According to findings published in health policy journal Health Affairs, few small businesses are likely to take advantage of two options allowing them to avoid new regulations under President Obama’s Affordable Care Act. Researchers believe that most small employers will likely eschew the two rules because opting to self-insure or maintain grandfathered insurance plans would leave them open to substantial financial risk should the medical expenses of their employees surge unexpectedly. Furthermore, researchers predict that the majority of small businesses won’t be able to grandfather existing health plans after 2014, as they will fail to meet the necessary requirements.

A report released by the Center for American Progress points out the momentous challenges small employers face in providing affordable, high-quality health insurance plans for themselves and their employees:

Small businesses, which employ 42 million Americans, continue to struggle with the rapidly escalating costs of health insurance. Over the past decade, small-business owners have watched their health insurance premiums rise 133 percent—the same kind of premium growth large businesses have experienced. But because of their smaller scale and thinner margins, they are less able than larger businesses to absorb these increasing costs.

Other factors make it more difficult for small businesses to offer coverage than large businesses. For instance, on average, small businesses pay 18 percent more than big businesses for the same coverage—often due to high broker fees, fixed administrative costs, and adverse selection, which is the upward price spiral that occurs when one plan or market disproportionately attracts high-risk employees.

To combat this obstruction, the ACA has introduced the Small Business Health Options Program (SHOP), which is intended to create a marketplace for small business owners to purchase health insurance for their employees. These proposed SHOP exchanges will allow small businesses to consolidate their buying power so they can purchase high-quality insurance with substantially reduced premiums. By spreading the financial risk associated with insuring high-cost enrollees across a wider pool of employers and employees, the exchanges will keep costs affordable, limit the burden posed by the insurance process, and reduce administrative expenses.

“The exchange is the most important component of health care reform for small businesses and it’s critical states set them up correctly so small businesses get the relief a strong exchange can provide,” said Terry Gardiner, Vice President of Policy and Strategy for Small Business Majority.

Under the ACA, open enrollment for SHOP exchanges should commence sometime in late 2013, while small employers and their employees can expect the exchanges to officially open for business on January 1, 2014.

– Fatima Najiy

Rick Santorum has been outspoken about his Catholic faith on the campaign trail, explaining how his faith and personal values have influenced his political positions. But at a campaign event at Oral Roberts University in Tulsa, Oklahoma today, Santorum had trouble rationalizing how he reconciled his opposition to health care reform with the Catholic Church’s support of the plan. A questioner asked Santorum, “With you lining up with the Catholic faith on so many issues, why not the Catholic Church on health care since it is a value and a human right?”

Santorum offered a rambling answer, first saying that church’s teachings had shaped his life and then insisting that he also has to consider reason as a politician. “I always say if your faith is true and your reason is right, then you’ll end up in the right place,” he said. “And of course why would God create something where reason would bring you one place and your faith would bring you another if your faith is true?” And as a public official, he said, he had an obligation to talk to people who share his faith and those who don’t:

My conscience was formed as a result of my life experiences and primarily through faith and through the moral values I was taught through the teachings within the Bible and the church. Yes, I bring that to the table. That’s who I am. [...]

I look at the Affordable Care Act and say, both from the standpoint of faith, do I believe that people should have the opportunity to purchase health care? Yes. Do I believe that it is the right that the government should impose and control? No. It’s one thing to say that people have an opportunity to access of care. It’s another to say that the government should be the implementer of that. And something tells me that government is the least effective tool to make that the best possible care.

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Of course, Pope Benedict XVI has called health care an “inalienable right,” and added that it is the “moral responsibility of nations to guarantee access to health care for all of their citizens, regardless of social and economic status or their ability to pay.” The Catholic Health Association supported the Affordable Care Act, and during the debate about health care reform, Catholic nuns broke with the U.S. Conference of Catholic Bishops to support it. But Santorum will continue to twist the logic to fit the position he wants to support.

While Republicans and the United Conference of Catholic Bishops claim that the Obama’s contraception regulation represents an “unprecedented” attack on the religious liberties of organizations that oppose the use of birth control, ThinkProgress has chronicled the growing number of institutions that are already providing the benefit as part of their overall health care coverage. For instance, Georgetown University in Washington D.C. and DePaul University in Illinois offer employees the option of receiving contraception and so do Catholic organizations across the country.

For instance, the New York Times reported in 2002 that the Catholic Archdiocese of New York extended contraception coverage before the state passed its requirement. Catholic universities, Marquette and Mount Mary in Wisconsin were also offering the benefit prior to enactment of the state’s contraception equity clause in 2010. “Marquette’s policy recognizes that a significant portion of the university’s employees are non-Catholic and that contraceptives are at times prescribed by physicians for purposes other than birth control, spokeswoman Mary Pat Pfeil said.” She stressed that “the choice to use a contraceptive is both a medical decision and a matter of conscience.”

Once the law passed, Catholics had to provide contraception benefits. But rather than accusing the state of starting a war against religion, the organization left the decision to the consciences of its members:

“Our employees know what church teaching is. And we trust them to use their conscience and do the right thing,” said Brent King, spokesman for the Madison Diocese, which began covering prescription contraception Aug. 1. [...]

Diocese of Madison employees, Catholic and non-Catholic alike, sign a document when they’re hired vowing to abide by the laws of both Wisconsin and the church. He said employees would receive “strong pastoral recommendations against” using the contraception benefit, but that the diocese has no intention of policing it.

Significantly, the Obama regulation exempts churches from including the birth control benefits in their plans and would provide an a new layer of conscience protections for the state. But since most Catholic women rely on contraception, it’s likely that many may still offer the benefit.

