On this past Wednesday, September 7, a Texas federal judge ruled that businesses are not required to cover, through their insurance plan, a medication known as PrEP that prevents HIV infection. The lawsuit was brought by Braidwood Management Inc., a Christian for-profit corporation owned by Steven Hotze, on the grounds that compulsory coverage under the Affordable Care Act substantially burdens his religious freedoms.
The Affordable Care Act requires that health insurance group plans provided by employers must pay for coverage of PrEP drugs for HIV, HPV vaccination, screenings for STDs, and behavioral counseling for drug use. Hotze objects to providing coverage for PrEP drugs because he believes that the Bible condemns sexual activity outside marriage between one man and one woman, as well as homosexual conduct; therefore, providing coverage for PrEP drugs violates his religious beliefs by making him complicit in encouraging homosexual behaviors, drug use, and sexual promiscuity, and infringing on his free exercise rights under the First Amendment. With this claim, Braidwood Management Inc. challenged the legality of the preventive-care mandates of the Affordable Care Act, under the Constitution and the Religious Freedom Restoration Act, with the desire to lawfully provide health insurance for employees that excludes the coverage of HIV drugs.
To expound on the facts of this case, the Religious Freedom Restoration Act of 1993 put into law the Sherbert test, which was a Supreme Court precedent set in the ruling of Sherbert v. Verner (1963). The Sherbert test and the RFRA, respectively, deem that the government can burden an individual’s free exercise of religion only if there is a demonstrated compelling state interest and the application is the least restrictive means of achieving this government interest. Judge O’Connor of the Texas District Court used this test to rule in favor of Hotze.
In my initial reading of the case brief, I was opposed to the court’s decision. If PrEP drugs reduce the spread of HIV, a potentially fatal infectious disease, then it seems obvious that the government has a compelling interest in public health and under the ACA, can require employers to cover this drug in group insurance plans. However, the real question lies in the contention of a substantial burden. Hotze believes it is a burden to his religious beliefs to cover PrEP in employee insurance plans because it facilitates homosexual behavior. But is providing this drug endorsing sexual conduct or simply allowing it?
Hotze claims that covering the PrEP endorses or facilitates homosexual and sexual behavior in his employees. This drug is preventive, meaning it is taken pre-exposure to reduce the risk of future exposure to HIV, so the employer providing PrEP insurance coverage is not influencing employees to take that action but allowing the health of the employee to be protected if they so choose to. The substantial burden placed on Hotze’s religious beliefs is sincerely a moral burden in that there is ongoing dignitary harm; providing coverage in Braidwood’s self-insurance plan would make him feel as though he were complicit in behaviors that directly violate his religious beliefs and would place a burden on his conscience. These beliefs are absolute and protected under the free exercise clause, regardless of the fact that providing PrEP may not be directly endorsing sexual behavior. An employee has the choice, dependent on their religious views, to take the preventive drug or not use the coverage in the policy, but Hotze was not given that choice, as the coverage is compulsory. Does that infringe on his free exercise of religion, while allowing employees the free exercise of theirs?
Furthermore, while there is a compelling government interest in public health–controlling the transmission of HIV–requiring employers to achieve this interest through the ACA’s compulsory coverage places the government’s interest on the shoulders of the employer rather than the state. In a very similar Supreme Court case, Burwell v. Hobby Lobby, the Court ruled that a less restrictive means of achieving the government interest of the Affordable Care Act would be for the government to assume the cost of providing the service to employees due to the employer’s religious objections against contraceptives. The Sherbert test provided a clean-cut decision to that case, and led to the same conclusion that Judge O’Connor reached: Hotze should receive an exemption from coverage of PrEP under the ACA because of his sincere religious beliefs.
A reasonable question to pose, following this decision is: Could this jeopardize access to many other preventive health services that the Affordable Care Act requires employers to cover? Although it is unclear what the impact of this ruling will be outside of the plaintiff company, I feel that it will not affect employee access to preventive care, but rather protect the employer’s free exercise of their religious beliefs by not requiring them to provide coverage of medication that they deem morally corrupt to their employees.
https://www.oyez.org/cases/2013/13-354




