[House Hearing, 112 Congress]
[From the U.S. Government Publishing Office]



 
  DO NEW HEALTH LAW MANDATES THREATEN CONSCIENCE RIGHTS AND ACCESS TO 
                                 CARE?

=======================================================================

                                HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                      ONE HUNDRED TWELFTH CONGRESS

                             FIRST SESSION

                               __________

                            NOVEMBER 2, 2011

                               __________

                           Serial No. 112-102



      Printed for the use of the Committee on Energy and Commerce

                        energycommerce.house.gov



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                    COMMITTEE ON ENERGY AND COMMERCE

                          FRED UPTON, Michigan
                                 Chairman

JOE BARTON, Texas                    HENRY A. WAXMAN, California
  Chairman Emeritus                    Ranking Member
CLIFF STEARNS, Florida               JOHN D. DINGELL, Michigan
ED WHITFIELD, Kentucky                 Chairman Emeritus
JOHN SHIMKUS, Illinois               EDWARD J. MARKEY, Massachusetts
JOSEPH R. PITTS, Pennsylvania        EDOLPHUS TOWNS, New York
MARY BONO MACK, California           FRANK PALLONE, Jr., New Jersey
GREG WALDEN, Oregon                  BOBBY L. RUSH, Illinois
LEE TERRY, Nebraska                  ANNA G. ESHOO, California
MIKE ROGERS, Michigan                ELIOT L. ENGEL, New York
SUE WILKINS MYRICK, North Carolina   GENE GREEN, Texas
  Vice Chairman                      DIANA DeGETTE, Colorado
JOHN SULLIVAN, Oklahoma              LOIS CAPPS, California
TIM MURPHY, Pennsylvania             MICHAEL F. DOYLE, Pennsylvania
MICHAEL C. BURGESS, Texas            JANICE D. SCHAKOWSKY, Illinois
MARSHA BLACKBURN, Tennessee          CHARLES A. GONZALEZ, Texas
BRIAN P. BILBRAY, California         JAY INSLEE, Washington
CHARLES F. BASS, New Hampshire       TAMMY BALDWIN, Wisconsin
PHIL GINGREY, Georgia                MIKE ROSS, Arkansas
STEVE SCALISE, Louisiana             JIM MATHESON, Utah
ROBERT E. LATTA, Ohio                G.K. BUTTERFIELD, North Carolina
CATHY McMORRIS RODGERS, Washington   JOHN BARROW, Georgia
GREGG HARPER, Mississippi            DORIS O. MATSUI, California
LEONARD LANCE, New Jersey            DONNA M. CHRISTENSEN, Virgin 
BILL CASSIDY, Louisiana              Islands
BRETT GUTHRIE, Kentucky              KATHY CASTOR, Florida
PETE OLSON, Texas
DAVID B. McKINLEY, West Virginia
CORY GARDNER, Colorado
MIKE POMPEO, Kansas
ADAM KINZINGER, Illinois
H. MORGAN GRIFFITH, Virginia

                                 7_____

                         Subcommittee on Health

                     JOSEPH R. PITTS, Pennsylvania
                                 Chairman
MICHAEL C. BURGESS, Texas            FRANK PALLONE, Jr., New Jersey
  Vice Chairman                        Ranking Member
ED WHITFIELD, Kentucky               JOHN D. DINGELL, Michigan
JOHN SHIMKUS, Illinois               EDOLPHUS TOWNS, New York
MIKE ROGERS, Michigan                ELIOT L. ENGEL, New York
SUE WILKINS MYRICK, North Carolina   LOIS CAPPS, California
TIM MURPHY, Pennsylvania             JANICE D. SCHAKOWSKY, Illinois
MARSHA BLACKBURN, Tennessee          CHARLES A. GONZALEZ, Texas
PHIL GINGREY, Georgia                TAMMY BALDWIN, Wisconsin
ROBERT E. LATTA, Ohio                MIKE ROSS, Arkansas
CATHY McMORRIS RODGERS, Washington   JIM MATHESON, Utah
LEONARD LANCE, New Jersey            HENRY A. WAXMAN, California (ex 
BILL CASSIDY, Louisiana                  officio)
BRETT GUTHRIE, Kentucky
JOE BARTON, Texas
FRED UPTON, Michigan (ex officio)

                                  (ii)


                             C O N T E N T S

                              ----------                              
                                                                   Page
Hon. Joseph R. Pitts, a Representative in Congress from the 
  Commonwealth of Pennsylvania, opening statement................     1
Prepared statement...............................................     3
Hon. Phil Gingrey, a Representative in Congress from the State of 
  Georgia, opening statement.....................................     4
Hon. Frank Pallone, Jr., a Representative in Congress from the 
  State of New Jersey, opening statement.........................     4
Hon. Janice D. Schakowsky, a Representative in Congress from the 
  State of Illinois, opening statement...........................     5
Hon. Michael C. Burgess, a Representative in Congress from the 
  State of Texas, opening statement..............................     6
Hon. Marsha Blackburn, a Representative in Congress from the 
  State of Tennessee, opening statement..........................     7
Hon. Tim Murphy, a Representative in Congress from the 
  Commonwealth of Pennsylvania, opening statement................     7
Hon. Henry A. Waxman, a Representative in Congress from the State 
  of California, opening statement...............................    11

                               Witnesses

David L. Stevens, Chief Executive Officer, Christian Medical 
  Association....................................................   123
    Prepared statement...........................................   125
    Answers to submitted questions...............................   215
Mark Hathaway, Director, Obstetrics and Gynecology Outreach 
  Services for Women's and Infants' Services, Washington Hospital 
  Center.........................................................   133
    Prepared statement...........................................   135
    Answers to submitted questions...............................   218
Jane G. Belford, Chancellor, Archdiocese of Washington, DC.......   139
    Prepared statement...........................................   141
    Answers to submitted questions...............................   261
Jon O'Brien, President, Catholics for Choice.....................   150
    Prepared statement...........................................   152
    Answers to submitted questions...............................   264
William J. Cox, President and Chief Executive Officer, Alliance 
  of Catholic Health Care........................................   163
    Prepared statement...........................................   165
    Answers to submitted questions...............................   266

                           Submitted Material

Letter, dated October 4, 2011, from Mr. Murphy to Kathleen 
  Sebelius, Secretary, Department of Health and Human Services, 
  submitted by Mr. Murphy........................................     9
Statement, dated November 2, 2011, of Hon. Jeff Fortenberry, a 
  Representative in Congress from the State of Nebraska, 
  submitted by Mr. Pitts.........................................    13
Statement, dated November 2, 2011, of John H. Garvey, President, 
  The Catholic University of America.............................    18
Letter, dated November 1, 2011, from Cardinal Daniel N. DiNardo, 
  Chairman, Committee on Pro-Life Activities, United States 
  Conference of Catholic Bishops, to Mr. Pitts, submitted by Mr. 
  Pitts..........................................................    22
Letter, dated November 2, 2011, from Jeanne Monahan, Director, 
  Center for Human Dignity, and Chris Gacek, Senior Fellow for 
  Regulatory Policy, Family Research Council, to Mr. Pitts, 
  submitted by Mr. Pitts.........................................    30
Statement, dated November 2, 2011, of Nancy Keenan, President, 
  NARAL Pro-Choice America, submitted by Ms. Schakowsky..........    46
Statement, dated November 2, 2011, of the Center for Reproductive 
  Rights, submitted by Ms. Schakowsky............................    53
Statement, dated November 2, 2011, of Judy Waxman, Vice President 
  for Health and Reproductive Rights, National Women's Law 
  Center, submitted by Ms. Schakowsky............................    80
Statement, dated November 2, 2011, of Laura W. Murphy, Director, 
  Washington Legislative Office, and Sarah Lipton-Lubet, Policy 
  Counsel, American Civil Liberties Union, submitted by Ms. 
  Schakowsky.....................................................    83
Statement, dated November 2, 2011, of Debra Ness, President, and 
  Judith Lichtman, Senior Advisor, National Partnership for Women 
  & Families, submitted by Ms. Schakowsky........................    98
Statement, dated November 2, 2011, of the National Health Law 
  Program, submitted by Ms. Schakowsky...........................   104
Statement, dated November 2, 2011, of Douglas Laube, Board Chair, 
  Physicians for Reproductive Choice and Health, submitted by Ms. 
  Schakowsky.....................................................   115
Letter, dated November 2, 2011, from Advocates for Youth, et al., 
  to Mr. Upton, Mr. Waxman, Mr. Pitts, and Mr. Pallone, submitted 
  by Ms. Schakowsky..............................................   120
Statement, dated October 31, 2011, of Rabbi Dennis S. Ross, 
  Director, Concerned Clergy for Choice, The Educational Fund of 
  Family Planning Advocates of New York State, submitted by Mr. 
  Pallone........................................................   175
Statement, dated November 2, 2011, of Nancy K. Kaufman, Chief 
  Executive Officer, National Council of Jewish Women, submitted 
  by Mr. Pallone.................................................   176
Statement, dated November 2, 2011, of The Rev. Debra W. Haffner, 
  Executive Director, Religious Institute, submitted by Mr. 
  Pallone........................................................   182
Statement, dated November 2, 2011, of The Rev. Lois M. Powell, 
  Justice and Witness Ministries, United Church of Christ, 
  submitted by Mr. Pallone.......................................   183
Letter, dated October 31, 2011, from Mary E. Hunt, Co-director, 
  Women's Alliance for Theology, Ethics, and Ritual, to committee 
  members, submitted by Mr. Pallone..............................   184
Statement, dated November 2, 2011, of The Rev. Dr. Carlton W. 
  Veazey, President and Chief Executive Officer, Religious 
  Coalition for Reproductive Choice, submitted by Mr. Pallone....   186
Letter, dated November 1, 2011, from James E. Winkler, General 
  Secretary, General Board of Church and Society of The United 
  Methodist Church, to subcommittee members, submitted by Mr. 
  Pallone........................................................   189


  DO NEW HEALTH LAW MANDATES THREATEN CONSCIENCE RIGHTS AND ACCESS TO 
                                 CARE?

                              ----------                              


                      WEDNESDAY, NOVEMBER 2, 2011

                  House of Representatives,
                            Subcommittee on Health,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The subcommittee met, pursuant to call, at 10:05 a.m., in 
room 2123 of the Rayburn House Office Building, Hon. Joseph R. 
Pitts (chairman of the subcommittee) presiding.
    Members present: Representatives Pitts, Burgess, Shimkus, 
Murphy, Blackburn, Gingrey, Latta, McMorris Rodgers, Lance, 
Cassidy, Guthrie, Pallone, Dingell, Towns, Engel, Capps, 
Schakowsky, Baldwin, Matheson, Christensen, and Waxman (ex 
officio).
    Staff present: Carl Anderson, Counsel, Oversight; Marty 
Dannenfelser, Senior Advisor, Health Policy and Coalitions; 
Brenda Destro, Professional Staff Member, Health; Andy 
Duberstein, Special Assistant to Chairman Upton; Paul Edattel, 
Professional Staff Member, Health; Ryan Long, Chief Counsel, 
Health; Nika Nour, New Media Specialist; Katie Novaria, 
Legislative Clerk; John O'Shea, Professional Staff Member, 
Health; Heidi Stirrup, Health Policy Coordinator; Phil Barnett, 
Democratic Staff Director; Alli Corr, Democratic Policy 
Analyst; Ruth Katz, Democratic Chief Public Health Counsel; 
Karen Lightfoot, Democratic Communications Director and Senior 
Policy Advisor; Elizabeth Letter, Democratic Assistant Press 
Secretary; Anne Morris Reid, Democratic Professional Staff 
Member; and Tim Westmoreland, Democratic Consulting Counsel.

OPENING STATEMENT OF HON. JOSEPH R. PITTS, A REPRESENTATIVE IN 
         CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA

    Mr. Pitts. The subcommittee will come to order. The Chair 
recognizes himself for 5 minutes for an opening statement.
    On August 3, 2011, the Department of Health and Human 
Services issued an interim final rule that would require nearly 
all private health plans to cover contraception and 
sterilization as part of their preventive services for women.
    While the rule does include a religious exemption, many 
entities feel that it is inadequate and violates their 
conscience rights by forcing them to provide coverage for 
services for which they have a moral or ethical objection.
    The religious employer exemption allowed under the 
preventive services rule--at the discretion of the HRSA--is 
very narrow. And the definition offers no conscience protection 
to individuals, schools, hospitals, or charities that hire or 
serve people of all faiths in their communities.
    It is ironic that the proponents of the healthcare law 
talked about the need to expand access to services but the 
administration issues rules that could force providers to stop 
seeing patients because to do so could violate the core tenets 
of their religion.
    I am also concerned about the process HHS used to issue the 
rule. The interim final rule was promulgated before the 
proposed rulemaking and the formal comment period were 
conducted by HHS. In issuing the rule, HHS acknowledged that it 
bypassed the normal rulemaking procedures in order to expedite 
the availability of preventive services to college students 
beginning the school year in August. HHS argued that there 
would be a year's delay in the receipt of the new benefit if 
the public comment period delayed the issuance of HRSA guidance 
for over a month.
    I believe that on such a sensitive issue there should have 
been a formal comment period so that all sides could weigh in 
on the issue and HHS could benefit from a variety of views. 
When the healthcare law was being debated last Congress, the 
proponents adamantly refuted claims that this would be a 
Federal Government takeover of our healthcare system.
    Now, we have the Federal Department of Health and Human 
Services forcing every single person in this country to pay for 
services that they may morally oppose. Groups who have for 
centuries cared for the sick and poor will now be forced to 
violate their religious beliefs if they want to continue to 
serve their communities. Whether one supports or opposes the 
healthcare law, we should universally support the notion that 
the Federal Government should be prohibited from taking 
coercive actions to force people to abandon their religious 
principles.
    I look forward to hearing from our witnesses. Thank you all 
for being here, and I yield the balance of my time to Dr. 
Gingrey from Georgia.
    [The prepared statement of Mr. Pitts follows:]

    [GRAPHIC] [TIFF OMITTED] T5050.221
    
  OPENING STATEMENT OF HON. PHIL GINGREY, A REPRESENTATIVE IN 
               CONGRESS FROM THE STATE OF GEORGIA

    Mr. Gingrey. Well, I thank the chairman for yielding to me.
    And absolutely the point that he is making in regard to 
conscience clause, surely, no matter how one may feel about 
Patient Protection and Affordable Care Act that was passed in 
March of 2010, whether you are strongly for it, as most 
Democrats on the committee were and strongly opposed to it, as 
most Republicans on our committee were, it seems to me that we 
should agree that conscience clauses should be protected.
    Each year, one in six patients in the United States are 
cared for in a Catholic hospital, and approximately 725,000 
individuals work in Catholic hospitals. These hospitals take 
all who are in need; it doesn't matter their religious 
background or their ability to pay. Come one, come all. But 
now, Obamacare would actually require with the rulemaking 
Catholic hospitals to primarily serve persons who share its 
religious beliefs or force them to provide benefits like 
abortion drugs to employees that contradict their faith.
    Let me rephrase. The White House is telling Catholic 
hospitals to deny care for those of other faiths or be forced 
as employers to provide coverage for services that they object 
to on religious and moral grounds. Why must President Obama 
insist that the price for healthcare reform be giving up the 
civil liberties through an individual mandate and the religious 
liberties that our Founding Fathers guaranteed us under the 
Constitution. This Congress can do better than that. Obamacare 
can do better than that.
    And I thank the chairman for yielding and I yield back.
    Mr. Pitts. The Chair thanks the gentleman and now 
recognizes the ranking member of the Subcommittee on Health, 
Mr. Pallone, for 5 minutes for an opening statement.

OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE 
            IN CONGRESS FROM THE STATE OF NEW JERSEY

    Mr. Pallone. Thank you, Mr. Chairman.
    Today's hearing will focus on the implementation of the 
Affordable Care Act's prohibition of cost-sharing for 
preventive health services, which will include prescription 
birth control methods. The rule released by the Department of 
Health and Human Services would permit certain religious 
employers to opt out of the requirement of providing 
contraception. But unfortunately, this is more than an 
examination of HHS's rule and whether or not it protects 
conscience rights. It is simply the latest in a series of 
attacks this year on the healthcare reform and women's health.
    The Federal health reform law represents unprecedented 
efforts to improve women's health and women's access to 
comprehensive healthcare. In fact, women will gain the most 
from healthcare reform. First, we must not forget that the ACA 
makes health insurance a reality for 19 million women in this 
country who were uninsured.
    In addition, it seeks to protect women from many insurance 
abuses. In the individual insurance market, women were being 
denied coverage for such preexisting conditions as pregnancy, 
having had a C-section, or in some cases, breast cancer. The 
ACA outlaws such a practice. Women were also often being 
charged substantially higher premiums than men for the same 
healthcare coverage, and the ACA outlaws these gender-rating 
practices.
    In many cases, women and children with insurance had not 
been receiving key preventive care from mammograms to well baby 
and well childcare visits to family planning services such as 
birth control because they could not afford the copays. Now, 
the Affordable Care Act is making groundbreaking strides in 
care for women by eliminating these copays and deductibles for 
preventive services.
    The new preventative coverage rules announced by HHS remove 
significant financial obstacles for women seeking preventive 
reproductive healthcare. These provisions ensure that a woman 
has access to all preventative services, regardless of who her 
employer is. And this is critical because it is well known that 
almost all women--99 percent in fact, including religious 
devotees--will use contraception at some point during their 
reproductive lives. Meanwhile, 3 recent studies have found that 
lack of insurance is significantly associated with reduced use 
of prescription contraceptives.
    But I absolutely support an individual's right to express 
their religious convictions. Today's hearing has nothing to do 
with religious rights and conscience protections. In my 
opinion, this hearing is about women's access to comprehensive 
healthcare coverage. And whether my colleagues admit it or not, 
their attempts here today are meant to turn back the clock on 
the great strides the Affordable Care Act has and will continue 
to make for women's health. We can't continue to allow 
obstacles to prevent us from insuring the affordability of 
family planning service for millions of women.
    I would now like to yield 2 minutes from the time I have 
left, Mr. Chairman, to the gentlewoman from Illinois, Ms. 
Schakowsky.

       OPENING STATEMENT OF HON. JANICE D. SCHAKOWSKY, A 
     REPRESENTATIVE IN CONGRESS FROM THE STATE OF ILLINOIS

    Ms. Schakowsky. Thank you for yielding.
    The attention this committee has focused on and continues 
to focus on the private lives of women makes it clear that one 
of the goals of the majority is to end access not just to 
abortions but to family planning. I fought for and will 
continue to fight for the guidelines adopted by the 
administration.
    After an exhaustive and thorough scientific review by the 
Institutes of Medicine to ensure insurance coverage of 
preventive services for women, it is no secret that substantial 
public health benefits and cost savings emerge when preventive 
services, including family planning, are accessible and 
affordable.
    As patients, caregivers, and as workers who still earn less 
than men, women have a particular stake in ensuring insurance 
coverage of prescription contraceptives and other preventive 
services. The new guidelines on insurance coverage of 
preventive services for women should apply to all women, 
regardless of where they work.
    Allowing employers to exempt themselves in providing 
prescription contraceptives for their employees is 
counterproductive, unfair, and paternalistic. Why should the 
conscience of an employer trump a woman's conscience? Why 
should an employer decide for a woman whether she can access 
the healthcare services that she and her doctor decide are 
necessary? Why are we talking about allowing some employers to 
put up a barrier to access at a time when woman are struggling 
to afford and access healthcare?
    It never used to be that family planning was considered a 
partisan issue and it never used to be that family planning was 
equated with abortion. My, how things have changed. Today, the 
full continuum of reproductive healthcare is under assault. 
Believe me, these conversations are heard far and wide among 
women out in the public, women of all ages and races and 
parties, political parties, who understand that these kinds of 
assaults on women's right to make a choice about a lot of 
things, including contraceptive care, and men, too, who want to 
be able to plan their families. Unacceptable.
    I yield back.
    Mr. Pitts. The Chair thanks the gentlelady and now 
recognizes the vice chair of the Subcommittee on Health, Dr. 
Burgess, for 5 minutes.

OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A REPRESENTATIVE 
              IN CONGRESS FROM THE STATE OF TEXAS

    Mr. Burgess. I thank the chairman for the recognition. And 
once again, we are here learning that those who are driving the 
regulatory train are in fact making the practice of medicine 
more difficult through their lack of thought. And we are left 
with consequences. The decision by Health and Human Services to 
issue an interim final rule, while that sounds like arcane 
Washington-speak, what that means is that the transparency and 
accountability of the normal Federal rulemaking process has now 
been circumvented, and as a consequence, we have got a rule 
being put forward that now has the force of law as if it were 
legislation passed by Congress and signed by the President.
    Now, we have got a rule that has the force of law that is 
unworkable, yes, for faith-based facilities but also was going 
to have dramatic cost implications across the board for all 
Americans. A good thing or bad thing, problem is we don't know 
because we never had the opportunity to explore the 
possibilities.
    So the administration now has singlehandedly rendered 
faith-based facilities fearful of their ability to continue to 
serve their patients. The lack of consideration for these 
organizations has manifested in an extremely narrow and in fact 
an unworkable exemption.
    The interim final rule further expands the power and reach 
of the Federal Government into the realm of private health 
insurance without regard for conscience rights to be sure, but 
also without regard to the bill that must be footed by the 
taxpayer. The requirement that all, underscore ``all,'' 
preventive FDA-approved contraceptives must be offered at no 
copay to all women was never examined for its cost or its 
practical implications. This policy considers both generic and 
brand name contraceptives the same, so how in the world do we 
expect there to be any price sensitivity in the marketplace if 
we have simply removed that obligation from the marketplace 
itself?
    The interim final rule does violate the conscience 
protections many healthcare providers rely upon and ultimately 
leads to diminished access of care--as Dr. Gingrey so 
eloquently pointed out--and also importantly, a rising monthly 
premium for all Americans.
    I yield now to the gentlelady from Tennessee.

OPENING STATEMENT OF HON. MARSHA BLACKBURN, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF TENNESSEE

    Mrs. Blackburn. Thank you, Mr. Burgess.
    And I want to welcome all of our witnesses. We are so 
pleased that you have taken the time to be here with us today.
    President Obama came before Congress and made a statement, 
``under our plan, no Federal dollars will be used to fund 
abortions and Federal conscience laws will remain in place.'' 
Then, at Notre Dame he said, ``let us honor the conscience of 
those who disagree with abortion.'' But the truth is this 
administration, by its actions, calls abortion essential care. 
Obamacare discriminates against hospitals, insurance plans, and 
healthcare professionals who don't want to violate what they 
know in their hearts to be true.
    HHS has published this new rule--we have all spoken about 
this--to force America's doctors and nurses to do the things 
that otherwise they would not do. Maybe it should be called 
coercion backed by the taxpayer dollars and that is a little 
bit of a poisonous medicine to swallow. It is unconstitutional 
and unethical and cheapens the civil rights of our medical 
professionals.
    Smuggling abortion into PPACA was destructive and it is 
another big reason why I think we need to repeal Obamacare.
    With that, I would like to yield the balance of the time to 
Dr. Murphy.

   OPENING STATEMENT OF HON. TIM MURPHY, A REPRESENTATIVE IN 
         CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA

    Mr. Murphy. Thank you. And thank you, Chairman Pitts.
    Since this rule was released, I have heard an outpouring of 
concern not only from religious leaders like Bishop David Zubik 
of the Diocese of Pittsburgh, but from over 1,000 individual 
constituents and a range of employers from the CEOs of 
multibillion dollar companies to small business owners. I have 
a hard time explaining to them that the Federal Government is 
forcing them to choose between their faith and providing health 
insurance to their employees.
    This mandate stands in stark contrast to the stated purpose 
of healthcare reform expanding access to healthcare. Instead, 
this mandate will strip countless Americans of their health 
insurance calling into question President Obama's promise that 
if you like your health insurance you can keep it. To that I 
would add a question. If you like your religion, can you keep 
it?
    Almost exactly a month ago, I sent a letter to Secretary 
Sebelius expressing my concern and that of the thousands I 
represent in Congress with the blatant disregard for the 
religious and moral beliefs of millions of Americans displayed 
in this new ``preventative services'' mandate. I am still 
waiting for Secretary Sebelius to respond.
    Mr. Chairman, toward that end, I ask for unanimous consent 
that my letter to Secretary Sebelius be included in the 
official record. And with that, I yield back.
    Mr. Pitts. Without objection, so ordered.
    [The information follows:]

    [GRAPHIC] [TIFF OMITTED] T5050.002
    
    [GRAPHIC] [TIFF OMITTED] T5050.003
    
    Mr. Pitts. The Chair recognizes the ranking member of the 
full committee, Mr. Waxman, for 5 minutes for an opening 
statement.

OPENING STATEMENT OF HON. HENRY A. WAXMAN, A REPRESENTATIVE IN 
             CONGRESS FROM THE STATE OF CALIFORNIA

    Mr. Waxman. Mr. Chairman, this is not a hearing about 
abortion. This is not a hearing about whether people can adhere 
to their religious beliefs and follow their own individual 
consciences. This is a hearing about whether the Republicans 
can have the government intrude to the point where people who 
buy health insurance could be denied insurance coverage for the 
preventive service of family planning. Preventing conception is 
what family planning is all about, and it is a legitimate 
medical service. In fact, the Institute of Medicine made 
recommendations to the Department for what would be covered 
under preventive services, and they recommended that this be a 
covered preventive service.
    So the question is, if somebody doesn't want to provide 
contraception because it violates their religion or their 
conscience, would they be required to? Absolutely not. The 
question then comes down to, what is the scope of the exception 
that church-provided insurance need not cover family planning? 
Well, I don't know why that should be even an exception. I 
disagree with the administration in providing that exception. 
But the Republicans would like to, first of all, extend that 
exception to all church-related groups whether it means that 
the people who are covered are of the same faith or not. But we 
are going to hear from a witness who would like to have no 
insurance coverage for contraceptives services because it 
violates her point of view.
    Now, we hear a lot from the other side of the aisle about 
government intrusion in our private lives. There can be no 
intrusion more significant than government telling people they 
cannot get contraception, they cannot get insurance to cover 
contraception, it should not be a provided service. Well, that 
is part of what the Republican agenda appears to be, but it is 
much more than that because what we have is a hearing today 
that purports to be about the conscience protection, but it is 
another attempt by the Republicans to undermine and undo the 
Affordable Care Act's provisions related to women's health. And 
no single piece of legislation in recent memory has done more 
to advance women's health and women's access to health services 
than the Affordable Care Act.
    It provides coverage for millions of Americans including 
19.1 million women who are uninsured. It makes health insurance 
coverage more affordable through premium assistance. It stops 
gender rating. It would no longer be legal to do that where 
women are charged higher premiums than men for the same 
insurance coverage. It will be illegal for insurance companies 
to discriminate against women and others on the basis of 
preexisting conditions, which by the way may even include 
history of breast cancer, pregnancy, or experience of domestic 
violence. And then the cost-sharing requirements under Medicare 
have been eliminated for women's preventive health services 
such as mammograms and well women visits. For new private 
health insurance coverage that prohibition against cost-sharing 
extends to breastfeeding counseling, screening, and counseling 
for domestic violence. And it would include FDA-approved 
contraceptives in addition to mammograms and well women 
checkups.
    Now, the Republicans would like to take all this away, not 
just the access to contraceptive services. They would like to 
repeal the Affordable Care Act. And if they succeed, newly 
established health benefits and health coverage for women would 
disappear. And what would they do to replace this? Nothing. 
They would leave the status quo in place.
    Now, let me be clear. I support policies that recognize and 
protect the right of individuals to express and act on their 
religious and moral convictions. If you have moral convictions, 
you can keep them, just don't try to impose them on everybody 
else. We cannot turn the clock back. We shouldn't let the 
Republicans confuse the issue.
    Deny health insurance coverage that includes contraceptive 
services to millions of American women, that is wrong. Women 
who don't want that service don't have to access it if it 
violates their conscience. A doctor does not have to provide it 
if it violates his or her conscience. But tell me less about 
the conscience of the employer or the insurance company and why 
that should take precedence over all the people who are to be 
covered that do not share that particular point of view. The 
Department's position on insurance coverage for family planning 
is in keeping with this goal and should move forward without 
delay.
    I am going to yield back my time and express a strong 
support for this preventive service which is now being used 
widely by people who even are members of a church that in 
theory and religious doctrine disapprove of the service.
    Mr. Pitts. The Chair thanks the gentleman. That concludes 
the opening statements of the members. The Chair has a UC 
request to submit for the record a statement by Congressman 
Jeff Fortenberry; a statement by the Catholic University of 
America president, John Garvey; some letters from the U.S. 
Conference of Catholic Bishops; and a letter from the Family 
Research Council. These have all been provided. Without 
objection, these will be entered into the record.
    [The information follows:]

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    Ms. Schakowsky. Mr. Chairman?
    Mr. Pitts. Yes?
    Ms. Schakowsky. I don't know if this is an appropriate 
time, but I have some things I would like to submit for the 
record.
    Mr. Pitts. All right. If you would----
    Ms. Schakowsky. Thank you. This is testimony from NARAL 
Pro-Choice America, Center for Reproductive Rights, National 
Women's Law Center, ACLU, National Partnership for Women and 
Families, National Health Law Program, Physicians for 
Reproductive Choice and Health, and then a letter organized by 
Advocates for Youth. These have all been submitted previously 
and I would appreciate if they could be part of the record.
    Mr. Pitts. All right. We have received these. Without 
objection, so ordered.
    [The information follows:]

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    Mr. Pitts. The Chair now is pleased to welcome the panel of 
witnesses to our hearing today. We would ask them to please 
take their seats at the witness table. And I will introduce 
them at this time.
    Today, our witness panel includes David Stevens, CEO of the 
Christian Medical Association; Mark Hathaway, Director of OB/
GYN Outreach Services for Women's and Infants' Services at 
Washington Hospital Center and Title X Medical Director at the 
Unity Healthcare, Inc.; Jane Belford, Chancellor and General 
Counsel of the Archdiocese of Washington; Jon O'Brien, 
President of Catholics for Choice; and Bill Cox, President and 
CEO of the Alliance of Catholic Health Care.
    We are happy to have each of you here today and ask that 
you summarize your statements in 5 minutes. We will enter your 
written testimony into the record.
    And at this point, we will start with Dr. Stevens. You are 
recognized for 5 minutes.

