covering birth control thing. Babies cost more than birth control. It’s that simple. Both of my boys went to the NICU, so the cost of just “having” them was about $30,000 each. That doesn’t even take into account their health care costs for the next 20 years. With delivery & NICU costs alone, you can pay for a whole lot of birth control. Probably more than I would ever use in my life time. Seems to me that our insurance company gets a deal when we choose a $600 procedure that prevents another $30,000 “expense” for them.
Liz: “If we have good preventative care, not only does our health improve, but our costs go down because we catch things early and in time to prevent them from turning into far more expensive conditions that are catastrophic.”
I agree that preventative care is good, and we would still have good preventative care — it just wouldn’t be paid by insurance. Insurance can still give people an incentive to get preventative care by offering lower premiums to those who do (which reflects the reduced risk of a catastrophic problem that the insurance would have the pay for — it’s similar to “good driver” discounts offered by auto insurance). And people already have an incentive to get preventative care (even if they have to pay for it) because people generally want to prevent major health problems…
“First of all, it is possible to just get catastrophic insurance.”
Not with mandates like the one in question.
“You have some really well-stated points on your blog about what you imagine as an ideal approach to health insurance, but it doesn’t match how Americans approach this issue. At all.”
I am aware that Americans don’t approach the issue my way. In fact, I wrote about a great article by Milton Friedman explaining how we came to have employer-paid health insurance at https://thenullspace.wordpress.com/2012/07/03/milton-friedman-on-health-care/.
“It currently costs us $10k/year to cover premiums and pulmonary care in our family. Are you suggesting that medical care for things like asthma, sleep apnea, GERD, hypertension, etc. shouldn’t be covered, because individuals with those things should suck it up and budget ahead of time?”
Either way, you have to budget ahead of time. The fact that you know it costs $10k/year for your family’s pulmonary care means you can predict your expense for it and are presumably/hopefully already budgeting for that expense. The question is whether you pay your insurance company or your health care provider(s) directly, and exactly how much you have to pay (it’s less expensive to pay it directly). The fundamental truth here is that if your health care expenses are predictable then your insurance company can predict the expense and charge you higher premiums to cover your health care expenses plus the insurance company’s administrative costs and profit, whereas if you pay your health care provider directly you don’t have to pay for that administrative and profit overhead.
It’s also worth noting that lower health insurance premiums mean your employer will have lower health insurance costs and can increase your paycheck without increasing your total compensation. So if you exclude the health insurance middleman you have more money with which to budget. And even if you still cannot budget high medical expenses we already have Medicaid, which is better suited to helping the poor cover medical expenses than insurance companies (it is, after all, the whole purpose of Medicaid).
Finally, as I argued in my above link there are many other large but predictable expenses that are not covered by insurance — groceries, housing, gas for your car, etc. Depending on your specific situation any one of these can exceed your health care expenses (even $10k) and combined they exceed health care expenses for most people. But do you really think it would cost less to pay an insurance company to buy your groceries and gas, pay your mortgage payment, etc.? As with health care, the insurance company can predict its cost in covering your expenses and charge you extra for its administrative costs and to make a profit. It is not merely that an expense is large but that it is also unpredictable which makes it a good candidate for insurance.
Note to all: several of you cited high health care expenses for your specific cases. My arguments above for Liz’s $10k/year pulmonary care expenses apply to your cases as well if they are predictable expenses.
funchefchick: “Also, for all of those companies which feel that they should be able to dictate whether or not birth control is covered: surely they will also require that any man who requests coverage for viagra prove that they are married and intend to use that prescription to conceive children? If the morals of the company will dictate what their insurance will cover, why would they stop at birth control?”
I made an economic argument, not a moral one. It should be clear from my argument that neither birth control or Viagra should be “covered” by insurance regardless of what you or I judge to be moral uses of those products because it is more expensive to use an insurance company middleman.
Susan: “Catastrophic health insurance makes little sense from an economic point of view once we decide that everybody should be covered, because there are far more catastrophes. It makes sense if you only cover people for a short period of time, and then hope they drop before anything happens, because you make money off of that short time. If everybody is covered, though, not taking care of the mundane things increases the number of hugely expensive catastrophes.”
