Capital Commentary is the weekly current-affairs publication of CPJ, written to encourage the pursuit of public justice.
Protecting Life and the Diversity of Medicaid Providers
Over the past year, at least ten states have acted to exclude Planned Parenthood from getting paid to provide Medicaid services. This comes in the aftermath of several videos released last summer showing Planned Parenthood employees discussing, in often cold and disturbing detail, fetal tissue extraction. Regardless of whether Planned Parenthood violated current laws, people across the ideological and political spectrum found these videos to be dehumanizing. As Michael Gerson wrote in a Washington Post column, “[M]ost people, even those who support Roe v Wade –intuitively recognize that the boy or girl in the sonogram is not a cyst…. And people generally don’t want developing human beings treated as rubbish or raw materials.”
On April 19 of this year, the Obama administration warned state officials that they may be violating federal law if they exclude Planned Parenthood from being a Medicaid provider. This warning raises the question of whether Planned Parenthood should be excluded because it is our nation’s biggest provider and advocate of abortion, or if it should be included because women have a right to all legal reproductive services, many of which Planned Parenthood provides.
There are also other essential public justice dimensions to this decision that are important to consider, especially in a time of growing public suspicion about faith-based services. Is it possible for pro-life people of faith to deeply object to Planned Parenthood’s provision of abortions, yet also object to the removal of access to other Planned Parenthood women’s health services for Medicaid recipients?
Understanding the Context
In concert with this warning, the federal Centers of Medicare and Medicaid Services (CMS) wrote to every state’s Medicaid office stating that eliminating particular healthcare providers from Medicaid is only permissible, in the words of a Washington Post article, if they “are unable to perform covered medical services or can’t bill for those services.” The letter requires states to treat comparable kinds of healthcare providers for Medicaid equitably.
This guidance is undergirded by the principle that healthcare recipients should be able to choose from a range of providers. As Marissa Padilla, federal HHS spokeswomen, told the Washington Post, “CMS is sending a letter to all states to ensure they have a clear understanding of their obligation to follow longstanding Medicaid law guaranteeing that beneficiaries have the right to receive covered services, including family planning services, from any qualified and willing provider of their choice.” The CMS letter also notes that for providers to be “qualified,” they have to be able to offer the services “in a professionally competent, safe, legal, and ethical manner.”
The CMS letter seems intended to warn states not to push Planned Parenthood out of providing Medicaid services. But is there a case to be made that Planned Parenthood should be pushed out because it provides abortion services? Federal law forbids spending federal Medicaid funds on abortion, except in extreme cases, such as saving the life of the mother. So the question here is not whether government money should be used for abortion, but under what circumstances a provider that many object to, such as Planned Parenthood, should be excluded from Medicaid funding.
Planned Parenthood’s affiliates have faced significant allegations of malfeasance, even beyond the high-profile charge of trafficking in fetal body parts. Because of the requirement that providers must be qualified (competent and not engaged in illegal or unethical action), the states that have acted so far may regard these charges and incidents to be sufficient cause to exclude Planned Parenthood. The federal letter seems to assume that there is not sufficient legal cause. But should Planned Parenthood be excluded anyway? The answer to that question is complex.
A Public Justice Response
Public justice principles affirm the role of government to protect and uphold all human life, especially the most vulnerable, including the unborn. Public justice principles also affirm the role of government to recognize and uphold the diverse organizational structures of civil society, obligating government to do justice to society’s varied nongovernmental organizations. Does this mean that the government should support every civil society organization, even those whose actions run contrary to other public justice imperatives, such as the protection of human life? No. As CPJ founder and former president Jim Skillen stated: “There is no room for public-legal pluralism with respect to abortion as there is with respect to parents choosing from among a variety of schools.”
In other words, an individual’s right to seek services from among a variety of diverse civil society organizations is limited by whether those services themselves are acceptable according to the public justice norm. Parents should have the right to choose from a variety of educational options for their children because public justice recognizes education as a social good. Likewise, women should be able to seek Medicaid-funded (non-abortion) health services from a diversity of providers. But can we go one step further to say that the diversity of providers should not include any that separately offer legal abortion services, even though current Medicaid law permits such providers, such as Planned Parenthood, to participate?