   STATEMENTS OF DAVID L. STEVENS, CHIEF EXECUTIVE OFFICER, 
    CHRISTIAN MEDICAL ASSOCIATION; MARK HATHAWAY, DIRECTOR, 
  OBSTETRICS AND GYNECOLOGY OUTREACH SERVICES FOR WOMEN'S AND 
INFANTS' SERVICES, WASHINGTON HOSPITAL CENTER; JANE G. BELFORD, 
   CHANCELLOR, ARCHDIOCESE OF WASHINGTON, DC.; JON O'BRIEN, 
PRESIDENT, CATHOLICS FOR CHOICE; AND WILLIAM J. COX, PRESIDENT 
 AND CHIEF EXECUTIVE OFFICER, ALLIANCE OF CATHOLIC HEALTH CARE

                 STATEMENT OF DAVID L. STEVENS

    Mr. Stevens. I am testifying on behalf of the over 16,000 
members of the Christian Medical Association, a professional 
membership organization that helps healthcare professionals to 
integrate their faith and their profession. I am a diplomat of 
the American Board of Family Medicine and hold a master's 
degree in bioethics.
    Our members include physicians who hold a range of 
conscience convictions on controversial ethics and moral 
issues, including contraception, healthcare reform, 
participation in the death penalty, and other conscience issues 
that span the political spectrum.
    Virtually all medical professionals and student members we 
recently surveyed say it is ``important to personally have the 
freedom to practice healthcare in accordance with the dictates 
of his or her conscience.'' Over 9 of 10 say they would not 
prescribe FDA-approved contraceptives that might cause the 
death of a developing human embryo.
    Many physicians today conscientiously profess allegiance to 
life-affirming ethical standards such as the Hippocratic Oath. 
Pro-life patients want to retain the freedom to choose 
physicians whose professional judgments reflect their own life-
affirming values.
    The Health and Human Services interim final regulation 
would force insurance plans nationwide to cover all Food and 
Drug Administration-approved contraceptive methods and 
sterilization procedures. This mandate does not exempt 
controversial drugs such as Ella and the morning-after pill, 
which according to the FDA have post-fertilization effects that 
may inhibit implantation of a living human embryo.
    The potential religious exemption in the contraception 
mandate--exempting only a nano-sector of religious employers 
from the guidelines--is meaningless to conscientiously 
objecting healthcare professionals, insurers, and patients. The 
contraception mandate can potentially trigger a decrease in 
access to healthcare by patients in medically underserved 
regions and populations.
    The administration's policies on the exercise of conscience 
in healthcare, including the gutting of the only Federal 
conscience-protecting regulation, actually threaten to worsen a 
growing physician shortage. A national survey of over 2,100 
faith-based physicians revealed that over 9 of 10 are prepared 
to leave medicine over conscience rights. Eighty-five percent 
of our medical professionals and students say that the policies 
that restrict the exercise of conscience in healthcare make it 
less likely they will practice healthcare in the future.
    The contraception mandate further contributes to an 
increasingly hostile environment in which pro-life physicians, 
residents, and medical students face discrimination, job loss, 
and ostracism. Seventy-nine percent of our members surveyed 
said the new contraception mandate will have a negative impact 
on their freedom to practice medicine in accordance with the 
dictates of their conscience. One out of five faith-based 
medical students surveyed said they will not go into OB/GYN as 
a specialty because of abortion-related pressures.
    The contraception mandate creates a climate of coercion 
that can prompt pro-life healthcare professionals to limit the 
scope of their medical practice. Over half of the medical 
professionals and students we surveyed said the new 
contraception mandate might cause them to restrict their 
practice of medicine.
    The contraception mandate can potentially cause a decrease 
in the provision of health insurance for employees of pro-life 
healthcare employers who want to avoid conflicts of conscience 
regarding controversial contraceptives. Sixty-five percent of 
the medical professionals and students we surveyed said the 
contraception mandate will make them less likely to provide 
insurance for their employees.
    The contraceptive mandate rule sweepingly tramples 
conscience rights, which have provided a foundation for the 
ethical and professional practice of medicine. The 
administration should rescind this mandate entirely for the 
ethical and practical reasons I have noted and also for the 
constitutional and statutory reasons outlined in our official 
comment letter of September 29 to HHS, which I am submitting 
separately and ask to be included in the record.
    We encourage Members of Congress to uphold conscience 
rights by passing the Respect for Rights of Conscience Act. 
Upholding a respect for conscience and our First Amendment 
freedoms protects all Americans, conservatives and liberals, 
capitalists and socialists, atheists and people of faith.
    Thank you for your consideration of these views.
    [The prepared statement of Mr. Stevens follows:]

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    Mr. Pitts. The Chair thanks the gentleman and recognizes 
Dr. Hathaway for 5 minutes.

                   STATEMENT OF MARK HATHAWAY

    Mr. Hathaway. Chairman Pitts, Ranking Member Pallone, and 
members of the committee, thank you for the opportunity to 
testify before you today.
    Good morning. My name is Dr. Mark Hathaway. I am a board-
certified OB/GYN. I am the director of OB/GYN Outreach Services 
for Women's and Infants' Services at the Washington Hospital 
Center. I am also the Title X director at Unity Health Care, 
Washington, DC's, largest Federally qualified health center.
    I work in several medical facilities here in Washington, 
DC. My patients tend to be women of color, primarily African 
American and Latina, and of lower socioeconomic status. Many of 
the patients I see are uninsured, underinsured, and seeking 
prenatal care or family planning services. Despite these 
obstacles, they desire to improve their lives and to have and 
raise healthy children.
    I see every day how increasing women's ability to plan 
their pregnancies makes a difference in their lives. And by the 
same token, I also see the negative consequences of unintended 
and unplanned pregnancy, late prenatal care, uncontrolled 
medical problems, poor nutrition, and sometimes depression. I 
see firsthand how cost can be a barrier. That is why the 
Institute of Medicine's recommendation is so critically 
important. Contraceptive counseling and methods should be 
covered under the Affordable Care Act without cost-sharing. Any 
attempts to broaden exemptions to that coverage requirement 
would mean leaving in place insurmountable obstacles to 
contraceptive services for far too many women.
    I know from my day-to-day experience what it means for 
patients who cannot afford to pay for their health services. 
The cost of a birth control method is frequently prohibitive 
for many of my patients. This is especially true for the more 
cost-effective, long-acting reversible contraceptive methods, 
also known as LARC.
    Women face many challenges in using contraception 
successfully. Too many women using methods like birth control 
pills, condoms and even injectables will experience an 
unplanned pregnancy during their first year of ``typical use.'' 
Long-acting reversible contraceptive methods, including 
intrauterine contraceptives and implants, are the most cost-
effective methods because they have an extremely low failure 
rate and are effective at preventing pregnancy for several 
years. The up-front costs of these methods, however, are 
several hundred dollars, placing them out of the reach of 
millions of women who would otherwise use them.
    Three recent studies have found that lack of insurance is 
significantly associated with reduced use of prescription 
contraceptives. In St. Louis, researchers at Washington 
University have recently found that over 70 percent of women 
will choose a longer-acting method if cost and barriers are 
eliminated.
    There are those who assert that unintended pregnancy is not 
a health condition and therefore prevention of unintended 
pregnancy is not a preventive healthcare. From my personal 
practice I can say that I cannot disagree more. Just last week 
I met ``Sarah.'' She is 22 years old, has 2 children under the 
age of 3, one a recent newborn. She came in for a pregnancy 
test. Her diabetes had gone unchecked, which would put her in a 
category of a high-risk pregnancy. She was visibly shaking 
waiting for her pregnancy test results. She is working over 40 
hours a week at 2 different jobs and was told by her primary 
care clinic that she would need to pay a copay of $40 and a 
$300 fee for the intrauterine device that she so desperately 
wants. She would have been devastated by a positive pregnancy 
test. She was incredibly relieved to learn she was not 
pregnant. She was also uninsured but we used our rapidly 
shrinking safety-net resources to provide her with long-acting 
contraception lasting up to 7 years.
    The evidence is also conclusive regarding pregnancy 
spacing. It is directly linked to improved maternal and child 
health. Numerous U.S. and international studies have found a 
direct causal relationship between birth intervals, low birth 
weight, as well as preterm births. In other words, we need to 
help women plan their pregnancies for their health as well as 
their children's.
    Using contraception is the most effective way to prevent 
unintended pregnancy. Again, I have seen the success of 
contraceptive services in my own practice, and again the 
evidence on this is clear. Ninety-five percent of all 
unintended pregnancies occur among women who use contraception 
inconsistently or use no method at all. Indeed, couples who do 
not practice contraception have an 85 percent chance of 
experiencing an unintended pregnancy within the first year.
    For all these reasons, the Institute of Medicine's 
recommendations are groundbreaking. Finally, all women will 
gain access to insurance coverage of family planning services 
regardless of income. All women will be able to get the 
counseling, education, and access to the most effective and 
medically appropriate contraceptive for them. This breakthrough 
has the potential to bring about major benefits for the health 
and well-being of women and their families.
    Most women will contracept for approximately 3 decades 
during their reproductive years. The adoption of the IOM's 
recommendations holds so much promise for millions of women who 
currently lack basic resources like health insurance coverage. 
All of my training and experience tells me that what we are 
striving for is healthy women. We are also working to ensure 
that if and when they are ready to have a child that they have 
a healthy pregnancy. The best way to achieve this is to help 
women and couples become as healthy as possible before 
pregnancy. This includes financial health, emotional health, 
and physical health. We should trust women and empower women to 
make the appropriate decisions for themselves. Therefore, I 
hope we can agree that guaranteeing contraceptive coverage and 
removing cost barriers should be at the forefront of preventive 
care so that women can achieve their own goals.
    Thank you very much.
    [The prepared statement of Mr. Hathaway follows:]

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    Mr. Pitts. The Chair thanks the gentleman and now 
recognizes Ms. Belford for 5 minutes.

                  STATEMENT OF JANE G. BELFORD

    Ms. Belford. Mr. Chairman and distinguished members of the 
subcommittee, thank you for the opportunity to testify before 
you today on an issue of vital importance to religious 
organizations like the one I serve.
    My name is Jane Belford, and I serve as chancellor of the 
Catholic Archdiocese of Washington, which includes 600,000 
Catholics and includes 140 parish church communities in the 
District of Columbia and portions of Maryland.
    The Archdiocese is one of 195 dioceses of the Catholic 
Church in the United States which represents more than 70 
million Catholics. Throughout this country's history, the 
Catholic Church has been one of the leading private providers 
of charitable educational and medical services to the poor and 
vulnerable. The Archdiocese continues that tradition of service 
today through its Catholic schools, medical clinics, maternal 
and pregnancy resource programs, social service agencies, 
senior and low-income housing, job training programs, and a 
vast number of other programs and services for persons in need 
regardless of their faith or no faith, without question, 
without exception.
    The late former Archbishop of Washington, Cardinal Hickey, 
once said, ``We serve them not because they are Catholic but 
because we are Catholic. If we don't care for the sick, educate 
the young, care for the homeless, then we cannot call ourselves 
the Church of Jesus Christ.'' Until now, Federal law has never 
prevented religious employers like the Archdiocese of 
Washington from providing for the needs of their employees with 
a health plan that is consistent with the Church's teachings on 
life and procreation. The Archdiocese provides excellent health 
benefits to its nearly 4,000 employees, consistent with 
Catholic teaching, and subsidizes most of the cost.
    We would lose this freedom of conscience under the mandate 
from the Department of Health and Human Services that the 
health plans of religious organizations like ours cover 
sterilization, contraceptive services, and drugs that in some 
cases act as abortifacients. This is not in line with the 
policy that has governed other Federal health programs.
    The HHS mandate provides a radically narrow test to be 
eligible for exemption. Essentially, under this test Catholic 
organizations like ours would be considered religious enough 
only if we primarily served Catholics, only if we primarily 
hired Catholics, and only if the whole purpose of our service 
was to inculcate our religious values.
    Under this analysis, organizations like ours would be only 
free to follow Catholic teaching on life and procreation if we 
stopped hiring and serving non-Catholics. However, as in the 
parable of the Good Samaritan, Catholic organizations serve 
people of all different faiths without question or condition 
and without knowing their faith.
    Just last year, Catholic Charities of the Archdiocese 
served over 100,000 people. I could not tell you what their 
faith is. Our 98 Catholic schools educate 28,000 students in 
the District of Columbia and Maryland, and in some locations, 
more than 80 percent of the students are non-Catholic.
    HHS has drafted an exemption that is so narrow that it will 
exclude virtually all Catholic hospitals; Catholic schools, 
colleges, and universities; and charitable organizations, none 
of which impose a litmus test on those they serve. Why does the 
government want to have us do that?
    In my written testimony, I allude to the vast array of 
services being provided right now in the Archdiocese of 
Washington--the medical care, educational services, and social 
services that are made available. This narrow religious 
exemption drafted as it has would burden our deeply held belief 
not only in life and procreation but in the belief that God 
calls us to serve our neighbors. Both those beliefs--our 
beliefs in life and procreation and our belief in service--are 
grounded in a fundamental teaching that upholds the dignity of 
human life of whatever race, status, or creed from the 
beginning of life to the end.
    It is part of our central mission and religious identity to 
be a witness in the world through acts of service to all who 
are in need, regardless of religion or creed. When we are 
fortunate enough to be able to partner with the government in 
providing these services, our devotion to the cause and our 
institutional resources can make each dollar of funding go 
further. Unfortunately, the mandate poses a threat to our 
rights of conscience in our services for our neighbors. At a 
time when local, State, and Federal governments have had to 
consider drastic cuts to their healthcare and social service 
programs and when our citizens' need for support is so great, 
it is difficult to understand why the Federal Government would 
impose requirements that are designed to undermine and restrict 
access to these services.
    We believe in the value and dignity of all human life from 
beginning to end, and we believe that we are called to serve 
our neighbors, all of them. We will continue to honor these 
beliefs. We have served, we serve now, and we will continue to 
serve, but I urge the committee to consider our Nation's 
historical commitment to religious liberty and the value and 
importance of the Church's service to the poor and vulnerable 
and to permit us to practice our faith consistent with the 
teachings of our church.
    Mr. Chairman and members of the committee, thank you for 
the opportunity to address you.
    [The prepared statement of Ms. Belford follows:]

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    Mr. Pitts. Thank you. The Chair thanks the gentlelady, 
recognizes Mr. O'Brien for 5 minutes.

