A recent health policy brief from Health Affairs evaluates the extent to which the Affordable Care Act (ACA) addressed the pervasive challenges of uninsurance that the Act was working, among other things, to address. The ACA worked in a number of ways to reduce the extent of uninsurance, such as by allowing individuals to stay on their parents' health insurance until the age of 26, and by vastly expanding Medicaid (initially required, and later made by the Supreme Court only optional), in addition to maintaining private marketplaces in which to shop for insurance. The brief reports that while the uninsurance rate had been over 30% in 2009, it declined to 19% in 2014. Uninsurance declined across all age groups to varying degrees and particular in the later years once more of the ACA provisions went into effect, though effects were, not surprisingly, the most modest in those states that chose not to expand Medicaid. An important takeaway: Medicaid expansion is an effective path toward combating lack of healthcare coverage. The states that witnessed the most notable differences in uninsurance were, in descending order: Kentucky (5.8 percentage point decline), Nevada (5.5), West Virginia (5.4), Oregon (4.9), California (4.7), Washington (4.7), Arkansas (4.2), Rhode Island (4.2), New Mexico (4.1), and Colorado (3.8). So interestingly, there's a great deal of ideological and geographic diversity represented among these states that witnessed the most marked changes. 

One caveat to the importance of this change has to do not with uninsurance, but with underinsurance, which I have written on previously here and here. In this case, what I am talking about is the concern regarding the fact that hospital mergers are on the rise, with mergers consistently resulting in higher prices for consumers given the reduction in competition. In 2015, 112 hospital mergers were announced, compared with 95 in 2014 and only 66 in 2010. Thus, these are dramatic increases over the last six years, with acquisitions occurring across for-profit, not-for--profit, academic, rural, and urban health centers. Recently, a large merger was announced in California, which would combined hospitals in Orange County, Los Angeles County, and part of Northern California (Providence Hospitals and St. Joseph Health), all told implicating $18 billion and would rank among the largest hospital chains in the nation. This accompanies much national news of major health insurance acquisitions, with Anthem proposing in 2015 a $48-billion takeover of Cigna, and Aetna proposing a $37-billion takeover of Humana, though both deals remain pending. 

On May 24, the State of Missouri issued an order banning a proposed Aetna-Humana merger with respect to certain insurance products, in particular the Medicare Advantage market. Given the clear reduction in competition that this merger would pose for Missouri, the American Medical Association (AMA) praised Missouri's protection against anticompetitive healthcare markets. The challenge, of course, is that when mergers are not precluded, premiums can rise; individuals may be unable to obtain better quality insurance; and thus should they become sick, they find themselves spending excessive shares of their income on health expenses not accounted for by their insurance company due to deductibles, coinsurance, and copayments. Indeed, the average cost of an inpatient stay in the absence of a competitive health insurance market is $1,900 higher than those facing at least four rivals. This is hardly a trivial sum. 

Reducing uninsurance is absolutely essential, and the ACA has made extraordinary progress in this regard as many obtain coverage for the first time (or for the first time in a while) and are able to successfully obtain services that they would not have otherwise. Even as of 2014, the rate of uninsurance was down 25%. But continuing to control costs is also imperative so as not to bankrupt the poor and working classes, effectively punishing people for using the coverage that they have worked to obtain (and Obamacare premiums are projected to increase next year to a degree higher than in years previous). The Third Circuit made some progress to this end in granting on May 24th the FTC's request for an injunction pending the appeal of a proposed hospital merger between Penn State Hershey Medical Center and Pinnacle Medical System. Arguments for the case will be held on the week of July 25. 

Corporations are by definition profit-motivated. That is the nature of doing business. But the FTC and others can work to control the extent to which such reductions in competition can occur to the detriment not simply of consumers' economic well-being, but also by extension, of their physical and mental well-being. 

