For millions of American women, the Affordable Care Act changed something fundamental about reproductive health care: contraception became preventive care that most employer-sponsored health insurance plans were required to cover without a copay.
On October 6, 2017, the Trump administration moved to weaken that guarantee.
New federal rules dramatically expanded the number and types of employers and organizations that could claim religious or moral objections to providing contraceptive coverage. The result was a significant shift in who could influence a woman's access to a health benefit: her employer.
When an Employer's Beliefs Affect an Employee's Coverage
The Affordable Care Act required most health plans to cover FDA-approved contraceptive methods as part of women's preventive health services without additional out-of-pocket costs.
Religious institutions already had protections under the law, and accommodations had been developed for certain religious nonprofit organizations.
The Trump administration went considerably further.
The new rules expanded exemptions for organizations and employers with sincerely held religious objections and created exemptions based on sincerely held moral convictions as well.
That meant an employee could potentially lose contraceptive coverage because of beliefs held not by her, but by the organization providing her health insurance.
Women affected by the change remained free to obtain and use contraception. The issue was whether their employer-sponsored insurance would continue paying for it without cost-sharing.
For women who depended on that coverage, the distinction could have significant financial consequences.
Birth Control Is Health Care
Contraception is used for more than preventing pregnancy.
Hormonal contraceptives are also prescribed to treat or manage conditions including painful or heavy periods, irregular menstrual cycles and other reproductive-health problems.
The American College of Obstetricians and Gynecologists strongly condemned the administration's October 6 action.
The organization warned that limiting contraceptive coverage could undermine women's access to preventive care and threaten progress in reducing unintended pregnancies.
ACOG also emphasized a broader principle at the center of the controversy: decisions about a woman's health care should primarily belong to the patient and her medical provider—not her employer.
Women Had Already Seen the Financial Benefits
The Affordable Care Act's contraceptive requirement had produced measurable financial benefits.
More than 60 million women with private insurance eventually gained access to women's preventive services without cost-sharing, including contraception. ACOG has cited research estimating that expanded contraceptive coverage saved women approximately $1.4 billion in out-of-pocket expenses in a single year.
Those savings mattered because not every form of contraception costs the same amount.
Monthly birth-control prescriptions can create recurring expenses, while longer-lasting methods such as intrauterine devices and contraceptive implants can carry much larger upfront costs without insurance coverage.
For some women, therefore, losing coverage wasn't simply an ideological dispute in Washington.
It could mean paying more for the same health care they had previously received through their insurance.
Religious Liberty Versus Women's Health-Care Autonomy
The Trump administration defended the policy as a matter of religious liberty and conscience.
Its position was that the federal government should not force employers and organizations with sincere religious or moral objections to pay for contraceptive services they opposed.
Supporters viewed the change as protection against government compelling people or organizations to violate deeply held beliefs.
Opponents saw the issue very differently.
They argued that protecting an employer's beliefs came at the expense of employees who might not share those beliefs—and that a woman's compensation and health benefits should not depend upon her employer's views about contraception.
That conflict became the defining question surrounding the policy:
Whose beliefs should determine a woman's health-care coverage—her own or her employer's?
A Major Reversal in Women's Health Policy
The October 6 rules did not outlaw contraception, nor did they prevent women from purchasing or obtaining birth control elsewhere.
What they did was weaken the federal guarantee that women enrolled in affected employer-sponsored health plans could receive contraception without paying additional costs.
That was enough to provoke immediate opposition from women's-health organizations and eventually extensive litigation over the administration's authority to create the exemptions.
For women affected by the policy, something that had been treated as a standard preventive health benefit could once again become an expense determined partly by the beliefs of the organization signing their paycheck.
On October 6, 2017, the federal government's approach changed significantly.
The administration chose to give greater protection to employers asserting religious or moral objections.
For their employees, that meant someone else's beliefs could once again influence whether their insurance paid for one of the most commonly used forms of women's health care.