                    STATEMENT OF JON O'BRIEN

    Mr. O'Brien. Mr. Chairman, Member Pallone, and members of 
the subcommittee, thank you for this opportunity to present 
testimony on this important question of conscience rights and 
access to comprehensive healthcare.
    For nearly 40 years, Catholics for Choice has served as a 
voice for Catholics who believe that Catholic teaching means 
that every individual must follow his or her own conscience and 
respect the rights of others to do the same. This hearing seeks 
to answer the question: Do new health law mandates threaten 
conscience rights and access to care? I firmly believe the 
requirements under the Affordable Care Act and the slate of 
regulations being created to implement it infringe on no one's 
conscience, demand no one change his or her religious beliefs, 
discriminate against no man or woman, put no additional 
economic burden on the poor, interfere with no one's medical 
decisions, compromise no one's health--that is, if you consider 
the law without refusal clauses.
    When the question is asked in light of these unbalanced and 
ever-expanding clauses, the answer becomes yes, it would do all 
those things. When burdened by such refusal clauses, the new 
health law absolutely threatens the conscience rights of every 
patient seeking care for these restricted services and of every 
provider who wishes to provide comprehensive healthcare to 
patients. These restrictions go far beyond their intent of 
protecting conscience rights for all by eliminating access to 
essential healthcare for many, if not most patients, especially 
in the area of reproductive health services. This will make it 
harder for many working Americans to get the healthcare they 
need at a cost they can afford.
    Like many Catholics, I accept that conscience has a role to 
play in providing healthcare services, but recent moves to 
expand conscience protections beyond the simple right for 
individual healthcare providers to refuse to provide services 
to which they personally object to go too far. It is incredible 
to suggest that a hospital or an insurance plan has a 
conscience. Granting institutions--or entities like these--
legal protection for the rights of conscience that properly 
belong to individuals is an affront to our ideals of conscience 
and religious freedom.
    Respect for individual conscience is at the core of 
Catholic teaching. Catholicism also requires deference to the 
conscience of others in making one's own decisions. Our faith 
compels us to listen to our consciences in matters of moral 
decision-making and to respect the rights of others to do the 
same. Our intellectual tradition emphasizes that conscience can 
be guided, but not forced, in any direction. This deference for 
the primacy of conscience extends to all men and women and 
their personal decisions about moral issues.
    Today, the 98 percent of sexually active Catholic women in 
the United States who have used a form of contraceptive banned 
by the Vatican have exercised their religious freedom and 
followed their consciences in making the decision to use 
contraception. Thus, they are in line with the totality of 
Catholic teaching if not with the views of the hierarchy. 
Having failed to convince Catholics in the pews, the United 
States Conference of Catholic Bishops and other conservative 
Catholic organizations are now attempting to impose their 
personal beliefs on all people by seeking special protection 
for their conscience rights. They claim to represent all 
Catholics when in truth theirs is a minority view. The majority 
of Catholics support equal access to contraceptive services and 
oppose policies that impede upon that access.
    Two-thirds of Catholics, 65 percent, believe that clinics 
and hospitals that take taxpayer money should not be allowed to 
refuse to provide procedures or medications based on religious 
belief. A similar number, 63 percent, also believes that all 
health insurance, whether private or government-run, should 
cover contraception. Sweeping refusal clauses and exemptions 
allow a few to dictate what services many others may access. 
They disrespect the individual capacities of women to act upon 
their individual conscience-based decision. They impede the 
rights of women and men to make their own decisions about what 
is best for them, their health and their families.
    Lawmakers of all political hues can come together to 
support a balanced approach to individual conscience rights and 
access to comprehensive healthcare. It makes sense for all 
those who want to provide more options to women seeking to 
decide when and whether to have a child. It makes sense for 
those who want to keep the government's involvement in 
healthcare to a minimum. Above all, it makes sense for a 
society that believes in freedom of religion, a right one can't 
claim for oneself without extending it to one's neighbor.
    The bottom line is that protecting conscience rights and 
preserving access to care shouldn't just be about protecting 
those who seek to dictate what care is and is not available, 
nor should it be for those who would dismiss the conscience of 
others by imposing their view of which consciences are worth 
protecting. Protecting individual conscience and ensuring 
access to affordable, quality care is not just an ideal, it is 
a basic tenet of our society and it is the right thing to do.
    I thank the subcommittee for inviting me today.
    [The prepared statement of Mr. O'Brien follows:]

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    Mr. Pitts. The Chair thanks the gentleman and recognizes 
Mr. Cox for 5 minutes for an opening statement.

                  STATEMENT OF WILLIAM J. COX

    Mr. Cox. Good morning, Mr. Chairman and members of the 
committee, and thank you for convening a hearing on this 
critically important matter. My name is Bill Cox and I am 
president and CEO of the Alliance of Catholic Health Care, 
which is based in Sacramento, California. We represent 4 
Catholic systems in California that operate 54 hospitals.
    My testimony focuses on the exceedingly narrow definition 
of religious employer in HHS's interim final rule.
    You have a copy of my extended remarks, so I will summarize 
them by making four brief points about the definition and the 
mandate.
    First, in order to benefit from the definition, a religious 
institution must primarily employ and serve its coreligionists 
and it must proselytize. As an essential element of the 
religious missions Catholic hospitals, universities, and social 
services hire and provide services to a broad array of people 
and they do not proselytize those they serve. Thus, the 
definition, together with the mandate, will require Catholic 
hospitals, universities, and social service agencies to cover 
in their health insurance plans contraceptives, abortifacients, 
and sterilizations in direct violation of their religious 
beliefs.
    Mr. Chairman, Catholics have been providing healthcare 
services in California since 1854 when eight Sisters of Mercy 
arrived in San Francisco from Ireland. The following year, a 
cholera epidemic broke out and the Sisters went to work in the 
county hospital. According to San Francisco's ``The San 
Francisco Daily News'' of that time, ``the Sisters of Mercy did 
not stop to inquire whether the poor sufferers of cholera were 
Protestant or Catholic, American or foreigners, but with the 
noblest devotion, applied themselves to their relief.''
    Mr. Chairman, had HHS's definition of religious employer 
been in effect in 1854, the ministry of the Sisters of Mercy in 
San Francisco would not have been considered by the Federal 
Government to be a religious ministry.
    Second, I think it is very important to emphasize this 
morning that neither the propriety nor the wisdom of nor the 
government's authority to impose a contraceptive mandate on all 
employers is at issue here. The question is actually a very 
narrow one related to the First Amendment, and that is whether 
the HHS definition of religious employer contravenes the First 
Amendment by putting the Federal Government in the position of 
determining what parts of a bona fide religious organization 
are religious and what parts are secular.
    In particular, it allows the government to make such 
distinctions in order to infringe the religious freedom of that 
portion of the organization the government declares to be 
secular. This is exactly what the founders of this country 
sought to avoid by adopting the First Amendment to the 
Constitution.
    Third, the definition is discriminatory in that it tracks 
identical language first enacted in a California statute that 
was deliberately designed to contravene the religious conduct 
of religious organizations such as Catholic hospitals, 
universities, and social services. At the time, one of the 
principal proponents of that definition of religious liberty 
said our purpose and intent here is to close the Catholic gap. 
That is, we want to compel these religious institutions by 
force of law to provide these services regardless of what they 
may think of them in terms of their religious belief.
    Fourth, there is no escape from the HHS mandate. Unlike 
most State contraceptive mandates that have a similar 
definition of religious employer, religious employers cannot 
avoid the HHS mandate by either dropping coverage of 
prescription drugs or by self-insuring through an ERISA plan.
    In conclusion, I would just like to note that Catholic 
hospitals provide a broad array of services not always 
available in other institutions. For example, in California 86 
percent of our hospitals have palliative care programs compared 
to only 43 percent of all California hospitals. Our palliative 
care programs address the physical, emotional, and spiritual 
needs of chronically ill and dying patients and their families.
    Moreover, a recent Thomson Reuters study found that on 8 
key metrics Catholic healthcare systems in the United States 
were significantly more likely to outperform their nonprofit 
and investor-owned counterparts on quality, efficiency, and 
patient satisfaction. It would be a great loss to the Nation 
and the communities we serve if our hospitals were compelled by 
Federal law to forgo their religious mission and consciences in 
order to comply with the HHS contraceptive mandate.
    I would be happy to answer any questions.
    [The prepared statement of Mr. Cox follows:]

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    Mr. Pitts. The Chair thanks the gentleman and thanks all 
the witnesses for their opening statements.
    I will now begin the questioning and recognize myself for 5 
minutes for that purpose.
    Mr. Cox, the Church amendment which became part of the 
Public Health Service Act in 1973 declares that hospitals' or 
individuals' receipt of Federal funds in various health 
programs will not require them to participate in abortion and 
sterilization procedures if they object based on moral or 
religious convictions. Also, no State in the country except 
Vermont requires insurance coverage of sterilization. How is 
the interim final rule on preventive services issued by HHS 
subsequent to passage of the healthcare law different in 
respect to conscience protections and sterilization mandates?
    And what are the implications for Catholic healthcare 
providers?
    Mr. Cox. Well, these are requirements that would force 
Catholic healthcare providers, Catholic universities, and 
social service agencies to include contraceptive services, 
sterilization, and other things in their health insurance plans 
in violation of their religious beliefs. And that is how it 
would affect them.
    Under most State laws there are options that we have 
available to us. One, if for instance in California a religious 
employer can drop prescription drug benefits entirely in their 
health insurance plan and get out from under California's 
contraceptive mandate. We have chosen not to do that because 
that would make absolutely everyone else worse off in our 
employ. But what we have done is moved to ERISA plans in order 
to self-insure and get out from under the mandate.
    Now, under the HHS mandate and definition of religious 
employer, as I said in my testimony, there is no escape. ERISA 
plans will be covered. All employers are required, regardless 
of religious views, to cover these services.
    Mr. Pitts. The supporters of the interim final rule on 
preventive benefits argue the substance of the rule is similar 
to contraceptive mandates imposed by States on health plans 
operating within their State. Just as you said, the question 
was do State contraceptive mandates apply to self-insured plans 
governed under ERISA? And does the HHS rule differ in this 
respect? You spoke to that.
    Do State contraceptive mandates typically require coverage 
of sterilization procedures?
    Mr. Cox. They do not. I think Vermont is the only State 
that does.
    Mr. Pitts. Do State contraceptive mandates force plans to 
cover such products even if they do not provide coverage for 
prescriptive drugs generally?
    Mr. Cox. I think the laws in the various States differ with 
respect to that, and many of the States that have a 
contraceptive mandate also have pretty strong and effective 
conscience legislation that allows religious employers and 
providers with a moral perspective on this to opt out of the 
mandates.
    Mr. Pitts. Thank you.
    Let me go to Dr. Stevens. You said that the contraceptive 
mandate ``violates the religion and free speech clauses of the 
First Amendment of the Constitution by coercing faith-based 
healthcare ministries to not only violate their very faith-
based tenets that have motivated patient care for millennia but 
also to pay for that violation. Such conscience-violating 
mandates will ultimately reduce patients' access to faith-based 
medical care, especially depriving the poor and medically 
underserved population of such care.'' Do you believe that the 
particular mandate could contribute to faith-based providers 
leaving the medical profession, reducing access to medical 
care, and are you concerned that faith-based providers might 
leave certain areas of medical care?
    Mr. Stevens. We are seeing a pattern from this 
administration to restrict conscience rights, including 
stripping regulations, deregulation. We actually surveyed our 
membership and 88 percent of them say the problem is getting 
much worse. The issues we are talking about today I never 
talked about during my training. And we are also seeing people 
coming under increasing discrimination in the workplace.
    One of my staff member's wife, a family practice doc, 
worked in Texas. She did not distribute contraceptives to 
single women, referred them across the hallway to another 
physician, and it wasn't even an inconvenience for them, and 
she was told she was going to lose her job and she had to go 
find other employment within a week. We have seen this with 
anesthesiologists; we have seen this with the family practice 
docs. Just this week, 12 nurses in New Jersey have been forced 
to participate in abortion in the workplace and there is a suit 
being brought at the medical school there. This is a pattern 
that concerns all of us because we have 16,000 members. They 
have over 125,000 doctors that we are in regular communication 
with. They are very concerned about this and it could affect 
healthcare in this country.
    Mr. Pitts. Thank you. My time has expired.
    The Chair recognizes the ranking member, Mr. Pallone, for 5 
minutes for questions.
    Mr. Pallone. Thank you, Mr. Chairman.
    I would ask unanimous consent to insert in the record 
statements from the following organizations: Concerned Clergy 
for Choice; National Council of Jewish Women; Religious 
Institute; United Church of Christ--Justice and Witness 
Ministries; Women's Alliance for Theology, Ethics, and Ritual, 
or WATER; Physicians for Reproductive Choice; Religious 
Coalition for Reproductive Choice; General Board of Church and 
Society of the United Methodist Church. I believe you have all 
these.
    Mr. Pitts. Without objection, so ordered.
    [The information follows:]