As I explained above to Liz, people would still have an incentive to get preventative care both internally (who wouldn’t want to prevent a major health problem?) and by lower premiums from their insurance companies (who also want to make sure people get preventative care, even if the insurance company itself doesn’t pay for it).
“Besides this, your argument is short-sighted and…foolish. Not according to me, but according to economists.”
The health insurance system I am arguing for is based quite heavily on Milton Friedman’s ideas (see https://thenullspace.wordpress.com/2012/07/03/milton-friedman-on-health-care/), who is of course a famous Nobel-winning economist. We both have experts on our sides so your appeal to authority is fallacious.
“Here’s an article that breaks it down…”
The Time article actually cites a Guttmacher paper (which is pro-abortion and obviously biased). I googled the citation in the Guttmacher paper and found the original study at http://www.businessgrouphealth.org/pdfs/healthypregnancy.pdf. On page 6 of that paper it is stated that the economic model “comes from a variety of sources, such as literature from the Alan Guttmacher Institute (AGI) and the Kaiser Family Foundation (KFF), as well as different databases that provide cost figures.” In other words, the Guttmacher economic model (and thus the study) is almost certainly biased, too.
Even so, it doesn’t really matter whether the study’s findings are true or not — as I’ve argued, insurance companies will provide contraceptives for free (even without a government mandate) if it truly costs them less than the alternative. Your position is that the government assumes it knows better than insurance companies whether free contraceptives cost less in the long run based on a study, which is a dubious claim since insurance companies are in the business of health care and can use their own empirical observations to determine the truth. If the government’s evidence was really so strong then it would have no trouble convincing insurance companies to voluntarily cover contraceptives for free.
Lara: “In the world of birth control, there are so many medications to choose from, some more expensive than others…On top of that, not every woman takes birth control just for family planning.”
I am well aware that there are many types of birth control (some of which are expensive) and that not all women use birth control to prevent pregnancy (I’m married and have other female relatives…), but that is beside the point. Whether you’re paying for an expensive birth control pill or $10k/year for pulmonary care or whatever, if it is a predictable expense then you are paying more to have the insurance company “cover” it since the insurance company can predict the expense and charge extra.
Null: You have a fundamental misunderstanding of how health insurance works. It’s not a simple transaction where everybody pays in and then the insurance company pays out and then also covers their cost. The insurance companies, because they have a huge amount of capital from the premiums, are able to invest the money in large chunks and that is how they make their money. So no, it’s not necessarily more efficient for somebody to budget their own money to pay for something – most of us don’t have the knowhow, the experience, the connections, or the capital to turn a profit on our savings. Or, for that matter, enough capital to risk it and swallow the losses and still make money.
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You argue very, very strongly for somebody who seems to have no interest in researching the situation. Here’s a quick link explaining what I just wrote: http://www.thetruthaboutinsurance.com/how-do-insurance-companies-make-money/
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Saying “you can cut out the middleman and then save money” is hugely, hugely oversimplified. And not true.
Null: There’s a reason why health insurance companies haven’t provided free birth control. It’s because there has been no mandate to cover *everybody*. When you can be choosy about who gets care and who doesn’t get care, you don’t have to worry about preventative care, because you can drop people later for pre-existing conditions, or you can not offer anything to them anyway because they are poor. When you have to cover EVERYBODY, the economics change.
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There’s another reason why many companies won’t, and that’s because of the “rightists’” weird media blitz about birth control being the same thing as abortion.
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But if you agree that the literature is murky (and I’ll give you that – further searches led me to this http://www.factcheck.org/2012/02/cloudy-contraception-costs/, which agrees that there are varying results (although a lot of the studies that support your argument are based on the idea that free birth control is simply replacing bought birth control, that the level of people using it remains the same, which has turned out not to be true http://www.foxnews.com/health/2012/10/05/study-free-birth-control-leads-to-fewer-abortions/)) – if you agree that the evidence is murky, your entire argument…falls. You have put forth that it is an obvious economic benefit to not offer birth control for free, and there is clearly no such obvious benefit. As the numbers have started to come in, more studies are showing that as birth control is free, it is effective and game-changing.
