The recent and narrowly decided (5-4) Supreme Court case of Burwell v. Hobby Lobby is significant and bears further reflection and discussion.

It gives for profit ‘closely held corporations’ (where five or fewer shareholders own over 50% of the company) the legal right to opt out of the Patient Protection and Accountable Care Act’s mandate to provide insurance coverage for some forms of birth control on the basis of religious objection. It is significant because up until this time, only religious affiliated organizations had the right to deny insurance coverage for specific healthcare services due to religious beliefs and there are literally thousands of for profit ‘closely held corporations in the United States who employ millions of people including: In-N-Out Burger, Chick Fil-A, and Forever 21 to name a few.

The denial of insurance coverage for healthcare services may be minor or significant. Emergency contraception may cost $45, insertion and maintenance of an IUD $1000, and more comprehensiveservices a great deal more. Now imagine, that the ‘for profit closely held corporation’ is owned by individuals of the following faiths, the resultant denials of healthcare insurance coverage may be as follows:

1. Catholic-denial of coverage for birth control and termination of pregnancy whatever the cause

(e.g. incest, rape, or when the health of the mother is in jeopardy)

1. Orthodox Jewish-denial of coverage for circumcisions and all non-Kosher dietary treatments

2. Jehovah’s Witnesses-denial of coverage for blood transfusions

3. Christian Scientists-denial of coverage for all non-homeopathic medical care

Nobody doubts the importance of religious freedom and an individual’s right to make moral and ethical decisions on the basis of religious precepts and principles. The questions that are raised include:

Should the decision to purchase or utilize healthcare services be made by a corporation or by an individual? Can a small group of individuals acting as a corporation enforce their personal religious decisions and values on their employees? Where do the legal rights between an individual and a corporation begin and end?

Potential implications of this decision for healthcare organizations include:

1. Carve outs for employer based contracts with coverage gaps

2. Potential for greater ‘bad debt’ based upon inability to pay with increased cost shifting

3. Greater costs for preventive services and certain interventions that may violate religious beliefs

4. Inability to fully standardize contracts and contractual agreements among payers, providers, and employers

One of the great healthcare challenges in our country is that there are millions of gainfully employed individuals with limited access to healthcare through under-coverage, high deductible coverage, or no coverage at all. Adding an employer’s right to ‘carve out’ selected healthcare services on the basis of religious preference does not get us closer to universal coverage but further away. When individuals cannot afford healthcare, the costs are passed onto those who can in the form of cost-shifting and this is neither efficient nor fair.

Hopefully, there will be a better balance between the religious rights of employers and the need for employees to access preventive healthcare services so that personal moral and ethical values do not have to be protected at the cost of our nation’s health.