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    Mr. Pallone. Thank you.
    I am going to start with Mr. O'Brien. Your testimony 
discusses use of contraceptive services among both Catholic and 
non-Catholic women. Is it your understanding that surveys and 
studies have shown virtually all Catholic women have used 
contraceptive services at some point in their lifetimes?
    Mr. O'Brien. Yes, Congressman, that is correct.
    Mr. Pallone. Thank you. Is it true that the use of 
contraceptive services among Catholic women mirrors that of 
non-Catholics?
    Mr. O'Brien. It is.
    Mr. Pallone. And I am going to go to Dr. Hathaway. I saw a 
recent poll of registered voters about their views on 
contraceptive services. I want to ask you a few questions about 
public support for contraception. Do the vast majority of 
Americans support access to contraceptive services?
    Mr. Hathaway. Yes.
    Mr. Pallone. And is this same view also held by people who 
are opposed to abortion?
    Mr. Hathaway. Yes, indeed.
    Mr. Pallone. And back to Mr. O'Brien, if you would chime 
in. Does research indicate that the majority of Catholics 
support access to contraceptive services?
    Mr. O'Brien. Yes, during the health insurance reform 
debate, Catholics were surveyed, and 6 in 10 Catholics believe 
that contraception should be covered as part of health 
insurance.
    Mr. Pallone. Thank you. For both gentlemen, your answers 
underscore an important point, and that is that improved access 
to contraceptive services is supported by the majority of 
Americans, and I certainly agree with some of the comments made 
by my colleagues and the witnesses about ensuring that 
individual health providers not be compelled to act against 
their conscience, but the subject of today's hearing is 
regulations that address what plans are required to do. Given 
what we have heard today, I think we should support coverage 
for contraceptive services and make these services available to 
the millions of women who would benefit from it.
    Now, I want to go to Dr. Hathaway again. In your testimony, 
you discuss the importance of making sure that women have 
access to contraceptive services and information that will help 
them better plan and space their pregnancies. Can you briefly 
describe the benefits of using contraceptive services?
    Mr. Hathaway. Briefly would be difficult. There are 
multiple, multiple benefits towards contraception. A woman's 
ability to maintain and get herself healthy before pregnancy is 
incredibly important--taking folate to reduce anomalies, 
getting her medical conditions under control. Many women have 
multiple medical conditions that are out of control before they 
get pregnant.
    Mr. Pallone. What about in terms of babies' health?
    Mr. Hathaway. Also. Birth spacing is incredibly important. 
We know from research that birth spacing, the shorter the 
interval, the greater likelihood of low weight births as well 
as preterm births, an incredible burden to both the family as 
well as society and the health industry.
    Mr. Pallone. Well, you know there are over 60 million women 
of reproductive age in the country but there are many women who 
do not use contraception regularly or at all. Could you 
elaborate on the extent to which cost is a barrier to the use 
of contraceptive services?
    Mr. Hathaway. It is an incredible barrier. Many women have 
to jump hoops to get contraceptives. If they have some 
insurance, perhaps it doesn't cover all of their contraceptive 
methods. And as I pointed out in my testimony, the longer-
acting methods are the most cost-effective and yet the most 
cost-prohibitive up front and those are the methods that we 
ought to be turning towards to provide better contraception in 
our country.
    Mr. Pallone. And what about when you have insurance 
coverage for contraception? I mean does that impact the ability 
of women to access those health services?
    Mr. Hathaway. In many cases, yes. Even insurance there are 
restrictions regarding copays, as well as additional fees for 
these, as I said, most effective methods.
    Mr. Pallone. And based on your clinical experience, do you 
believe that elimination of out-of-pocket costs for birth 
control pills and other forms of contraception would increase 
their use?
    Mr. Hathaway. Most definitely. Most definitely.
    Mr. Pallone. All right. I just want to thank you, Dr. 
Hathaway. I mean it is clear from your testimony and responses 
that there are compelling policy reasons why we should promote 
access to contraception and also limit cost-sharing associated 
with those services.
    Thank you and thank you to Mr. O'Brien.
    I yield back, Mr. Chairman.
    Mr. Pitts. The Chair thanks the gentleman and recognizes 
the vice chair of the subcommittee, Dr. Burgess, for 5 minutes.
    Mr. Burgess. Thank you, Mr. Chairman.
    Dr. Hathaway, along the lines as Mr. Pallone was just 
exploring, they said that there are valid policy reasons to 
consider providing contraception, but you also allude to the 
fact that in your world cost is a consideration. Is that 
correct?
    Mr. Hathaway. I am not sure I understand the question. Cost 
as a consideration for an individual patient?
    Mr. Burgess. You talk about the individual in your clinic 
who wanted a long-term method of contraception but it nearly 
exhausted your safety net dollars----
    Mr. Hathaway. Right.
    Mr. Burgess [continuing]. And cost is an issue whether we 
like it or not. Money has got to come from somewhere, has it 
not?
    Mr. Hathaway. Indeed. And yet if you look at a lot of the 
research, including Guttmacher Institute's research on cost 
savings for contraception overwhelmingly----
    Mr. Burgess. Yes, let us hold that. We will get to that in 
a minute because I am not quite sure we have delivered on the 
promise of the cost savings. And of course, we are Members of 
the House of Representatives. We live under the rule of the 
Congressional Budget Office and as all of us on both sides of 
the dais know, we are not allowed to score savings. We can only 
talk about cost. That is an important point; I do want to get 
to it.
    But here is my beef with this thing. I mean it came to us 
as an interim final rule. There was obviously a rush. There 
were some calendar considerations. We have got to get it done 
within some certain time constraints, but it didn't really 
allow for the proper input and transparency of the normal 
Federal agency process. The Affordable Care Act is a lot of 
pages of very densely worded instructions to Federal agencies, 
and whether you agree with or not, going through the process at 
the Federal agency, there is a reason that it does that because 
it allows the public to comment. Before the rule is put 
forward, it allows for the people to weigh in on it.
    But in an interim final rule, that is kind of a different 
world because although it sounds like, well, it is only 
interim. Either you come back and do--you really can't. I mean 
this thing comes out of the agency with the force of law and 
you see right now in this environment how difficult it is for 
Congress, the House and Senate to get together and pass any law 
that the President will sign, but this thing can come out with 
the force of law in a relatively condensed period of time with 
maybe public input but maybe it ignores public input.
    Now, I worked my residency with Parkland Hospitals--a long 
time ago I grant you--but we provided a lot of healthcare to 
women who were very, very poor and I never wrote a prescription 
for an oral contraceptive except Ortho-Novum 1/50 for 4 years' 
time because that was the formulary that Parkland Hospital 
used. In order to provide the services for the vast numbers of 
people that they had to serve, they got a deal with the 
contraceptive manufacturer, and that was the birth control 
pill. It was a learning experience for me to be out in private 
practice and see all of the choices that were out there.
    But those choices come with a cost, don't they?
    Mr. Hathaway. Yes. Yes, indeed.
    Mr. Burgess. Can you give us an idea of what kind of the 
range of cost? Let us just stick with oral contraceptives for 
right now. I know you are interested in long-term 
contraception, but just for oral contraceptives right now, 
there is a pretty wide variation of cost, is there not?
    Mr. Hathaway. Yes, the brand name contraceptives probably 
run in the neighborhood of upwards of $50 per month.
    The generics have probably in the neighborhood of 30 or 
somewhere in that neighborhood.
    Mr. Burgess. Well, through the miracle of the iPad and 
Leslie's List, I can tell you that there is a cost differential 
of about $20 a month for a generic Ortho-Novum 1/35, Necon--
funny name for that pill--and there is another one called 
Seasonique that is, according to research done by my staff, 
$1,364 a year, so about $110 a month. So that is a pretty wide 
discrepancy, isn't it?
    Mr. Hathaway. Indeed, and yet if we were able to help a 
woman with a longer-acting method for that year, you would 
save----
    Mr. Burgess. Let us not go there just yet because----
    Mr. Hathaway [continuing]. A lot of dollars right there----
    Mr. Burgess [continuing]. The Institute of Medicine and the 
interim final rule says without regard to cost, we have to 
provide all methods now across the board. And this is the 
problem with having an interim final rule. I didn't get to go 
to the Federal agency and say you know what? This is a pretty 
wide cost discrepancy here. You can provide 5 women with the 
same type of oral contraceptive protection that one woman gets 
for Seasonique. And there are reasons that patients want to 
take that. I get that. Perhaps it should be available with a 
copay or paying a little extra for that premium contraceptive 
coverage. This would be something that I think would have been 
useful to the Federal agency. But unfortunately, we didn't get 
to have input on that because it was promulgated as an interim 
final rule.
    Mr. Chairman, you have been generous with my time. If we 
have time for a second round, I do want to talk about the cost-
benefit stuff.
    Mr. Pitts. The Chair thanks the gentleman and now 
recognizes the ranking member emeritus, Mr. Dingell, for 5 
minutes.
    Mr. Dingell. And the questions here I direct at Mr. 
O'Brien, and I hope that the answers will be by yes or no.
    The interim rule issued by HHS on August 3, 2011, regarding 
coverage of preventive services under ACA included language 
that exempted certain religious employers from covering 
contraceptive services without cost sharing. A religious 
employer is defined by one that has religious values as the 
purpose of the organization, primarily employs and serves 
persons who share the religious tenets of the organization, and 
is a nonprofit organization. Isn't it true that this definition 
of religious employer is set forth by HRSA and the interim rule 
is not wholly a new definition of a religious employer? Yes or 
no?
    Mr. O'Brien. Yes, Congressman.
    Mr. Dingell. Now, isn't it also true that the 20 States 
that exempt certain religious employers from having to cover 
contraceptives that they allow them to be exempt from providing 
contraceptive services, and at least half of these States use a 
definition of a religious employer similar to that in the 
definition used by HRSA in the interim final rule? Yes or no?
    Mr. O'Brien. Yes.
    Mr. Dingell. Isn't it also true that 2 State Supreme Courts 
in California and New York upheld a definition of religious 
employer similar to the definition of a religious employer in 
the legislation as constitutional? Yes or no?
    Mr. O'Brien. Yes.
    Mr. Dingell. So I think everybody in this room should agree 
that individuals have the right to decline to provide certain 
medical treatment if they conscientiously object to their 
religious beliefs. That is not interfered with under the 
regulations, is it?
    Mr. O'Brien. Yes.
    Mr. Dingell. The answer is it is not interfered with.
    Mr. O'Brien. No.
    Mr. Dingell. Thank you. And under current healthcare 
professionals who conscientiously object to providing certain 
medical services or procedures due to their religious beliefs 
are allowed to again not to provide those services, is that 
right?
    Mr. O'Brien. That is right.
    Mr. Dingell. But isn't it true that the broadening 
definition of a religious employer would allow an employer, say 
a hospital or health insurer, to deny coverage for 
contraceptives or other preventive services based on their 
religious beliefs? Yes or no?
    Mr. O'Brien. Yes.
    Mr. Dingell. Now, isn't it also true that the broadening of 
the religious exemption would limit access to contraceptives to 
nearly 1 million people and their dependents who work at 
religious hospitals and nearly 2 million students and workers 
at universities with a religious affiliation? Yes or no?
    Mr. O'Brien. Yes.
    Mr. Dingell. One of the ways the Affordable Care Act works 
to address the need of lowering costs in our health system is 
by putting renewed emphasis on prevention and wellness programs 
to help American families to live healthier lives and reduce 
the need for more costly treatments later in life. The 
Affordable Care Act does this by eliminating copays and cost-
sharing for preventive service. Is that correct?
    Mr. O'Brien. Yes. Yes.
    Mr. Dingell. And he doesn't have a nod button so you have 
got to answer yes or no. HHS has asked the Institute of 
Medicine, an independent organization who is convening a panel 
of experts to make recommendations about what preventive 
services for women would qualify for no cost-sharing. The 
Institute of Medicine identified 8 preventive services as being 
necessary to improving women's health and well being, including 
all FDA-approved contraceptive methods and patient education 
counseling, amongst other benefits. HHS adopted these 
recommendations in full, is that correct?
    Mr. O'Brien. Yes.
    Mr. Dingell. Now, wouldn't you agree that--by the way, is 
that yes or no?
    Mr. O'Brien. Yes.
    Mr. Dingell. Wouldn't you agree that broadening the 
religious exemption would limit or prevent access to critical 
preventive services that are intended to improve the health and 
well being of women? Yes or no?
    Mr. O'Brien. Yes, absolutely.
    Mr. Dingell. Now, wouldn't you also agree that the limiting 
or preventing of access to critical preventive services is 
counter to the goal of the Affordable Care Act to help make 
prevention affordable and accessible to all Americans? Yes or 
no?
    Mr. O'Brien. Yes, that is true.
    Mr. Dingell. Now, I note in the testimony that I have heard 
this morning, I have heard no complaints that what we have done 
here is to expand the right to abortion or to change the basic 
language of the legislation in the Affordable Care Act on that 
point. Am I correct in that understanding?
    Mr. O'Brien. You are correct.
    Mr. Dingell. Thank you.
    Mr. Chairman, I note I yield back 2 seconds.
    Mr. Pitts. The Chair thanks the gentleman and recognizes 
the gentleman, Mr. Shimkus, for 5 minutes for questions.
    Mr. Shimkus. Thank you, Mr. Chairman.
    About a year ago, we had some theologians here on climate 
change and I quoted some scripture, got myself in trouble, made 
myself a name. But I mean if we are going to go down the right 
and talk about safe--and especially for Christians, God's word 
is the final arbiter of truth. Jeremiah 1:5, ``before I formed 
you in the womb, I knew you.'' Psalm 71:6, ``you brought me 
forth from my mother's womb.'' Those are just a few of numerous 
scripture references on the pro-life debate for confessional 
Christians, and this is where I really appreciate my fellow 
Christians in the Catholic Church. I am Lutheran by faith 
tradition, so hold a really distinct close bond. But there is a 
strong position on the right to life.
    And what we have done in the national healthcare law has 
attacked the very providers of healthcare and social services 
for the poor in this country, which are church, faith-based 
institutions. And Mr. O'Brien, what we are doing is we are 
depriving them of their choice. That is what we are doing. And 
Illinois as aside has just done this in the adoption realm 
where now the Catholic Church is suing the State of Illinois 
because of now the Illinois legislation that grants same-sex 
couples under the State law all the rights of married couples. 
So when a faith-based institution like a Christian 
denomination--and in this case, Catholic charity does 20 
percent of all adoptions in the State of Illinois--you take the 
other faith-based, I think it is up to 33 percent, they now 
have to make a moral decision of whether they are going to 
continue adoption services or comply with their faith-based 
teachings. So that is going on in Illinois. That is exactly 
what is going on here with the healthcare law. So I will follow 
up with these questions.
    To Ms. Belford, Mr. Cox, Mr. Stevens, should individuals or 
institutions lose their rights to follow their moral and 
religious beliefs once they decide to enter a healthcare 
profession? Ms. Belford?
    Ms. Belford. No, they should not lose that right.
    Mr. Shimkus. Mr. Cox?
    Mr. Cox. Absolutely not.
    Mr. Shimkus. Mr. Stevens?
    Mr. Stevens. We shouldn't be asking our medical schools to 
ethically neuter healthcare professionals based upon only what 
the State decides is right.
    Mr. Shimkus. To the same three, should we compel providers 
to act in violation of their conscience?
    Mr. Cox. Absolutely not. It is a violation of the First 
Amendment to the Constitution.
    Mr. Shimkus. OK. That was Mr. Cox. Ms. Belford?
    Ms. Belford. No. No, we shouldn't. That is a right 
enshrined in our history, in our Constitution, in our laws the 
right not to violate our firmly held, sincerely held religious 
beliefs.
    Mr. Shimkus. And Dr. Stevens?
    Mr. Stevens. I agree. We cannot ask people to take 
professional license and lay aside their personal morality.
    Mr. Shimkus. Another question. When a provider makes a 
conscious objection, is there anything that prevents a patient 
from going to another willing healthcare provider for service? 
Dr. Stevens?
    Mr. Stevens. Absolutely not.
    Mr. Shimkus. Ms. Belford?
    Ms. Belford. No.
    Mr. Shimkus. Mr. Cox?
    Mr. Cox. No.
    Mr. Shimkus. Ms. Belford, in order to qualify for the 
religious employer exemption to HHS's interim final rule on 
preventive services, an employer would have to meet all 4 
criteria delineated in the rule, including that it primarily 
serves persons who share its religious tenets. What would be 
the impact on sick and needy people in the Archdiocese in 
Washington if the Archdiocese organizations had to limit the 
provision of their services in such a manner?
    Ms. Belford. Well, Congressman, let me just say right at 
the outset we have served, we are serving, and we will continue 
to serve the people who need help. We would hope that our 
