ObamaCare and cooperation with evil

Marie Hilliard: Organizations helping enroll people in ObamaCare may be problematic . . .

Marie T. Hilliard

ObamaCare has caused confusion and reams of additional paperwork for Americans. The National Catholic Bioethics Center (NCBC) continues to review the various enrollee registration roles developed to implement this law and is advising Catholic agencies to exercise caution.

As new information is disclosed on the implementation of the Affordable Care Act (ACA), the NCBC deems it prudent to advise Catholic agencies assuming ACA Navigator and other related roles in enrolling persons for coverage. There are three specific roles:

Navigator: All exchanges (also known as marketplaces) — whether state-based, partnership or federally facilitated — are required to establish a navigator program. Each exchange will designate entities as navigators and provide them with grants for helping individuals and small employers with the application and enrollment process.

In-Person Assisters (IPAs): In the final exchange blueprint, the Center for Consumer Information and Insurance Oversight (CCIIO) outlined IPAs as a second type of assister that is distinct from navigators and other application assistance programs.

Certified Application Counselors (CACs): Being certified as CACs enables organizations that would likely be engaged in application assistance anyway to help consumers in a more formal capacity. For example, although not all community health centers and community-based organizations will be chosen to serve as navigators or IPAs, they are well-positioned to provide application assistance because they are trusted messengers.

There is a significant possibility of scandal, which is to be judged by the diocesan bishop, when a Catholic agency participates not only as a Navigator but also in providing IPAs or CACs for enrollment in coverage. This is not just because of the morally illicit drugs and procedures which will be facilitated by implementing the ACA, but also because of the violation of religious liberty occurring pursuant to the Department of Health and Human Services’ contraceptive mandate in the ACA’s implementation.

There are also additional concerns, especially for states that have not banned abortion coverage in the Exchanges. The ACA stipulates that by 2017 only one plan per Exchange must not include such coverage; all of the other plans may or may not cover abortion, and all plans include coverage of abortifacients.

In order to circumvent certain restrictions on government funding for abortion, the ACA requires that persons holding an Exchange policy which includes abortion coverage, pay a private surcharge of at least $12 per year specifically for the abortion coverage. Enrollers may be engaging in formal cooperation in evil, which is always morally illicit. Explicit formal cooperation in evil occurs when the cooperator (enroller) has the same evil intent as the principal agent (enrollee, who desires insurance coverage specifically for abortion, intending to make use of it if the occasion arises). If the enroller would prefer that coverage not include abortion coverage, yet acts to ensure that the enrollee has this specific type of coverage as an IPA, CAC, or contracted Navigator, this could constitute implicit formal cooperation.

This scenario is complicated by the fact that the law prohibits insurers from telling potential enrollees whether a plan under consideration includes abortion. It allows the abortion surcharge and its amount to be disclosed only at the time of enrollment and prohibits insurers from itemizing it on premium bills. Obviously, if enrollers have no knowledge of whether the plan includes abortion coverage, they are not engaging in cooperation in evil. If they have reasonable certitude that the plan includes abortion coverage, but the enrollee has not explicitly requested such coverage, they may be engaging in justifiable mediate material cooperation in evil; however, an enroller has the responsibility to discover, if possible, whether abortion is part of a particular plan.

It may make the evil possible by contributing to the overall financing of the plan, not dissimilar to paying taxes. For such an enrollee, who acts for the sake of the proportionate good of the family’s health care coverage, this remote mediate material cooperation could be justified, with the understanding that the family does not intend to utilize the immoral drugs and devices, makes known its objections to the public policy, and works to effectuate policy change.

The NCBC opinion is that Catholic agencies cautiously and diligently assess the danger of formal cooperation and weigh the proportionate good to evil in terms of mediate material cooperation before sponsoring or assuming the roles of Navigator, IPA, or CAC for the Exchanges.

MARIE T. HILLIARD, JCL, PHD, RN, is a staff ethicist at the National Catholic Bioethics Center.