 A great deal of the 2016 election season has focused on things below the belt, both literally and figuratively. Even had previous elections been conducted in the era of 24/7 internet and social media, it would be difficult if not impossible to find a candidate who has garnered a list of not ten, not twenty, but 223 people, places, and things that a national electoral candidate had insulated on the record (in this case, on Twitter). It would also be difficult to conceive of many other candidates in modern American history for whom such insults do not trigger dips in polling numbers. And yet...

The extent of intra-party squabbling has likewise remained notably high this election season. Many Democrats and Cruz-opposers alike (yes, myself included) enjoyed Boehner's calling Ted Cruz "Lucifer in the Flesh" and Lindsay Graham's pointed comment, "If you killed Ted Cruz on the floor of the Senate, and the trial was in the Senate, nobody would convict you." For the record, that was not a private joke made dangerously close to a hot mic. That was at the Washington Press Club Foundation's Congressional Dinner. Not your garden variety dinnertime fodder. As a partisan, one's initial response might be simply surprise that one would publicly  speak that way of a member of one's own party, though a bigger point of surprise should have been to publicly speak that way of one's colleague. I admit that historically I have been more interested in winning than on focusing on the tenor of campaigns -- probably an artifact of having been exposed only to elections of recent decades and thus having ingrained in me a certain level of acceptance of the nastiness that seems invariably to accompany life in politics -- and even I have been at times caught  off guard this year.

The simple truth is that we have become desensitized, or at least exposed to so such vitriol that we have become cynical. Politics no longer appears to be a game of strategic compromise to work toward policy solutions for large swaths of the American public, some of them catering more toward some worldviews than do others but which are not necessarily in themselves nefarious. I make no secret of my Democratic Party affiliation, though I have friends who believe in smaller government and investment in businesses and states that can provide benefits that better suits their goals and preferences. I respectfully disagree, and we move on to other topics of conversation. Respectful disagreement, however, is hard to find in the Republican Party's presumptive nominee, and is difficult to expect when that individual routinely refers to the Democratic Party's presumptive nominee as "crooked," among (many) other things.

This election season has also brought about not simply vitriolic rhetoric, but also wedge issues that invariably divide Americans rather than stimulating potentially productive discussions about balancing competing priorities of delivering health care while controlling health care costs; protecting American industry while also reducing our contribution to climate change; investing in public education; investing in benefits for Americans without raising tax burdens too much; and the like. One can scarcely read the news without reading of state legislation on transgender bathrooms, with North Carolina instigating much of this discussion with its prohibition against transgender individuals' use of public restrooms matching their gender identity and its prohibition against cities passing their own antidiscrimination ordinances that would protect the LGBT community.

On May 13, the Obama Administration's Department of Education and Department of Justice Department issued a directive that schools "must not treat a transgender student differently from the way it treats other students of the same gender identity," with the additional directive of provision to transgender students of equal access to educational programs and activities regardless of student, parent, or community objections, given the need to not disadvantage certain students. Included in this directive was the policy that public school districts allow transgender students to use the bathrooms matching their gender identity as opposed to requiring that they use those facilities matching the gender that they were assigned at birth. To be clear, this directive came in the form of administrative guidance rather than rules, and thus does not carry the force of law, though eleven states -- Texas, Arizona, Georgia, Wisconsin, and others -- have now signed on to challenge the Obama Administration's stated policy on this matter.

Admittedly, as a heterosexual woman, this is not something that I have personally had to think about, and I find myself surprised by the preoccupation that some on the right have had with thinking at such great lengths about the restrooms that people may or may not go to. In his segment on transgender rights, John Oliver rightly pointed out that a gender identity-based conception of restroom use is already essentially what we do, with pictures on doors being stereotypical representations of how men and women dress and appear, as opposed to being biologically-based depictions of the male and female reproductive systems. And with rising underinsurance, persistent problems of untreated mental illness and obesity and diabetes, climate change, reproductive rights, and the Supreme Court, it would seem to me that regulating where people deal with bodily functions should rank low on the list of priorities. Of course, that isn't what this battle is about. It is about defining an "other," thus inherently creating a division where there needn't be one, and preying on ill-founded fears one may have of their young daughter using the same restroom as a transgender woman (who knows what could happen?).

