What The Debate Over Birth Control Pills As An Essential Benefit Tells Us About National Health Policy Making

While the physician Disease Management Care Blog understands the logic behind essential health benefit determinations, believes good health care includes access to reproductive services and also knows that an unintended pregnancy poses special threats to a woman's health, it also sympathizes with the U.S. Catholic Bishops' stand on birth control pills. 

Such is the luxury of cognitive dissonance.  Yet, the DMCB's real discomfort is over the broader health policy implications of defining BCPs as an essential health benefit that must be covered with only a few exceptions:

1. There are really two ultimate paths to a federal takeover health care.  The first is obvious: formal through the "nationalization" of either the payment or delivery of services. The second is de facto is through the creation of laws, regulations and standards that amount to an expanding domination of the payment or delivery of services. From an end-user perspective, the DMCB thinks there is little difference between the two and believes we are underestimating the ultimate end game for this and multiple other rules and regulations.

2. Decision-making like this can cut both ways.  While womens' health advocates can take comfort in the Obama Administration's courage in the face of the Bishops' push-back, it's possible that future hyper-rational, inflexible, evidence-based, legalistic, uniformist and technocratic decision-making like this will result in endless legalistic, politically charged and awkward decision-making that will always vex some big constituency.  This is the same science used to provoke the controversy over the merits of mammography in women less than age 50 as well as prostate cancer screening in men.  To make the point, the DMCB poses this silly but troubling thought experiment:  since men are just as responsible and should be given every incentive to not cause unwanted pregnancy, should condoms be an essential health benefit?  If persons with cancer run out of treatment options, should a right to control their own bodies and its technical availability make assisted suicide an essential health benefit? 

This time it was the Catholics' turn.  The next one could be yours.

3.  Without some sort of accommodation (which may be in the works), the Bishops aren't going to back down.  While a majority of their parishioners may believe in and have used birth control, that test fails at two levels: 1) society's institutions are supposed to stand for a higher standard and 2) decades and even centuries of religious interpretation are not up for a vote.  Standing for something is what faith is all about and Church leaders are simply not going to roll over on insurance that covers birth control for their employees and they're not going to offer access to birth control pills in the course of the provision of health care. Their only choice, other than millions in fines is to exit the health care arena.  David Brooks has an excellent discussion of why that's a problem. 

4.  It is said that the art of politics is the art of the possible: to work out compromise where everyone can walk away a winner.  While coverage of birth control pills is a victory for women's health advocates that a "base" can feel good about, this is also arguably a failure for a President who was committed to bridging differences and creating a health care system that had broad support.

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