government would recognize the value of those services and the 
importance of those services and the right that has been 
granted to us under the Constitution and the laws of this 
country to be able to provide those services without violating 
our religious beliefs. But we will serve. We have been here for 
hundreds of years in this country serving. One of our oldest 
agencies in the Archdiocese is St. Ann's Infant and Maternity 
Home. It was chartered by President Lincoln and it is still 
here serving. We will be here.
    Mr. Shimkus. And let me personally thank you for your 
service.
    And I yield back.
    Mr. Pitts. The Chair thanks the gentleman and recognizes 
the gentlelady from Illinois, Ms. Schakowsky, for 5 minutes for 
questions.
    Ms. Schakowsky. I just wanted to note the number of 
religious organizations that Mr. Pallone inserted testimony 
into the record, and I note that one of them was the National 
Council of Jewish Women, which I am a proud member of.
    So let me understand from Dr. Stevens and Ms. Belford and 
Mr. Cox. We are not talking about--as my colleague from 
Illinois was saying--individual healthcare providers. You are 
talking about healthcare systems, am I right? Institutions and 
networks of institutions that would be exempted from having to 
provide contraception, is that true, Dr. Stevens?
    Mr. Stevens. Yes.
    Ms. Schakowsky. Ms. Belford?
    Ms. Belford. In the case of the Archdiocese of Washington, 
we conduct our ministries through separate organizations, but 
in addition to what we as church do----
    Ms. Schakowsky. In your testimony are you asking to expand 
it?
    Ms. Belford. Excuse me?
    Ms. Schakowsky. In your testimony are you saying that the 
narrow exemption should be broadened if not dropped and to 
include systems as well and broader----
    Ms. Belford. It should include religious organizations that 
operate in accordance with their teachings and beliefs, yes.
    Ms. Schakowsky. And Mr. Cox, hospital systems as well and 
hospitals?
    Mr. Cox. The definition puts HHS in the position of 
trolling through the religious beliefs and practices of 
religious organizations----
    Ms. Schakowsky. So that would include institutions?
    Mr. Cox [continuing]. And determining, Congresswoman, which 
ones it agrees with and which ones it doesn't agree with, and 
if it doesn't agree with them, then it uses the force of law to 
compel that organization to follow its beliefs.
    Ms. Schakowsky. And let me ask the three of you, then, if 
this regulation were not changed, would you drop your health 
insurance coverage? Dr. Stevens?
    Mr. Stevens. I think it would be something we would have to 
consider because it is a problem when you are dispensing an 
abortifacient and paying for it. It is called moral complicity.
    Ms. Schakowsky. OK. Ms. Belford?
    Ms. Belford. It is unthinkable that we would drop our 
health insurance coverage but we would not provide coverage for 
contraception and sterilization as required by this law.
    Ms. Schakowsky. Mr. Cox?
    Mr. Cox. We will have to challenge it in court if it isn't 
dropped.
    Ms. Schakowsky. OK. So I just want to make sure that the 
word goes forth into the country that this is about depriving 
women of contraception by large hospital systems, smaller 
organizations, and potentially even all healthcare coverage for 
the employees of those organizations despite the fact, as it 
was pointed out, that all but perhaps 5 percent of Catholic 
women also use contraception, that virtually all Americans in 
recent surveys--women--use contraception.
    Mr. O'Brien, this issue of conscience is so important 
because I perceive that as an individual right of conscience, 
can you elaborate on the difference between individuals and 
institutions and the right of conscience that you mentioned 
before?
    Mr. O'Brien. You are absolutely correct, Congresswoman.
    I think one of the things that is interesting about this is 
the Catholic Church is not actually asking for an exemption. 
The Catholic Church is all of the people in the Church, which 
includes the 98 percent of Catholic women who use a 
contraceptive. The consciences of these women, of the people in 
the Church, are absolutely essential. The Catholic hierarchy, 
the United States Conference of Catholic Bishops, represents 
about 350 bishops. It is the bishops and the people involved in 
the Catholic healthcare industry who are asking for these 
exemptions. The conscience of an individual within Catholicism 
and St. Thomas Aquinas told us very clearly that it is a mortal 
sin not to follow your conscience, your individual conscience, 
even if you have to go against church teaching. I think that 
Catholics do that every day on an individual basis. The idea 
that an institution or a health insurance plan in some way has 
a conscience and there is no tradition of that and the reality 
is that conscience is applied to real people and individuals.
    Ms. Schakowsky. And since we are getting into very personal 
and private matters dealing with women, I am just curious from 
Dr. Stevens, Ms. Belford, and Mr. Cox, do you have any problem 
with the insurance companies providing prescription drugs for 
erectile dysfunction, Cialis or Viagra? Just curious.
    Mr. Stevens. I don't have any problem at all. I also don't 
have any trouble with contraceptives, most of them, but that 
doesn't mean I am going to prescribe all of them or that my 
Catholic brothers and sisters should not have the right to 
decide they are not going to pay for them.
    Mr. Cox. Our plans don't cover those services.
    Ms. Belford. I think as I indicated, Congresswoman, in my 
testimony, our plan does not cover contraceptive coverage, 
sterilization, and the drugs that are mandated here.
    And if I would just add I recognize that the teachings of 
the Catholic Church on procreation and life may not be the 
majority view and may not be popular, but I also understand 
from all the testimony that I have just heard this morning that 
contraception is widely available and universally used. So the 
issue here is not whether or not women are using it or have 
access to it. The issue for me and why I came here today is 
because the Catholic Church has a teaching about procreation 
and life and we are talking about whether us as an employer, 
the Archdiocese of Washington, would be required to provide 
coverage for something that we teach is morally wrong. I know 
not everyone----
    Ms. Schakowsky. And I hope you would inform all of your 
women employees of that policy. Thank you.
    Mr. Pitts. The Chair thanks the gentlelady and recognizes 
the gentleman from Pennsylvania, Dr. Murphy, for 5 minutes.
    Mr. Murphy. Thank you, Mr. Chairman.
    Dr. Hathaway, in your testimony you spoke of your many 
uninsured patients and the cost they face to excess 
contraceptives, just to be clear, because this interim final 
rule is directed at those providing insurance, nothing in this 
rule would actually change your uninsured patients' ability to 
access contraceptives, is that correct?
    Mr. Hathaway. I am not a legal scholar and I can't truly 
point to that, but I do know----
    Mr. Murphy. They would still have access to that?
    Mr. Hathaway. Access and copays and coverage for some of 
the most effective methods are prohibitive for many, many, many 
insured and uninsured women in our country. It is----
    Mr. Murphy. I am asking under this interim rule, would 
nothing that would change the uninsured patient's ability to 
access contraceptives in this?
    Mr. Hathaway. I think it would.
    Mr. Murphy. Excuse me. Now, there are many business owners 
in my district guided by their faith who are struggling with 
whether or not they can continue to provide health insurance to 
their employees in light of this new rule. Do you honestly 
think that thousands of individuals and families in my district 
who could lose their health insurance altogether are really 
better off as a result of this rule?
    Mr. Hathaway. I feel that this rule, in the Institute of 
Medicine's evidence-based looking into this issue is pretty 
clear that removing copays, removing cost barriers will have a 
dramatic positive impact on reducing unintended----
    Mr. Murphy. And the issue before us here is also one of 
people's ability to practice their faith, that the government 
is not saying that people cannot access these at all, but the 
question really before us is whether or not government has the 
right to force faith-based hospitals or clinics or providers or 
employers certain services that violate their church teachings. 
And the question is whether the Secretary of HHS can act 
unilaterally to force employers, medical providers, hospitals, 
clinics, and others to act in ways that violate their faith and 
conscience.
    And to that, Mr. O'Brien, I strongly disagree with your 
analysis of the Catholic Church. Conscience is at the core of 
Catholic teaching, you said, but slavery was not left to 
personal decisions and conscience, thank goodness.
    Conscience, according to Father Anthony Fisher, tells us 
that ``it is the inner core of human beings whereby, compelled 
to seek the truth, they recognize there is an objective 
standard of moral conduct and they make a practical judgment of 
what is to be done here and now in applying those standards.'' 
That and I think, too, it teaches us the moral character of 
actions is determined by objective criteria not merely by the 
sincerity of intentions or the goodness of motives. And the 
church of the modern world and all people are called to form 
their conscience accordingly and to fit with it as opposed to 
rewrite their image of the church and of the Lord's teachings. 
It is not--I repeat--it is not our duty as Catholics to tell 
God what he should do or the image that he should adhere to or 
what he should think, but it is up to us to shape our 
conscience to conform with the teachings he has given us.
    When Moses came down with the 10 Commandments, he didn't 
put it up for a vote or ask for a referendum or say to people, 
so what do you think, folks? Our life is spent in continuous 
struggle to learn that which is good and conscience is not 
merely to declare it in terms of humanism and then form some 
image of God based upon some desires. Conscience, sir, is not 
convenience.
    Father Fisher goes on to say that ``deep within their 
conscience, human persons discover a law which they have not 
themselves made but which they must obey. Conscience goes 
astray through ignorance and the key here is to shape our 
conscience to conform to the laws of God, not to practicality 
or solecism.'' ``Conscience,'' he goes on to say, ``is formed 
through prayer, attention to the sacred, and adhering to 
certain teachings of the church and the authority of Christ 
teachings in the church.'' Conscience is not that which 
described by Shakespeare when he says in Hamlet ``nothing is 
either good or bad but thinking makes it so.''
    So asking a group in a survey whether or not they have ever 
acted or thought of acting a certain way that runs counter to 
the church's teachings is no more a moral code than asking 
people if they ever drove over the speed limit as a foundation 
for eliminating all traffic laws.
    With that, I end with a quote from John Adams, which he 
said in 1776 when he was writing our Declaration of 
Independence of the United States. He said, ``it is the duty of 
all men in society, publicly and at stated seasons, to worship 
the Supreme Being, the Creator and Preserver of the universe, 
and no subject shall be hurt, molested, or restrained in his 
person, liberty, or estate for worshipping God in the manner 
most agreeable to the dictates of his own conscience or for his 
religious profession, or sentiments provided he doth not 
disturb the public peace or obstruct others in their religious 
worship.'' The foundation of our Nation is not to impose laws 
which restrict a person's ability to practice their faith, sir.
    With that, I yield back.
    Mr. Pitts. The Chair thanks the gentleman and recognizes 
the gentlelady from California, Ms. Capps, for 5 minutes.
    Mrs. Capps. Thank you, Mr. Chairman.
    One thing that does trouble me in today's testimony is some 
confusion about what the preventive service rule applies to and 
what it doesn't. I would like to set the record straight as I 
understand it. The rule we are discussing today is whether or 
not an employer--as in a hospital or university system--can ban 
the coverage of a medical service but it would not mandate that 
any individual prescriber's control or that any woman or man 
take birth control. Period. Today's hearing is yet another 
example of how out of touch the majority side is with the 
American people. My constituents tell me that we should be 
spending our time here considering jobs and the economy, not 
blocking women's access to contraceptive services. But instead 
here we are again poised to attack another important piece of 
the healthcare law to rile up an extremist constituency at 
women's expense.
    The Institute of Medicine report illustrates the strong 
evidence and sound science that proper birth spacing and 
planning of pregnancies does improve the health of a woman and 
her future children. The HHS rule then translates the science 
into provisions to give women options to choose if, when, and 
how to space their pregnancies, something they should be 
discussing with their medical provider, not with their boss. As 
we have heard, especially in these tough economic times, women 
are sometimes forced to choose between paying for their birth 
control prescription or paying for other necessities. These 
economic concerns are the threat to public health we should be 
discussing, not whether or not your boss' conscience is more 
important than your own.
    Now, Mr. Cox, I want to praise the good work of your 
institutions in California because many of them are serving my 
constituents in my congressional district----
    Mr. Cox. Thank you.
    Mrs. Capps [continuing]. On the central coast. In your 
testimony you say that you represent Catholic healthcare 
organizations in California, including 54 hospitals. Is that 
correct?
    Mr. Cox. That is correct.
    Mrs. Capps. So to be clear, you are not speaking for or 
representing the views of all Catholic hospitals or nursing 
homes in the United States?
    Mr. Cox. No, but I would believe that my views would be 
consistent----
    Mrs. Capps. Right, but you do not represent any other than 
the ones in California.
    Mr. Cox. That is correct.
    Mrs. Capps. As I understand it, California has a 
requirement for coverage of contraception that is very much 
like the one that HHS has now proposed, and that includes the 
religious exemption that you are now saying is too narrow. I 
also understand that this coverage requirement has been 
reviewed by the California Supreme Court and found not to be 
religious discrimination and that the United States Supreme 
Court refused to review that decision. So my question to you, I 
assume that your hospitals in their role as employers comply 
with the California law and do provide insurance coverage for 
your employees for contraceptive services. Is that correct?
    Mr. Cox. Most of our members have moved or are moving 
towards self-insurance under ERISA, which would be denied to us 
by the HHS rule.
    Mrs. Capps. But they do now?
    Mr. Cox. Pardon?
    Mrs. Capps. They do now?
    Mr. Cox. Yes, they either have or are moving towards----
    Mrs. Capps. But they do now use it?
    Mr. Cox [continuing]. Self-insured ERISA plans in order to 
get out from under----
    Mrs. Capps. But they do provide insurance coverage now as 
required?
    Mr. Cox. Yes, of course, we do.
    Mrs. Capps. OK. I wondered if you would tell us all have 
any of your hospitals closed as the result of this requirement? 
Yes or no, please.
    Mr. Cox. We have other options.
    Mrs. Capps. So they have not.
    Mr. Cox. They have not.
    Mrs. Capps. Have any of your hospitals dropped insurance 
coverage for its employees as a result of this requirement?
    Mr. Cox. No.
    Mrs. Capps. Have any of the Catholic bishops severed ties 
with your hospitals over this requirement?
    Mr. Cox. No.
    Mrs. Capps. Thank you.
    Now, I would like to address Mr. Hathaway. I only have a 
few seconds left, but if there was an expansion of refusal 
provisions for employers, in some estimates that would affect 
over a million employees and their families. Where would these 
women go for their care?
    Mr. Hathaway. My guess is they would end up in a safety net 
system somehow and struggle to make ends meet.
    Mrs. Capps. Like a Title X?
    Mr. Hathaway. Right.
    Mrs. Capps. And a clinic like the one you describe with 
certain patients that you serve gets Title X funding to provide 
these services for women who can afford them?
    Mr. Hathaway. Correct.
    Mrs. Capps. Thank you.
    Mr. Hathaway. I think it should be pointed out that the 
areas of the United States where there is less access to 
healthcare are also the areas where there is higher epidemic 
rates of unintended pregnancies, and those are the population--
if I am here representing anyone, I am representing the 
thousands of women that I have seen daily that just don't have 
access to good healthcare. And I truly hope we can move forward 
on this Preventive Care Act.
    Mrs. Capps. That is exactly what I wanted to allow you the 
opportunity to say because as a former public health nurse in a 
school system I see those faces before me every single day as I 
serve here in Congress. Thank you very much.
    Mr. Hathaway. Thank you.
    Mrs. Capps. I yield back.
    Mr. Pitts. The Chair thanks the gentlelady and recognizes 
the gentlelady from Tennessee, Ms. Blackburn, for 5 minutes.
    Mrs. Blackburn. Thank you, Mr. Chairman, and thank the 
panel for their time.
    Dr. Stevens, I want to talk with you for a couple of 
minutes, but before I do, the gentlelady from California 
mentioned that we should be talking about jobs. I would like to 
say that straightening out this Obamacare bill is a way for 
us--to repeal it, to replace it is a way to deal with jobs 
because we heard from CBO that passage of this bill would cost 
us about 800,000 jobs. So I appreciate that we are looking at 
the dynamic that this has.
    But Dr. Stevens, I want to talk with you. Since you are 
from Tennessee and you are familiar with the impact that 
TennCare program had on Tennesseans, I want to look at this 
access-to-care issue because as I have told my colleagues here 
in this committee many times over the past few years that what 
we saw happen in Tennessee was individuals had access to the 
queue but they didn't have access to the care. And there is an 
enormous difference that is there. On the contraceptive 
mandate, I want to be certain that I am quoting you right. And 
your quote was, ``it violates the religion and free speech 
clauses of the First Amendment of the Constitution by coercing 