The regulation of sex is yet another area in which some have made the mystifying case that we must talk about in election seasons. For a party that discusses at such length the merits of small government, it seems quite keen on shrinking government to the point of being just small enough to fit in someone's bedroom. Outside of the occasional appeal for advice, I and most of those whom I know do not solicit or provide unsolicited lurid details of sexual encounters. "May it be consensual, fun, safe, fulfilling, and your business" seems like a generally reasonable, healthy, and not-too-prudish way to think about sex, and yet in February 2016, the Michigan Senate passed legislation that reaffirmed the state's prohibition of sodomy, which would be a felony punishable by up to 15 years in prison. And despite the Supreme Court holding in 2003 in Lawrence v. Texas that anti-sodomy laws are unconstitutional, a dozen states continue to keep them. Setting aside the obvious logistical difficulty of enforcement (as well as the fact that its enforcement would also outlaw behavior also prevalent between heterosexuals), the continued regulation of sexual behavior between consenting adults is troubling in its persistence in the year 2016.

The more amusingly trivial discussion of sex and machismo came in the dialogues between Rubio and Trump over the size of Trump's hands and the implication that he might have a small penis, which must naturally be correlated well with the ability to effectively run a country. The interplay culminated in Trump defending during a presidential debate the size of his hands as well as the size of his "hands." On the one hand, for a presidential candidate to talk about his penis during a presidential debate is quite shocking, both in its inappropriateness and its irrelevance. On the other hand, the macho nature of his campaign -- from the blanket insults to the aggressive policies to the accusations of playing the woman card -- almost makes it fitting.

One of Trump's more recent strategies has been to attack Hillary Clinton for allowing her husband, President Bill Clinton, to be unfaithful and to have stayed with him despite his infidelity. To rehash the Lewinsky scandal is admittedly not the dream scenario for any Democrat, Clinton supporter or not, though the fact of the matter is that where Bill put his cigars or from whom he received oral sex did not change the fact that he turned the nation from a recession to a surplus with a balanced budget. And while he did engage in more deregulation than some on those on the left would like (see, e.g., the Telecommunications Act of 1996), he created more jobs than did Ronald Reagan or George H.W. Bush combined. It is perhaps for these reasons that Clinton's approval ratings remained high even throughout the Lewinsky scandal, with his average job approval rating from 1993-1999 being 53.8, with a mean approval rating of 63.8 in 1998, which was the year in which the affair became public knowledge. Indeed, his approval rating in the first quarter of 1998 was 5.6 points higher  than that in the fourth quarter of 1997. What's more, as of February 2016, CNN polling showed his favorables being 56% compared to only 38% unfavorables (CBS estimates of favorables were lower at 45%, Bloomberg's and Gallup's slightly higher at 58% and 59% respectively, and ABC/Washington Post comparable at 53%). Bottom line, whether people are voting enthusiastically or begrudgingly for Hillary, Americans still really like Bill.

Moreover, setting aside the notion of blaming a woman for her husband's infidelity, not to mention the notion of doing so at the expense of talking about the substantive issues affecting everyday Americans, a family values argument might in fact be that she preserved her marriage and her family rather than walking away from her marital challenges and getting divorced. If preserving the notion of the American family is indeed what "family values conservatives" seek to defend, they should be consistent in that stance as applied to both the left and the right. Conservatism is acceptable in a pluralistic society such as ours. Hypocrisy should not be.

In one of my favorite films, The American President (my "gateway drug" to all that is Aaron Sorkin), President Andrew Shepherd tells his chief of staff A.J. on the subject of his new girlfriend, "This is NOT the business of the American people!" to which A.J. responds, "With all due respect, sir, the American people have a funny way of deciding on their own what is and what is not their business." Sadly, this is true, particularly in the era of 24/7 media attention on everything from profound to the most banal and trivial. But politicians can and should play a role in this by not perpetuating discussions about marginal issues that divide us unnecessarily when rather than emphasizing sodomy or infidelity or Clinton's emails, the most important issue to Gallup's recent survey respondents was the economy (dare I say, "it's the economy, stupid"). For the sake of the nation and its voters, let's keep our eye on the ball.