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Martin Friedman says a lot of things that are very much the case – but that have nothing to do with birth control. Nobody is saying that the current system (pre-Obamacare) is amazing; that is actually why Obamacare was put forth. And that is neither here nor there. Martin Friedman said nothing about birth control, he was talking about the failures of the employer-based insurance system as a whole. This is an argument about the economics of providing free birth control. If your economic argument falls (and at best it is iffy), and the moral argument falls (and it does) – you’re left with nothing.
“The insurance companies, because they have a huge amount of capital from the premiums, are able to invest the money in large chunks and that is how they make their money.”
And the capital from the premiums ultimately comes from the insured customers. Even if the customers’ employers are paying the premiums the employers do so by paying their employees a smaller paycheck (i.e. the total compensation is the same).
“When you can be choosy about who gets care and who doesn’t get care, you don’t have to worry about preventative care, because you can drop people later for pre-existing conditions, or you can not offer anything to them anyway because they are poor.”
My insurance (medical, dental, etc.) has long paid for preventative care (yearly check-ups, etc.). Insurance companies will encourage customers to get preventative care in order to reduce the risk those customers will require more expensive care later on (which costs the insurance company money and thus cuts into its profit).
People with pre-existing conditions have a much higher risk of requiring expensive care later on. To account for this higher risk, either the person’s premium must rise or the insurance company will refuse to insure the person if that person cannot (or is unwilling to) pay for a higher premium. In that case a person who cannot afford the insurance premium should be supported by Medicaid if that person cannot afford his or her medical care. Honestly, I’m surprised you do not support moving people with pre-existing conditions to (government-controlled) Medicaid and away from (private) insurance companies as the left typically prefers to do.
“if you agree that the literature is murky”
Most of the studies which have mixed results compare premiums before and after contraceptives are covered for “free”. But the problem is that premiums are driven by many more factors than contraceptives since premiums cover much more than just contraceptives and pregnancy-related expenses. These studies can only show correlation (which even that is mixed), not causation (only a controlled experiment, rather than an observational study, can show causation, since a controlled experiment would control for confounding factors with also influence premiums). But you are claiming that “free” contraceptives cause lower costs (and therefore lower premiums), which is certainly not supported by observational studies with mixed results.
Interestingly, factcheck does cite a “recent survey of 15 insurance companies” which found that “six of them expected costs to rise while another three believed the mandate would be cost neutral” and that “none predicted a net cost savings by reducing unintended pregnancies.” This survey is more revealing than all the mixed observational studies since the insurance companies themselves are best equipped to determine whether “free” contraceptives cause lower or higher costs overall. Insurance companies are best equipped to know the effect of “free” contraceptives because (a) they know exactly what costs (contraceptive, pregnancy-related, or otherwise) determines their premiums and (b) are most incentivized to lower contraceptive/pregnancy-related costs since they earn their living from profits that are increased by reducing these costs. What you have to explain is: how does the government, relying on observational studies with mixed results, know more about the costs of contraceptives and pregnancies than the very insurance companies which are in the health insurance business and have first-hand knowledge of the costs of contraceptives and pregnancies in the long run? Moreover, if it really costs less to cover contraceptives for “free” then why does the government have to mandate such coverage (i.e. why don’t for-profit insurance companies cover them voluntarily to increase their profits)? The fact that insurance companies don’t cover contraceptives for “free” indicates that “free” contraceptives don’t actually result in a net cost savings as you claim.
“Martin Friedman says a lot of things that are very much the case – but that have nothing to do with birth control.”
First of all, it’s Milton Friedman. Milton. Have you ever heard of him before? I highly recommend you search his name on Youtube — he is very informative on economics and his explanations are easy for anyone to understand.
