Codebook –
Health Insurance Contraceptive Mandate
The Affordable Care Act (ACA) mandates that health-insurance coverage include contraceptives, exempting houses of worship from this requirement. In 2018, the Trump administration enacted a rule allowing more employers with religious and moral objections to opt out of health-insurance coverage of contraceptives, and this rule was upheld in 2020 in the Little Sisters of the Poor v. Pennsylvania decision. This safeguard captures whether states maintain the existing exempt space for religious employers, either by having no state-level contraceptive mandate or by offering broad exemptions to their own mandate, or if the state effectively reduces that space with its own mandate and no or narrow exemptions.
Federal Context
States cannot expand the religious exemptions to federal mandates but can effectively narrow the federally provided religious exemption if there is a state-level contraceptive mandate that makes no religious exemptions or reduces those who are eligible for it (say, to only houses of worship). The 2018 Trump era rule, still in effect, expands the ACA exemptions for houses of worship to any employer with a religious or moral objection except for publicly traded companies.
External Sources
NARAL Pro-Choice America once maintained a log of state laws and exemptions for various medical procedures and citations for state contraceptive mandates. RLS 2022 made use of the version available online in December 2021 (updated as of 2018) but this site is now defunct. We used the citations provided for relevant state codes to identify the general location in states’ laws where these contraceptive mandates and exemptions could exist for each state. Health insurance laws tend to be spread out across multiple areas of state law (e.g., health law, insurance law, and family law) so the NARAL citations were used to streamline the search process. Data and notes from the Kaiser Family Foundation (KFF) State Requirements for Insurance Coverage of Contraceptives database were used in data verification. Since the current site no longer reports on religious exemptions, for RLS 2023 we use both the most current (May 1, 2022) KFF data and the data from the same site on July 1, 2021, which we archived for its treatment of religious exemptions for RLS 2022.
Identifying Codes and Assigning Scores
We read each state’s law(s) assigning codes according to the contraceptive mandates (if any) that exist, the exemptions (if any) that apply to that mandate, and the extent to which that exemption is applicable to employers (as opposed to insurance carriers). Those states that have contraceptive mandates and either make no exemption for religious employers or reduce the scope of employers to which the exemption applies (relative to the federal standard) are scored as reducing the space for free exercise compared to their peers who have no contraceptive mandate or provide broad religious exemptions for employers.
Possible Codes
A = No state contraceptive mandate
B = State has a contraceptive mandate and makes no exemptions for employers
C = State has a contraceptive mandate and exempts only houses of worship (including by mention of “inculcation”)
D = State has a contraceptive mandate and has exemptions beyond houses of worship (to, say, religious-controlled nonprofits, religious nonprofits, or religiously owned for-profits)
Possible Scores
1 = State does not functionally eliminate the broad exemptions and accommodations offered by the federal government to any employer with a religious exemption (A, D)
0 = State restricts the exemptions and accommodation offered by the federal government to any employer with a religious exemption by having its own mandate with narrower exemption allowances (B, C)
Verifying Data
Throughout 2022, BillTrack50 provided the RLS team with updates on relevant bills and state laws related to state contraceptive mandates and all the citations from RLS 2022 data, ultimately revealing one statutory change that impacted the code and score in a state (South Carolina). The statutes cited for this safeguard, whether changing this year or not, were reread in December 2022 and confirmed with the external data source from KFF. The research team noted the reason for any disagreement with that external source in the notes of the publicly available data set. Most of the differences between RLS and KFF are due to differences in the definition of “religious employer.” For example, we interpret the statutory language “inculcation of religious values” to be more on par with “houses of worship” and thus, where it appears in state law, yielding a narrower provision of the exemption than the current federal rule.
Missing Data
Some states do not have their own contraceptive mandates. In order to confirm that these states have no mandates and therefore, no exemptions, we verified the lack of mandate with the KFF data.