Republicans in Congress have gone to war over the administration’s new rule requiring employers and insurers to provide contraception coverage to women. Despite the fact that the regulation already excludes more than 335,000 entities, Republicans have introduced legislation seeking to expand the conscience clause protection to exclude even more religiously affiliated institutions from the requirement. The move, which is opposed by women’s groups, would significantly restrict access to affordable birth control by allowing Catholic colleges, universities, or hospitals to deny contraception coverage. As a result, these women would have to spend up to $600 a year buying birth control without the help of insurance.

But interestingly, members of Congress who seek to limit the availability of affordable birth control all enjoy contraception insurance as part of the government managed Federal Employees Health Benefits (FEHB). Members first approved the so-called “contraception equity” provision in 1998, through the FY 1999 Omnibus Supplemental Appropriations Act, H.R. 4328, PL 105-277, and have passed the measure ever since. The language “ensures that federal employees participating in FEHBP have insurance coverage of FDA-approved prescription contraceptives and related services.”

A ThinkProgress analysis reveals that 12 members of Congress who approved the conference report for the 1999 omnibus bill have signed on as co-sponsors of the current GOP-led measure to limit women’s access to contraception by changing the Obama administration’s rule. From the original FEHBP requirement:

A new law requires FEHB plans to provide contraceptive coverage. For 1999, the Office of Personnel Management will require all plans to cover the full range of contraceptive drugs and devices approved by the Food and Drug Administration.

A few plans will be exempt from this requirement, and they are noted below. Because the law was signed on October 21, 1998, after the FEHB brochures for 1999 were printed, the FEHB brochures you will receive during the Open Season do not reflect these additional benefits. You should use this notice when you read the brochures, so that you will have an accurate understanding of the benefits offered by plans that you are considering.

An official at the Office of Personnel Management, which administrates the program, has confirmed to ThinkProgress that all FEHB plans provide coverage for contraception, meaning that every single member of Congress opposing Obama’s rule now has the birth control coverage they’re seeking to deny to others.

Catholic bishops and their GOP allies have been in an uproar ever since the Obama administration announced new rules that require employers, including most religiously-affiliated institutions, to cover contraception in their health plans with no cost-sharing. Republican candidates have accused Obama of waging a “war against religious freedom.” Rick Santorum went so far as to say Obama has put America on “the path” of beheading devout citizens.

The less shrill voices have implored Obama to “compromise” by broadening the religious exemption to let religiously-affiliated hospitals refuse women contraception. But the U.S. Conference of Catholic Bishops has made it clear they’re not interested in compromise. According to a report in USA Today, they aren’t just demanding a broader religious exemption from the new contraception coverage rule — they want contraception coverage removed from the Affordable Care Act altogether:

The White House is “all talk, no action” on moving toward compromise, said Anthony Picarello, general counsel for the U.S. Conference of Catholic Bishops. “There has been a lot of talk in the last couple days about compromise, but it sounds to us like a way to turn down the heat, to placate people without doing anything in particular,” Picarello said. “We’re not going to do anything until this is fixed.”

That means removing the provision from the health care law altogether, he said, not simply changing it for Catholic employers and their insurers. He cited the problem that would create for “good Catholic business people who can’t in good conscience cooperate with this.”

“If I quit this job and opened a Taco Bell, I’d be covered by the mandate,” Picarello said.

In short, Catholic bishops are saying that federal laws shouldn’t apply to anyone who claims to have a religious objection to them. Houses of worship and other religious nonprofits are already completely exempt from the rule. It is only when religious institutions choose to go into business as hospitals and serve the general public that they are bound by the same laws as everyone else. Yet the U.S. Conference of Catholic Bishops has promised a legal challenge.

But the organization does not speak for a majority of American Catholics, 52 percent of whom support requiring health plans to cover contraception. Several major Catholic universities and hospitals already offer contraception coverage.

Democrats took to the House floor last night to defend President Obama’s regulation requiring employers and insurers to provide a wide range of health care benefits in their insurance plans, including contraception coverage. Houses of worship and non-profits primarily employing and serving those of the same faith are exempt from the requirement.

Rep. Jerry Nadler (D-NY) made a particularly persuasive case, arguing that the federal law treats Catholic affiliated institutions like colleges, universities, and hospitals as employers and requires that they follow standard employment laws and regulations and treat all employees fairly. And while the government would never muddle in a church’s religious operations — for instance, it would never ask that it take on female priests, it would object to it turning away female doctors from its hospitals or refusing to perform a certain medical procedure that undermines the liberties of the patient.

These organizations — which receive tax benefits from the federal government — can’t discriminate in their hiring practices or general operations and they shouldn’t discriminate against sex in the coverage they offer to their employees. Here is how Nadler put it:

NADLER: The difference here is that churches are and should be protected in their religious role. Protected against having to violate their religious views. But they must not be protected in their role as employers. We permit a church, for example, to discriminate a religious practice. No one asks the Catholic Church how come you do not permit women priests, that’s their business. But we do not permit them to discriminate as employers. We do not permit a religious hospital or university to say we will not permit the hiring of female doctors or female professors or black doctors or nurses because that would impinge on liberty. [...]

The church can preach its views, it can seek to persuade people, but it cannot coerce people who may work for a church affiliated university or hospital that they may not use contraceptives if they want to. The liberty here is the liberty of the employee that must be protected. The liberty of the church must be protected in its churchly function and in its function as a religious institution. In its function as an employer, the liberty belongs to the employees and that is the distinction that is made here. It is the proper distinction.

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