Friedman does not speak of birth control specifically because (a) he is making a general argument for a health insurance system and (b) no one was proposing a contraceptive mandate at the time (he is deceased). Nonetheless, he argued (as I have) that predictable expenses do not belong in the domain of insurance. As I quoted in my blog post on him, “Employer financing of medical care has caused the term insurance to acquire a rather different meaning in medicine than in most other contexts. We generally rely on insurance to protect us against events that are highly unlikely to occur but that involve large losses if they do occur—major catastrophes, not minor, regularly recurring expenses. We insure our houses against loss from fire, not against the cost of having to cut the lawn. We insure our cars against liability to others or major damage, not against having to pay for gasoline. Yet in medicine, it has become common to rely on insurance to pay for regular medical examinations and often for prescriptions.” Where I have used the term “predictable expenses” he uses “regularly recurring expenses”. The connection to birth control is, obviously, that birth control is a predictable (alternatively, “regularly recurring”) expense and is not a “highly unlikely…major catastrophe”.
Also, as Friedman points out, if regularly recurring expenses should be covered by insurance simply because they are large expenses, why don’t you insure yourself against having to pay for gas? Or against having to pay for your mortgage/rent? Or against having to buy your groceries? All of these expenses cost considerably more than birth control (even the most expensive forms of birth control) and in some cases are even more essential to life than birth control (e.g. groceries). If you would like me to insure you against these things I would *love* to do so. It would be the easiest money I’ve ever earned.
“Nobody is saying that the current system (pre-Obamacare) is amazing; that is actually why Obamacare was put forth…Friedman said nothing about birth control, he was talking about the failures of the employer-based insurance system as a whole.”
And the problem is that Obamacare moves America’s health insurance system even further from what Friedman advocates by (a) issuing mandates that insurance must cover regularly recurring expenses like birth control and (b) strengthening the employer-based insurance system (the impetus for the blog post we are commenting on was that Hobby Lobby is defying Obamacare). The pre-Obamacare system was bad, and the Obamacare system is even worse. Friedman has explained why.
1) The “what do insurance companies expect” study is the one you think is most legitimate? Really? “Hey, what do you think might happen,” as opposed to actual studies that show before and after? From insurance companies who aren’t happy about adding high-risk patients to their bills?
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2) And yes, before and after *can* show causation, as long as there is a control group – as in the 1990s when some states added free contraception to their Medicaid plans and some did not. It’s not a perfect study, but it’s better than simple correlation. Further, independent actuarial studies show cost savings or no difference: http://aspe.hhs.gov/health/reports/2012/contraceptives/ib.shtml.
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3) The capital that goes to the insurance companies *does* come from the person with the cost of increased premiums, sure. But the overall cost is, according to the available data, not going to rise. Your original argument was that you can cut out the middle man and bam! you save money, but as I said, that’s not how insurance companies make their money. If it ends up being cheaper to give free contraceptive coverage (which seems likely), and the middle man argument is moot, there’s no reason why “employers do[ing] so by paying their employees a smaller paycheck” would make any difference.
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4) I’m not sure what you mean about health insurance companies covering preventative care. I mean, yes, I understand, but I don’t know why you brought it up. Sure they do. That is what makes medical and dental insurance companies different than automobile or any sort of catastrophic insurance. By saying that health insurance companies have an incentive to pay for preventative care, aren’t you conceding the point? Wasn’t your argument based on the idea that health insurance should be catastrophic coverage only? Or am I reading this wrong: “Insurance is properly designed to pay for unexpected and catastrophic expenses like emergency surgeries and hospitalization, not predictable and mundane expenses like contraceptives”?
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5) I apologize for the typo in Friedman’s name. My Ph.D. program focused more on critical thinking than on static facts, and I tend to refer to him by last name. I also am amused that you want to help me to educate myself using videos that “anybody can understand” when you have demonstrated a fundamental lack of understanding in the finances of health insurance.
Oh, Susan, I wish so much that WordPress supported gif format, because both you and Null would be getting a lot of them in response to your most recent posts.
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This one would probably be for Null: http://d2tq98mqfjyz2l.cloudfront.net/image_cache/1315550015703489.gif
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You? You get the Citizen Kane clapping gif.