A case can certainly be made that excluding Planned Parenthood furthers vital pro-life goals in important ways. Yet such an exclusion can have critical negative consequences for other important public justice goals, and even, potentially, for pro-life aims as well. The Medicaid policy maximizes the choice of service providers. That’s crucial because service recipients have diverse values, needs, and preferences. Allowing a range of providers to serve, as long as they are qualified and offer services that are covered by Medicaid, does indeed allow Planned Parenthood to get Medicaid money, despite the opposition of pro-life citizens. But this same policy also allows health clinics that refuse to perform elective abortions to receive Medicaid funds, despite the opposition of pro-choice citizens.
The Value of Diverse Providers
The openness of government programs to a diversity of providers is a precious value in our time of narrowing enthusiasm for faith-based services. Faith-based organizations of all kinds are facing increasing opposition to their eligibility for government funding. One of the most compelling arguments that proponents of institutional religious freedom can make in response is that it is important for individuals seeking services—whether substance abuse treatment, healthcare, education, or jobs training—to have a diversity of options available to them, including faith-based options for care. In order for this argument to ring true, advocates of religious freedom for faith-based organizations need to be especially careful that they do not unintentionally support public policies that would limit the right of service recipients to seek legally permitted services from all legally eligible providers.
Today’s public policy and public opinion climate is often hostile to faith-based service providers, seeking to undermine their access to government funding. For example, during efforts to reauthorize the Runaway and Homeless Youth Act, LGBT advocates sought to defund, for all intents and purposes, faith-based RHYA grantees despite no substantiated evidence that faith-based service providers had discriminated against LGBT youth. They did this by pressing for a very broad “nondiscrimination” clause that would force many FBOs to give up their government partnerships because they hired based on faith, despite the fact that they served everyone.
In recent months, progressive groups, including Planned Parenthood and other organizations that support Planned Parenthood, have waged their own battles to exclude otherwise eligible providers from government programs simply because the objecting organizations do not approve of some of the other policies of those providers. They object to faith-based providers that consider religion when making employment decisions—a perfectly legal practice, even when the government is funding the provider. They want the administration to declare such faith-based organizations ineligible for government funding, even though the organizations are capable of providing the services the government seeks.
The argument can be made from the other side that Planned Parenthood is an exceptional case; issues involving life, including unborn life, are special. But state efforts to end Medicaid funding for Planned Parenthood providers give us cause to think carefully. Are there more effective ways to support life through public policies that limit access to abortion specifically, or that strengthen the supports available to women experiencing unplanned pregnancies?
When it comes to such supports, it is worth noting that Planned Parenthood, whatever else it does, reports these kinds of services: prenatal medical care (18,684 instances in 2014-15) pregnancy tests (1,128,783), family practice services (65,464), adoption referrals (1,880), and urinary tract infection treatments (47,264). Ending Medicaid funding for these local Planned Parenthood affiliates could mean limiting access to prenatal and other vital women’s healthcare in some places. Isn’t it a better strategy to increase the number of pro-life alternative service providers that are part of the Medicaid mix?
Yes, the Medicaid law could be changed so that any provider that offers abortion services as well as the services covered by Medicaid is ineligible. However, the next step down that path might very well be that some states not favorable to religion exclude faith-based providers because–outside of the Medicaid-funded services–they offer religious comfort and teaching. This would be a slippery slope, indeed.
Questions for Reflection:
- Faith-based healthcare providers and hospitals often get pushback because they cannot, based on their religious beliefs, provide women with certain reproductive services. How does an argument for a diversity of providers in the public square support both progressive healthcare providers and religious options? What are the benefits of providing women access to diverse options for their healthcare? What are the drawbacks?
- Pro-life values lead many to attempt to shut down as many abortion providers as possible, despite the collateral consequences such as limiting access for low income women to other health services, including prenatal and preventative reproductive services. How should people of faith who value life advance this value in a society where abortion is legal?
Chelsea Langston is the Director of Equipping and Membership at the Institutional Religious Freedom Alliance, a division of the Center for Public Justice. She holds a JD from the University of Michigan and is a licensed attorney by the State Bar of Michigan.
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Capital Commentary is a weekly current-affairs publication of the Center for Public Justice. Published since 1996, it is written to encourage the pursuit of justice. Commentaries do not necessarily represent an official position of the Center for Public Justice but are intended to help advance discussion. Articles, with attribution, may be republished according to our publishing guidelines.”