The controversy over whether religious employers, including colleges, should be required to offer insurance covering birth control for free shows no signs of abating. Anticipated final regulations on insurance plans that colleges offer to their students might only open another front in the battle.
A final version of the rule governing student health plans, which some colleges require students to purchase if they are not otherwise insured, is expected to be announced soon. If, as predicted, it adheres closely to a proposed version  announced last year, college-sponsored plans would also be required to offer birth control at no cost.
In a proposed version of the rule published in the Federal Register in February 2011, the Department of Health and Human Services clarified  that colleges could continue to offer institution-sponsored insurance under the new health care law, but that those plans would be subject to the same rules that now govern individual insurance plans. School-sponsored insurance could no longer reject students with pre-existing conditions or put a lifetime maximum on the amount of benefits the plans will pay. The plans would also have to offer preventive care at no charge.
Student health plans have been criticized  in the past for overcharging students, capping benefits and providing no coverage at all for many of the most expensive (but not uncommon) illnesses or injuries. Still, about half of all colleges offer the plans, and up to three million students use them for insurance coverage, according to HHS.
An investigation by then-New York Attorney General Andrew Cuomo in 2010 found that some student health plans maxed out at $700 in benefits per illness and that others would not cover care for injuries related to alcohol or suicide attempts. A report by the U.S. Government Accountability Office  found that more than half of student health plans had benefit ceilings of $30,000 or less.
The final rule -- which isn’t expected to change significantly from the proposed version -- would end many of these practices, beginning with health coverage for the 2012-13 school year. Insurers have warned that it will also drive up premiums for students.
“The proposed rules, which we were very supportive of, for the first time set a uniform standard,” said Aaron Smith, co-founder and executive director of Young Invincibles, a nonprofit group that advocated for the health care overhaul. “College students deserve the same basic protections as all Americans under the new health care law.”
The American College Health Association was also pleased with the proposed rule, because it would allow student health plans to continue to operate (a clarification from the original health care legislation), and because student coverage would fulfill the mandate for obtaining individual insurance. The proposed rule also provides a path to compliance, rather than immediate punitive measures, for plans that do not currently meet the federal government’s requirements, said Anita Barkin, the association's president and director of health services at Carnegie Mellon University.
“We believe our student consumers and their parents should have the opportunity to have choice and decide which plans provide them with the best coverage for the dollar,” Barkin said. “We believe student health insurance programs will rise to the occasion and be able to compete and provide a good product, and we’re encouraged by that.”
A New Climate
The rule might turn out to have changed little in the year since it was first proposed. But the circumstances surrounding it have changed more.
The Affordable Care Act has required rounds of rule-making to fill in legislative gaps, including specifying what types of “preventive care” would have to be covered by individual and employer-sponsored plans. The department has ruled that preventive care, for women of childbearing age, includes all FDA-approved methods of birth control. Proponents of that requirement argue that planned pregnancies are safer for women (and less expensive for insurers) than unplanned ones and that contraceptives are a crucial part of preventive health care.
But a decision to require religious employers, including faith-based organizations such as colleges and charities, to abide by that requirement and offer free birth control on their insurance plans kicked off a firestorm that has raged through the Republican primary debates and the halls of Congress in recent weeks. A proposed compromise by the Obama administration  -- that insurers, not institutions, would pay for contraceptive coverage for women working for religious employers -- mollified some critics, but has not quelled the controversy.
Whether the final rules on student plans will be changed to include a similar clarification, drop the requirement for student plans to cover birth control, or extend the deadline for religious colleges to comply with the rules, isn’t clear. The Department of Health and Human Services did not respond to a request for comment from Inside Higher Ed.
But if the requirement is preserved, the outcry from some religious colleges about having to offer free birth control to students will dwarf objections about the requirement to offer it to employees. In addition to concerns from Roman Catholics about covering birth control at all, and from some Christian colleges about covering the “morning-after pill,” which some pro-life groups consider tantamount to abortion, many evangelical Christian colleges have student codes of conduct that forbid premarital sex. And at least one Catholic university, Georgetown, offers birth control coverage to employees but not to students.
The Association of Catholic Colleges and Universities, as well as the Council for Christian Colleges and Universities, praised the moves toward compromise on employer plans Feb. 9 but said they were still concerned about student plans. The associations were unavailable to comment Thursday.
In lawsuits against the rule, two religious colleges (one evangelical, one Catholic), argued in part that it would require colleges to be hypocrites: pastors and priests could inveigh against premarital sex or birth control, but the colleges would offer contraceptive pills for free through insurance plans.
But many students will welcome the regulation, Smith said. “That’s a big victory for students and particularly for young women,” he said. “Lots of young people are really passionate about that issue.”