faith-based healthcare ministries to not only violate the very 
faith-based tenets that have motivated patient care for 
millennia but also to pay for that violation. Such conscience-
violating mandates will ultimately reduce patients' access to 
faith-based medical care, especially depriving the poor and 
medically underserved populations of such care.''
    Mr. Stevens. That is very much the case. You know, the 
intention may be to expand coverage, but actually what this is 
going to do I believe if it is carried forward will reduce care 
as faith-based professionals, because they are forced into a 
situation, begin not providing those services or not providing 
insurance for the staff that are working with them. So that is 
a great concern because the bottom line is we want to take care 
of the poor, we want to provide good services, but we cannot 
violate our conscience.
    Mrs. Blackburn. OK. And you also noted a national survey at 
FreedomToCare.org of over 2,100 faith-based physicians revealed 
that 9 of 10 are prepared to leave the practice of medicine if 
pressured to compromise their ethical and moral commitments. So 
do you believe that this particular mandate could contribute to 
more faith-based providers leaving the medical profession and 
thereby reducing patients' access to medical care? And are you 
concerned that faith-based providers might leave certain or 
particular areas of medical care in especially large numbers?
    Mr. Stevens. I know that is happening. We work on 222 
medical and dental campuses across the country where we have 
student chapters and I remember meeting with 5 students down at 
the University of Texas, 5 girls, and I said what are you guys 
interested in? And they all said OB/GYN. How many of you are 
going into it? Only one. Why not? Because of right-of-
conscience issues, because of pressures in residency, coercion 
to participate in abortions or do things that violate their 
conscience. So we are already beginning to change the face of 
healthcare. The sad thing, Congresswoman, is that I think that 
is what some people want.
    I was debating a Planned Parenthood lawyer on National 
Public Radio on right of conscience; he said you have no 
business being in healthcare if you are not willing to provide 
legal services. And I think there are some that would love to 
see faith-based people out of the whole healthcare equation.
    Mrs. Blackburn. OK. Let me go to Mr. Cox and Dr. Stevens 
and Ms. Belford with this one. And Dr. Stevens, starting with 
you and working across. Let me just ask you--this is a yes or 
no--and then you can explain if you would choose. We only have 
a minute and 45 seconds left. Does this preventive services 
rule adequately protect freedom of conscience?
    Mr. Stevens. Absolutely not. It is the most constrictive 
thing we have had in Federal law in history.
    Mrs. Blackburn. So the fears of the students would be 
realized under that?
    Mr. Stevens. Absolutely.
    Mrs. Blackburn. OK. Ms. Belford?
    Ms. Belford. I agree.
    Mrs. Blackburn. OK.
    Mr. Cox. Completely agree.
    Mrs. Blackburn. Thank you. Thank you very much.
    And with that, I will yield back my time so that we can 
move through the rest of the panel.
    Mr. Pitts. The Chair thanks the gentlelady, recognizes the 
gentleman, Mr. Towns, for 5 minutes for questions.
    Mr. Towns. Thank you very much, Mr. Chairman. Let me thank 
you and the ranking member for holding this hearing.
    The Supreme Court and lower courts throughout this land 
have repeatedly ruled that a law that is applied generally is 
enforceable even if some religious groups oppose the action or 
the inaction that it requires. Let me give you a few examples. 
The Quakers must pay taxes that support wars. Native Americans 
may not use traditional drugs. Mormon men may not have multiple 
wives. Some courts have ruled that the Muslim women must remove 
their veils for photo identification cards and et cetera, et 
cetera, going on and on and on.
    The question for the court is whether the government is 
pursuing a legitimate goal. Family planning is a legitimate 
goal. We have reams of data and medical consensus that family 
planning improves health outcomes for mother and child. We have 
shelves of studies that show that unintended pregnancies are 
likely to result in worse health and are much more likely to 
result in abortion. The government, of course, cannot require 
individuals to use family planning, it cannot require 
individuals to provide family planning, but it can require 
employers to pay for insurance that covers family planning, and 
it should.
    Let me go to you, I guess, Dr. O'Brien. I fully respect the 
rights of an individual provider to exercise his or her 
conscience. However, I believe that this right must be 
carefully balanced by the rights of patients' access to safe, 
legal healthcare. We must be certain that any right of refusal 
provided is solely granted to an individual and not to an 
institution to ensure that we strike the right balance.
    Dr. O'Brien, do you believe that the Affordable Care Act 
refusal clauses have the potential to compromise the health of 
women?
    Mr. O'Brien. I believe the Affordable Care Act is an 
absolutely marvelous initiative that would greatly improve the 
lives and the healthcare of women, men, and families. I think 
the difficulty really comes about when what we are hearing all 
the time is trying to bestow conscience rights on institutions. 
I fully agree with you that with regards to doctors, nurses, 
pharmacists, individuals have a right of conscience. They have 
a right to refuse to provide services.
    If they find themselves in that situation, obviously the 
onus is to ensure that somebody can access those services. 
Because in Catholicism--and also I believe within fair play in 
the United States of America--the idea that someone cannot 
access services, there is something wrong with that. I think 
there is a real difficulty that we didn't hear a lot today from 
some members about the conscience rights of those individuals 
who would be denied service. What these refusal clauses are 
really intending to do would be to have the State sanction 
discrimination against individual workers just because they 
happen to work in an institution that is a Catholic 
institution. The idea that an employer can decide what services 
you do or do not get, I think there is something very wrong 
with that, something very un-American about it.
    Mr. Towns. Right. Thank you very much. I much admit that I 
agree.
    Dr. Hathaway, why do you as a medical professional support 
the ACA preventative coverage provision? As a doctor who 
specializes in women's health, could you please explain why 
unintended pregnancies are considered by doctors a health 
condition? And I only have a few seconds left because I want to 
make a statement in reference to I know we keep using the word 
Obamacare. I am going to suggest for this committee, which is 
the Health Committee, refer to it as President Obamacare. Thank 
you.
    Mr. Hathaway. Yes. Thank you, Chairman.
    Mr. Towns. Thank you.
    Mr. Hathaway. After I had been practicing in a public 
health clinic for several years, I took some time to go to 
public health school and it was for the exact reason as we are 
speaking about today that I found many, many, many women, my 
patients, coming in with unplanned, unintended pregnancies. And 
I felt as though we need to be doing something about that. And 
when this recommendation came out from the Institute of 
Medicine, many of my colleagues throughout the country, OB/
GYNs, family, nurse practitioners, midwives, family medicine 
doctors, pediatricians all to my knowledge are overwhelmingly 
supportive of this recommendation that preventive healthcare 
should include contraception care, family planning care, as 
well as the multitude, 7 or 8 other points that they recommend. 
Public health is an incredibly important issue for our country 
and preventive health is paramount.
    Mr. Towns. I yield back.
    Mr. Pitts. The Chair thanks the gentleman and recognizes 
the gentleman from Georgia, Dr. Gingrey, for 5 minutes.
    Mr. Gingrey. Mr. Chairman, thank you for yielding, and I 
thank our witnesses. I want them to know if they don't already 
know that prior to Congress I spent 26 years practicing 
obstetrics and gynecology in Marietta, Georgia, my hometown.
    I am going to address my first questions to Dr. Stevens, 
Ms. Belford, and Mr. Cox, and I will get each of you to quickly 
answer these questions. They are pretty straightforward yes or 
no.
    Are you aware that President Obama promised every American 
that they could ``keep what they have if they liked it'' when 
referring to health insurance?
    Mr. Stevens. Yes.
    Ms. Belford. Yes.
    Mr. Cox. Yes.
    Mr. Gingrey. And the second question for the same three, I 
referenced the Catholic hospitals in my opening statement. Does 
this interim rule in your opinion support President Obama's 
promise that workers, including the 750,000 of the Catholic 
Hospital Association, could keep what they have if they like 
it?
    Mr. Stevens. No.
    Ms. Belford. No.
    Mr. Cox. No.
    Mr. Gingrey. Thank you. The next question I want to address 
to Mr. O'Brien. Mr. O'Brien, you stated that you believe in 
choice and Mr. Waxman referenced in his statement the need for 
employees to have the choice to access services. I am glad to 
hear that because I basically agree with the two of you. I also 
believe that choice is a two-way street, both to do and not to 
do.
    In 2014, according to supporters of the new health law, 
President Obamacare, every single person will have numerous 
choices in the health plans through these exchanges. So instead 
of forcing every person to pay for a service they may have a 
moral conscience objection to, Mr. O'Brien, don't you agree it 
would be better to allow them to choose whether they want these 
services and if they want to pay for them?
    Mr. O'Brien. I think that there is a lot of people in the 
United States of America who have problems with taxes, problems 
paying taxes, the amount of taxes they pay. But we don't get to 
pick and choose what we pay and what we don't pay for. Some 
people disagree with the wars, some people disagree with the 
incarceration system in the United States. Other people feel 
that as regards to welfare that they don't feel like paying for 
it. But we do. As a society, this is an important way for 
society to be constructed so that it can actually operate. So 
we don't always get to pick and choose.
    I think the idea that one religious group would receive a 
free pass, I think that that is very unfair and I don't think 
that that is right.
    Mr. Gingrey. Well, I am going to interrupt you because I 
think that your answer is no. And no matter how long you talk, 
the answer is going to be no. It seems to me quite honestly the 
only choice you believe people should have are choices that fit 
with your own philosophical views. The views that you espouse 
are not choices but rather imposing of those views on people 
regardless of their moral or religious views or convictions. 
Quite honestly, Mr. O'Brien, that doesn't sound very American 
to me.
    I am going to go back to Dr. Stevens and Ms. Belford and 
Mr. Cox in the remaining time that I have. In looking at this 
interim rule, I guess that Catholic hospitals and providers 
could limit their hires to Catholics and of course only deliver 
care to Catholics. Is that the healthcare system that we 
ultimately want, one in which Catholics treat Catholics, 
Protestants treat Protestants, Muslims treat Muslims, or should 
this government instead encourage hospitals and providers, the 
doctors, to treat all patients?
    Mr. Stevens. Should encourage to treat all patients.
    Ms. Belford. That is a fundamental tenet of our faith, that 
we care for our neighbor and love our neighbor as ourselves. So 
yes, we should care for all.
    Mr. Cox. It would be inconsistent with our religious 
mission to limit our services only to Catholics.
    Mr. Gingrey. Well, I thank the three of you. I certainly 
agree with that.
    Mr. Cox, I am going to conclude with you in the half-minute 
I have left. Going back to previous questions, can you explain 
the difference between California's law on benefits and the 
impending HHS rule that we are discussing here today?
    Mr. Cox. They are very similar and particularly with 
respect to the definition of religious employers. HHS borrowed 
or utilized the definition that was first developed by 
California in its contraceptive mandate statute. They differ in 
this regard: that you can get out from under the mandate in 
California if you decide not to cover those prescription drug 
benefits in your health insurance plan, and our members are 
also able to self-insure under ERISA. They have been able to up 
until now self-insure under ERISA and get out from under the 
mandate. Also, the California statute does not cover 
sterilization, which the HHS rule does and will compel us to 
cover in our health insurance plans.
    Mr. Gingrey. Thank you, Mr. Cox.
    Mr. Chairman, I yield back. Thank you for your patience.
    Mr. Pitts. The Chair thanks the gentleman and recognizes 
the gentlelady from Wisconsin, Ms. Baldwin, for 5 minutes for 
questions.
    Ms. Baldwin. Thank you, Mr. Chairman.
    I have a few questions for our witnesses but I would like 
to first point out that here we are again, once again in the 
middle of what has been described as the Republican war on 
women. At a time when our committee and our Congress should be 
coming together to put America back to work, putting partisan 
divisions aside in the interest of the people, once again our 
committee is advancing issues that divide Americans, and in 
this case, issues that infringe on women's rights.
    Today, the majority is focusing on yet another effort to 
limit women's access to essential and medically necessary 
treatment options. And in particular, my colleagues would like 
to limit the number of new group or individual health insurance 
plans that will be required to provide preventative services 
for women without cost-sharing requirements. The Affordable 
Care Act makes significant strides in expanding access and 
making healthcare affordable for women. Thanks to this law, 
being a woman can no longer be considered a preexisting 
condition, and thanks to a provision in the Affordable Care Act 
that we are discussing today, women will now have access to 
preventative services that have been too costly for so many up 
until now. That is unless Republicans succeed in their efforts 
to limit the number of health plans that are required to cover 
such preventative services.
    I would like to explore this issue further and ask our 
witnesses some questions. Dr. Stevens, Mr. Cox, and Ms. 
Belford, as you know, I believe Congressman Fortenberry has 
introduced a bill, H.R. 1179, the Respect for Rights of 
Conscience Act. This bill would amend the Affordable Care Act 
such that health plans would not be required to provide 
coverage or pay for coverage for any service that is ``contrary 
to the religious or moral convictions of the sponsor or issuer 
or the plan.'' Just so the record is clear--and this question 
is for each of you--do you support this legislation? Dr. 
Stevens?
    Mr. Stevens. I do support that legislation.
    Ms. Baldwin. Mr. Cox?
    Mr. Cox. We support it.
    Ms. Baldwin. Ms. Belford?
    Ms. Belford. Yes.
    Ms. Baldwin. Thank you. Now, Ms. Belford, as the attorney 
on the panel, I want to ask you some questions related to the 
provision of H.R. 1179. As I read it, an employer can exclude 
from its insurance coverage for its employees coverage of any 
service that is contrary to the religious or moral convictions 
of that employer. So if you can answer the following with a yes 
or no, that would be greatly appreciated with our time 
constraints. Under this language that I quoted, could a plan 
exclude coverage for certain infertility services because the 
plan sponsor has a religious objection to such services?
    Ms. Belford. I can only speak to what our plan provides and 
what our----
    Ms. Baldwin. No, the quoted provision of Mr. Fortenberry's 
bill if it were to be passed into law, I am wondering if under 
that language I quoted could a plan exclude coverage for 
certain infertility services because the plan's sponsor has a 
religious objection to such services?
    Ms. Belford. Hypothetically, I think it probably could.
    Ms. Baldwin. Thank you. Under that language, could a plan 
exclude coverage for alcohol and drug addiction services 
because a plan's sponsor believes that use of alcohol or drugs 
is sinful?
    Ms. Belford. I honestly don't know the answer to that 
question because these are all services that we provide under 
our health plan.
    Ms. Baldwin. But under the language of the Fortenberry 
bill, health plans would not be required to provide coverage or 
pay for coverage of any service that is contrary to the 
religious or moral convictions of the sponsor or issuer. So 
under that language could a plan exclude coverage for alcohol 
and drug addiction because the plan's sponsor believes that the 
use of alcohol or drugs is sinful?
    Ms. Belford. Theoretically. I am not aware of religions 
that do and I guess I would have to look with reference to what 
our Federal laws and constitutional cases have indicated with 
regard to what our moral and religious----
    Ms. Baldwin. So you don't know the answer to that question.
    Ms. Belford. I really don't.
    Ms. Baldwin. OK. Under the language I quoted, could a plan 
exclude coverage for HIV and AIDS patients because the plan's 
sponsor expresses moral objections to homosexuality?
    Ms. Belford. This is a hypothetical question but I just 
have to say in our church we care for all people and we don't--
--
    Ms. Baldwin. That is not the question.
    Ms. Belford. We don't decline services----
    Ms. Baldwin. We are considering legislation that will have 
impacts if passed. Mr. Chairman, would I be able to be granted 
an additional 30 seconds?
    Mr. Pitts. Without objection.
    Ms. Baldwin. Under the language that I quoted could a plan 
exclude coverage for blood transfusions because the plan's 
sponsor is religiously opposed to this medical service even in 
an emergency situation?
    Ms. Belford. I don't know the answer to that.
    Ms. Baldwin. Under this language could a plan exclude 
coverage for unmarried pregnant women because the plan's 
sponsor has a religious objection to premarital sex?
    Ms. Belford. We don't exclude such coverage so I don't----
    Ms. Baldwin. I am not asking about your plan.
    Ms. Belford [continuing]. Know whether that would be the 
case.
    Ms. Baldwin. Well, I hope that you see the point that I am 
trying to make here. The scope of H.R. 1179 is broad enough to 
exclude anything to which an employer decides it is religiously 
or morally opposed. There is absolutely no standard, no 