1) Insurance companies are the most directly affected by the cost of contraceptives vs. pregnancies and so are the most reliable sources (their profit motive actually makes them more reliable in this case since an error costs them money). Insurance companies have put their money where there mouths are, so to speak, by not covering “free” contraceptives. They know exactly how their premiums are calculated (since they set them) and therefore what causes those premiums to rise or fall. The fact that the government had to issue a mandate to force them to cover “free” contraceptives is proof that insurance companies themselves do not view “free” contraceptive coverage as a net cost reduction (otherwise they would have already added coverage for “free” contraceptives, voluntarily).
2) The presence of a control group alone does allow you to determine causation. It depends on whether it is a controlled experiment (the researcher chooses the controls) or an observational study (there may be a control group, but not necessarily controlling for all confounding factors since the researcher did not get to choose the controls. See http://stats.org/in_depth/faq/controlled_vs_observational.htm. Quoting the link: “The other reason to favor controlled studies is that they can tell us something about the cause of an observed correlation…If the study were observational and found that those who take the medicine have a lower rate of headaches, one could only conclude that the medicine and fewer headaches are correlated. There may not be a direct causal relationship.” As I mentioned before, the birth control studies cited compared premiums before and after contraceptives were covered for “free”, but since premiums are also determined by all the other things covered by insurance there are confounding factors which prevent us from determining causation (we can only determine correlation, and even so the studies’ results are mixed). The Medicaid studies from the 90s you cite suffer from a number of confounding factors, including but not limited to differing state demographics, income distribution, health insurance laws and mandates, economies, insurance companies in the market, etc.
3) The capital that goes to insurance companies comes from all insured persons, not just the ones with a higher risk and higher premium. My argument (it has not changed) is not that every single individual will save money (the few outliers who require the most expensive birth control medications would save money) but that the overall cost is lower by eliminating the middleman. No insurance company worth its salt will lose money on a predictable expense like birth control — it will adjust its premiums upward until it acquires enough capital to pay for its predictable expenses of handing out “free” contraceptives plus enough to pay for its administrative costs and gain some profit.
4) Health insurance companies do not have to directly pay for preventative care in order to encourage people to get preventative care. Health insurance companies can offer discounts on premiums to people who pay for their own preventative care since those people have a lower risk of experiencing a health catastrophe that is expensive for the insurance company. We see this with auto insurance companies which offer “good driver” discounts — drivers who take care to drive safely represent a lower risk and can be covered with a lower premium. So what, specifically, is different about medical and dental insurance which makes it better for them to offer “comprehensive” coverage rather than auto insurance, rental insurance, etc., which only offer “catastrophic” coverage? Put another way (as I’ve asked before), why don’t you insure yourself against gas purchases, mortgage/rent payments, etc.?
5) I corrected your typo since you made it twice and I wanted to make sure you used the right name if you decided to search him on Youtube. I also was not trying to insult you by saying that anybody can understand his arguments, I was simply conveying the fact that his intended audience is non-economists. Out of curiosity, what subject do you have a Ph.D. in?
I have noticed that you have not answered any of my direct questions. Maybe you missed them. In the event that is the case, here they are again:
1. How does the government, relying on observational studies with mixed results, know more about the costs of contraceptives vs. pregnancies than the very insurance companies which are in the health insurance business and have first-hand knowledge of the costs of contraceptives and pregnancies in the long run?
2. If it really costs less to cover contraceptives for “free” then why does the government have to mandate such coverage (i.e. why don’t for-profit insurance companies cover them voluntarily to reduce their costs and increase their profits)?
3. If regularly recurring expenses (like purchasing birth control) should be covered by insurance simply because they are large expenses, why don’t you insure yourself against other regularly recurring expenses like having to pay for gas? Or against having to pay for your mortgage/rent? Or against having to buy your groceries? All of these expenses cost considerably more than birth control (even the most expensive forms of birth control) and in some cases are even more essential to life than birth control (e.g. groceries).
Also, here is another good article I found in case another explanation would help: http://www.hoover.org/publications/defining-ideas/article/136011