No one enjoys losing. Well, maybe masochists, but that’s a different discussion. When we get invested in something, we want to see a payoff, and are disappointed when it fails to come to fruition. It’s natural. The problem is when we fail to accept something as our own shortcoming or else bad luck, instead charging that a system was rigged, unfair, skewed in favor of those who best us. It is an even greater problem when we use those allegations to justify an unprecedented level of incivility in the political arena (and yes, that is saying something).
 
I cried when Hillary lost the nomination. I had desperately wanted her to win the nomination, and especially after the devastating general election losses of the 2000 and 2004 campaigns, I was saddened to see her hard-fought battles result in the nomination of the man on whose general election campaign staff I ultimately served, and who has done an immensely impressive job of reversing the economic downturn created by his predecessor. I believed that Clinton was more experienced and had the command and the gravitas to challenge the status quo, and would not be as conciliatory toward the opposing coalitions in defending a progressive agenda. What’s more, I had concerns about the persistent racial tensions of the United States and the potential hindrance it would pose in reclaiming the White House. (Thankfully, I was wrong on that point). However, there was a surge of enthusiasm that propelled his campaign forward to garner the Democratic nomination and ultimately the presidency, and upon the official declaration of Obama as the Democratic nominee, I was on board, because while I have well-ordered preferences within my party, my allegiance to my party and the principles for which it stands vastly exceed any particular attachment that I have to one particular candidate over another given the similarity in policy positions within the party.
 
At the end of the day, some elections will fundamentally be more favorable to certain candidates more so than to others, whether because of idiosyncratic features of the candidate himself/herself (e.g., charisma), or because of factors pertaining to the political environment (e.g., the centrality of a particular issue in political discourse). John Kerry’s war service and his tenure on the Senate Foreign Relations Committee made him the candidate with the most fitting experience in the 2004 election, though to be sure there is not perfect correlation between candidate quality and leadership quality. Barack Obama’s 2004 convention speech put him on the map and captured the excitement of new cohorts of Democratic voters and independents who had been previously turned off from the system or felt that the Republican Party had to too great a degree fled the center, thus building new electoral coalitions for the party.
 
Many people raise qualms with the two-party system. I am not one such person, but I understand the frustration with the lack of diversity of representation among those running for office. (My greater concern is having diversity represented in candidates but having winners who garner a potentially very elite and non-representative 35% of the popular vote rather than anywhere close to a majority). People challenge the role of money in politics, and again I’m sympathetic though don’t see an easy solution – and moreover, prefer to win and fix things once elected than make a point at the risk of losing in November. But regardless of where one stands on those positions,  Clinton and Sanders are playing by the same rules as one another, and the same rules as applied in 2012, and playing by those rules, Clinton is winning.
 
When we dislike how a system is structured, we can always complain about it. Identifying, diagnosing problems is no difficult task. The question is whether we want to make a point about the system or whether we want to fix it, and fixing it requires working from the inside. It requires being  in a position of power. It requires keeping in mind the broader, potentially lofty goals while nevertheless being mindful of the political and economic realities of the present circumstances within which one is operating. To win down the road, you need to win in the present first. The fact is, Sanders ran a remarkable campaign considering where he started out even just months ago. Another fact is that he chose to run his campaign in a certain way, to hammer home a certain message, knowing the nature of presidential campaigns and the role of money and networks and strategy and the more-than-just-occasional reality check. That Clinton works the system better (whether you want to call that being intelligent and savvy or overly ambitious) does not make the system rigged. It means that within the confines of the way that American institutions operate, Sanders did well and Clinton did better.
 