guidelines in place for making such a decision. This bill would 
also undo State law and it would completely undermine the 
Affordable Care Act.
    Mr. Gingrey. Would the gentlelady yield to me when she has 
a little time?
    Mr. Cassidy. I would point out she is way over 30 seconds.
    Mr. Pitts. The gentlelady's time has expired.
    Ms. Baldwin. Thank you, Mr. Chairman.
    Mr. Pitts. The Chair thanks the gentlelady, recognizes Dr. 
Cassidy for 5 minutes for questions.
    Mr. Cassidy. Folks, I got 5 minutes so if I interrupt you, 
it is not to be rude. It is just because I have 5 minutes.
    Now, Mr. O'Brien, Dr. Stevens raised an interesting point 
of moral complicity, but it appears and frankly if we view the 
employer as merely an extension of the State, we can take 
Representative Baldwin's point and extend it to terrible things 
where the State might demand something terrible and the 
employer is merely an extension, a puppet being dictated by a 
law who would have to comply. So I think this cuts both ways, 
but I gather that you feel as if moral complicity is not an 
issue if an employer is mandated to cover a service which he 
particularly finds objectionable.
    Mr. O'Brien. We think Catholicism and we think----
    Mr. Cassidy. No, no, no, just in general.
    Mr. O'Brien. In general fairness I think that a properly 
formed conscience requires us to have respect for the 
consciences of others. So I think that----
    Mr. Cassidy. That said, we also are responsible for 
ourselves, so if the employer finds something objectionable, 
again, if you say that it is incredible to suggest that a 
healthcare plan has a conscience, but it is not really the 
healthcare plan; it is the purchaser of the healthcare plan 
that has a conscience. I gather that you think it is incredible 
that the purchaser of that healthcare plan would manifest her 
conscience through the benefits covered. Is that correct?
    Mr. O'Brien. I believe that due deference to the 
consciences of others is an essential element----
    Mr. Cassidy. No, but is it correct that you would find it 
incredible that the purchaser of a healthcare plan would 
manifest her conscience as regards with services she would 
elect to cover for employees?
    Mr. O'Brien. I think if you are talking about individuals, 
I believe in the right of individual conscience.
    Mr. Cassidy. So I am thinking of a small business owner, 
she has got 35 employees and she is making a decision as to 
what benefits to cover. It is she that is making it, she is an 
individual, and you find it I gather incredible that she would 
reflect her values through the services provided.
    Mr. O'Brien. I think an employer, a company, an 
institution, I think that the job of an institution is to give 
due deference to the consciences of all----
    Mr. Cassidy. So she is also filing as an S corp. so she is 
actually taking income from the business as her own income. If 
you will there is an identity that is respected in other 
aspects of the law that is recognized by the IRS and others. 
But again, you seem to find it incredible--I am not quite 
getting the yes or no. In fact let me do what Ms. Baldwin did 
or Mr. Pitts, which is a yes or no.
    Do you find it incredible that that small business owner--
--
    Mr. O'Brien. No.
    Mr. Cassidy [continuing]. Would attempt to reflect her 
values in the services she covers.
    Mr. O'Brien. I don't think that an employer has a right to 
insist that their values--for example, if an employer----
    Mr. Cassidy. OK. That is fine. You know, you have made your 
point. You don't think so. Again, I have only 5 minutes.
    Mr. O'Brien. Sorry.
    Mr. Cassidy. So at that point, the employer's conscience 
merely becomes an extension of what the majority party is able 
to put through without an open hearing through HHS. Ultimately, 
that is it, correct? Yes, no?
    Mr. O'Brien. I believe that it is the job of the 
institution to facilitate the consciences of all people.
    Mr. Cassidy. So again all people is interesting because we 
are not really facilitating the conscience of that small 
business owner who would like her values to be reflected in the 
benefits she provides. And you also reject moral complicity. So 
if that small business owner puts out a product, somehow you 
have divorced her from the actions of her company. So if she 
puts out a product which is harmful, there is no moral 
complicity there?
    Mr. O'Brien. I don't think that it is speaking to what the 
actual issue is.
    Mr. Cassidy. No, the question is----
    Mr. O'Brien. The issue is whether----
    Mr. Cassidy. I only have 5 minutes.
    Mr. O'Brien. OK.
    Mr. Cassidy. And so again if we are going to take a 
holistic viewpoint of what this small business owner is doing, 
if she put out something which was known to be harmful, we 
would call that--in terms of a product--we would call that 
morally reprehensible and we would ask her conscience to be 
sharper. But then we can turn around and say she has no right 
to judge what products should be covered by her insurance that 
she provides for her employees. That is a cognitive dissonance.
    That said, let us also make the point, Dr. Hathaway, that 
this is really not about access for preventive services for 
those who are poor. They are currently covered through Medicaid 
and SCHIP, that I have been told IUDs can be placed right after 
delivery, which is a long-term form of birth control. I am not 
an OB/GYN; I am a gastroenterologist, you know, so whatever 
that is worth. But that said, this is not about access for the 
poor, and for those who have coverage, I see that the generic 
birth control pill can cost $14 a month through 340(b) pricing. 
If we are going to say through legislation that everything has 
to be covered equally, then really we are saying to people 
don't choose the $14-a-month pill; choose the $100-a-month 
pill, which is also bad social policy. We just run out of money 
at some point in our good will.
    I yield back. Thank you.
    Mr. Pitts. The Chair thanks the gentleman and we have----
    Mr. Gingrey. Mr. Chairman?
    Mr. Pitts [continuing]. Unanimous consent request from Dr. 
Gingrey for 1 minute to respond since our friend, Ms. Baldwin, 
went 1 minute over, so without objection.
    Mr. Gingrey. And I thank my colleagues for allowing me the 
minute because Ms. Baldwin was going down a line of 
hypotheticals in regard to objection to blood transfusions, 
objection to treating AIDS patients, and I want to make sure 
and I want to particularly direct this to the 3 panelists that 
I asked questions of before in regard to the Catholic principle 
that the intimate relationship between husband and wife is for 
the purpose of procreation of children and not simply 
recreation as a number one principle. And the second principle, 
even more important, the Catholic principle is that life begins 
at conception and should never be deliberately terminated. I 
would think that this is the reason that the three of you are 
opposed to this interim rule and I just want to get your 
response on that because this is a very narrow area in which 
you would be opposed to sterilization, you would be opposed to 
abortion, you would be opposed to your hospital prescribing 
birth control pills or abortifacients. Is that not the crux of 
this problem? Very quickly yes or no.
    Mr. Stevens. Yes.
    Ms. Belford. Yes.
    Mr. Cox. Yes, we have not been covering those services in 
our health insurance plans for a very, very, very long time. It 
is only now that the government comes forward and says we are 
going to require you to abandon that practice and violate your 
conscience.
    Mr. Gingrey. Thank you all very much.
    And Mr. Chairman, thank you for----
    Mr. Pitts. The Chair thanks the gentleman. That concludes 
the first round of questioning. We will go to one follow-up per 
side. Dr. Burgess for 5 minutes.
    Mr. Burgess. Yes, Dr. Hathaway, if I could--and I won't use 
the entire 5 minutes to question. What I am going to ask is 
likely going to require a longer response, and if you wish to 
respond in writing, that is perfectly acceptable.
    But first let me ask you, you talked a little bit in your 
testimony about the amount of money that is spent. Can you tell 
us between Title X, Medicaid, and temporary assistance for 
needy families how much money is spent on family planning by 
the Federal Government every year?
    Mr. Hathaway. I don't know that number.
    Mr. Burgess. But it is a lot, right?
    Mr. Hathaway. I presume so. I don't know that number.
    Mr. Burgess. Yes, I don't either. That is why I am asking 
you but it is likely to be well in excess of a billion dollars. 
In fact it may be a multiple of that. And you referenced----
    Mr. Hathaway. Pardon me, Chairman. I think also we need to 
recognize that what this Institute of Medicine's recommendation 
has to do with is insurers would cover contraceptive family 
planning methods. We are not talking exclusively about public 
assistance programs. We are talking about insurers throughout 
the board. So we are now paying a tremendous amount of money, 
those of us that have private insurance----
    Mr. Burgess. Correct.
    Mr. Hathaway [continuing]. For coverage and we are not 
talking about an incredibly----
    Mr. Burgess. Reclaiming my time. And we are going to pay 
more under the IOM's guidelines. Dr. Cassidy is a 
gastroenterologist. He doesn't prescribe birth control pills, 
but I would submit that if the IOM were to require that 
everyone who comes into his clinic be able to get whatever 
proton pump inhibitor that they want, regardless of cost, 
nobody is going to buy the generic Wal-Mart $4-a-month 
prescription, which is available for the generics of Tagamet 
and Zantac and some of the earlier products. Everyone is going 
to get NEXIUM because that is the best and why wouldn't you 
want to best? But the cost differential is substantial between 
$4 a month to $100 a month. That is going to have the effect of 
driving up the cost of the product for everyone, whether they 
be on public assistance or not. Everyone who is on employer-
sponsored insurance is going to bear the brunt of that cost. 
That is the way insurance works, is it not?
    Mr. Hathaway. My understanding is that insurers, insurance 
systems have formularies for just that reason, to reduce----
    Mr. Burgess. Correct. And that is a good point because that 
is the point I was trying to make with my experience at 
Parkland Hospital. But under the interim final rule, my read of 
the Federal Register is you don't get to use a formulary. You 
get to have any product that is marketed as being used for 
that, and that is the reason for the comparison between Necon 
and Seasonique. There is a vast difference in the price 
differential of those 2 compounds.
    Mr. Hathaway. So can I interrupt?
    Mr. Burgess. Yes.
    Mr. Hathaway. Let me put it this way. It is interesting 
sitting here----
    Mr. Burgess. Well, let me just ask you the question. I have 
Aetna health savings account.
    Mr. Hathaway. Um-hum.
    Mr. Burgess. I use a formulary with them. I only go to 
their Web site and buy the products they tell me I can buy. But 
as I understand it, under the IOM guidelines, there would be no 
such prohibition. There would be no allowance for a formulary 
for contraception, is that correct?
    Mr. Hathaway. I am not aware of that. I don't know that.
    Mr. Burgess. Well, that is my read of the Federal Register.
    Now, again, this is the problem with an interim final rule. 
We didn't get to talk about any of that, we didn't get any 
transparency, and, you know, forgive me if I make the leap of 
faith and say the reason for the interim final rule was 
precisely for these conscience protections that are getting so 
much discussion this morning. There was a reason that they 
followed that trajectory. There is a reason that they went 
there, say, we can't wait past August because we have got this 
to get out there. Well, that is nonsense. This argument is 
going to be going on for a long time and just so you could get 
this year's student population covered under these rules to me 
was not a valid assertion unless you have a political 
calculation that may be geared for November 2012. And that may 
very well have been the case with this, but in the meantime, 
the individuals who claim that their conscience provisions are 
going to be violated--and I think they are exactly right with 
that--they are the ones who are suffering as a consequence of 
what is very bad policy and a very bad way of going about that.
    Let me ask you, though, you mentioned that child spacing 
and that there is a societal benefit and I don't disagree with 
that. I am an OB/GYN myself. I agree with what you are saying 
but I am certainly interested with the billions that we are 
spending on family planning through all areas of the Federal 
Government, what is our return on investment for that? Now, we 
already know, for example, that many of the people who are 
counted as uninsured actually have access to SCHIP, Medicaid, 
maybe even a COBRA program that they don't avail themselves of. 
And if you really scrutinize emergency room populations, you 
will come across those folks. So what is the evidence that 
providing these dollars in the family planning area gives us 
that benefit in child spacing?
    Mr. Hathaway. Lots and lots of evidence. For every dollar 
spent on family planning services, there is about $4 or $5 
saved----
    Mr. Burgess. And I would appreciate it very much because we 
are out of time if you could provide me references for those, I 
would be anxious to look at that.
    Mr. Hathaway. I would be delighted. Thank you so much. 
Thank you.
    Mr. Burgess. Thank you very much.
    I will yield back, Mr. Chairman.
    Mr. Pitts. The Chair thanks the gentleman and recognizes 
the gentleman, Mr. Engel, for 5 minutes for the follow-up.
    Mr. Engel. Thank you very much, Mr. Chairman.
    First of all, I want to say that I respect people's 
consciences. This is a sensitive issue, and it is sensitive all 
the way around, and while I don't think anyone should be forced 
to provide services that morally they feel that they cannot do, 
I think conversely it works the other way as well. I think that 
people who make their own choices and their own decisions 
should not be impeded from getting the services that they want 
and they need. I think this is an important hearing to discuss 
this very important issue of coverage for preventive services. 
And I believe there have been many significant advances that 
the Affordable Care Act made in access to quality and 
affordable care for women.
    I am sorry we have another hearing which seems designed to 
attack the significant advances that the Affordable Care Act 
made for women. HHS's final interim rule is a significant step 
in the right direction of providing women access to coverage to 
a whole range of healthcare needs that are very specific to 
women, and I applaud their efforts. I am just concerned once 
again we are undermining or attempting to undermine these 
benefits that women have. The cost that is placed on women in 
order to get access to all their healthcare needs is something 
that we ought to be concerned with.
    And again with respect to the religious exemptions, I would 
say that the Department of Health and Human Services has made a 
significant effort to allow religious organizations to opt out 
of the requirements, to provide coverage for contraception. I 
support that. I don't think anyone should be forced to do it, 
but I think that works again both ways. I mean you need to be 
sensitive both ways.
    So my first question is for Dr. Hathaway. HHS's interim 
final rule has already accounted for the concern of providing 
coverage for contraception. In your testimony, you mention that 
cost is a barrier for many women who cannot afford access to 
quality medical information. In your opinion, Doctor, what will 
be some of the most significant benefits for women who can now 
have access to coverage for preventive services?
    Mr. Hathaway. You know, I am sitting here thinking some 
days I feel as though I am pretty passionate about this. There 
are other days that I wish I could be more passionate, and the 
only way I think I could do that is if I were a woman or a 
woman of color or a woman of lower social economic strata. And 
since I can't do that, I have to hope that I can present the 
voice that I try to do as best I can. Preventive healthcare, 
contraception care, family planning services are incredibly 
important for multitudes of women in our country, and I think 
we are fooling ourselves if we are not looking at the cost 
savings and the amount of despair we have put women into for 
years and years and years. We have moved to a whole different 
era of contraception. You know, this is a 50th anniversary of 
oral contraceptive pills and yet they have saved and helped 
many, many women for years throughout our country as well as 
many other countries, and yet we are in a different era. If I 
were to ask any of us in this room how easy it is to take a 
pill every day, most of us would say it is pretty darn 
difficult. Most women would say they would like to wait at 
least a year or more to avoid the next pregnancy or a pregnancy 
at all. And therefore, we ought to be able to help them. 
Whether it is private insurance or no insurance, we need to be 
able to help those women space and prevent the pregnancies when 
they want to.
    Mr. Engel. So let me just follow up with that because you 
mention in your testimony--which is consistent with what you 
just said--that access to coverage for counseling, education, 
and contraception is very important for women of all 
socioeconomic backgrounds, but specifically, the women who 
cannot afford access. So what impact would efforts to roll back 
this interim rule have on women's health and what would a 
continued cost barrier mean for women who cannot afford the 
access to care?
    Mr. Hathaway. Detrimental. I feel as though, you know, the 
women who are currently not using the most effective methods or 
have no access to any method at all are still going to struggle 
without this moving forward. I think the Institute of 
Medicine's recommendations are very, very strong and I applaud 
them. I think it is a wonderful move for our country.
    Mr. Engel. Thank you, Dr. Hathaway.
    Thank you, Mr. Chairman, and I yield back.
    Mr. Pitts. The Chair thanks the gentleman.
    That concludes the final round of questioning. I would like 
to thank the witnesses for your testimony today and this 
concludes today's hearing.
    I remind members that they have 10 business days to submit 
questions for the record, and I ask that the witnesses please 
agree to respond promptly to these questions.
    With that, thank you. The subcommittee is adjourned.
    [Whereupon, at 12:21 p.m., the subcommittee was adjourned.]
    [Material submitted for inclusion in the record follows:]

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