What is particularly distressing about the nature of the Sanders campaign’s discourse with respect to the election is the seeming inability to accept defeat or criticism or even listen respectfully to opposing views even from within their party, when a general election would have posed far greater policy-based challenges to their ideals. The American electorate is split on a number of key issues, some of them central to his campaign, and in making no secret of his identification as Socialist, the campaign virtually invited blunt criticism from moderates and conservatives (or at least, those who aren’t supporting him strategically so as to maximize their chances of running against him in the general election and then defeating him resoundingly) to whom they refused to listen without scowls, sighs, and interruptions, exceeding the condescension that cost Gore more than a few votes and SNL jabs in 2000.
 
Saying that the system is unfair is a reason to find a way to maximize one’s effectiveness in working toward a better system in the future, not to use it as justification for throwing out attacks, insults, and threats; and it is not a reason to serve as the spoiler candidate we saw Nader become in 2000 under the self-righteous guise of standing up for “the people” (with another point being that those who have supported him bear little resemblance to the Democratic base, a fact that he often dismisses outright when pushed on his failure to capture the support of minorities). It is a reason to acknowledge the success that he has had in pushing important issues on the agenda, pushing Clinton farther to the left, and to work toward ensuring that the Democratic Party remain in the White House, whoever that Democrat is. His willingness to put himself before his party, time and again -- not simply by remaining in the race but further by waging outright attacks to delegitimize Clinton -- is immature and is only a disservice.  

In my field of political science, as well as many others, we talk at length about the promises of big data. With the advancements of technology and statistical computing, we have a wealth of information at our fingertips, with a fraction of the time spent toward computation to gain (hopefully) valuable new insights, whether on candidate speeches, judicial opinions, social media, financial data, or any number of other topics. However, there is one notable and immensely important industry that has lagged behind in this regard. 

Many have discussed the shortcomings of big data within the health care industry, with some raising possibilities for tangible progress that might be made within this venue (e.g., improving workflow automation and improving the general reliability of the technology hospitals have before investing in new innovations that may or may not pan out as desired), and some calling attention to the challenges of the fragmentation of the American system as being a prime culprit in our limited ability to use data to the fullest: "Despite the technological integration seen in banking and other industries, health care data has remained scattered and inaccessible. EHRs remain fragmented among 861 distinct ambulatory vendors and 277 inpatient vendors as of 2013. Similarly, insurance claims are stored in the databases of insurers, and information about public health—including information about the social determinants of health, such as housing, food security, safety, and education—is often kept in databases belonging to various governmental agencies. These silos wouldn’t necessarily be a problem, except for the lack of interoperability that has long plagued the health care industry" (Kaushal and Darling, Brookings Institution). 

One obvious concern with respect to the use of big data in healthcare is HIPAA compliance, requiring the privacy and security of patient data by those in the medical field. Another is the reality that adopting any new system, even one built to improve efficiency and patient outcomes, has often significant start-up costs, which can be difficult to invest in when trying desperately to stay afloat with patients and billing. It also requires that people know how to use the data efficiently in order to justify those costs and deliver results.  

But consider the potential value in such investments. We already have technologies through smart phones and the like that track our steps, through which we can track our caloric intake, and our other fitness goals. Given the right tools, we can track vitals and measurements, test results, and symptoms, and leverage predictive modeling to gauge patient predispositions toward conditions, the propensity of developing a problem or his/her likely responsiveness to a treatment, given that patient's history as well as the wealth of data from patients with similar genetic predispositions, medical histories, and/or lifestyles. If it is true that an ounce of prevention is worth a pound of cure, then surely such investments would improve patient care and outcomes, potentially averting the need for more expensive treatments made necessary because of delayed diagnoses. 

The Pittsburgh Health Data Alliance, a joint venture among the University of Pittsburg, UPMC, and Carnegie Mellon University, is a novel and important organization working toward this very goal of bridging health care and technology, beginning with developing technologies aimed at reducing patient falls, preventing and monitoring ulcers, and improving the accuracy of cancer diagnoses and personalizing treatment plans. Among these projects is the Clinical Genomics Modeling Platform, which aims to build precision-based models for different diseases and populations. While even with the continued expansion of health care under the Affordable Care Act and beyond, we will continue to have a fragmented health insurance system (Medicare, Medicaid, Obamacare, private insurance from a number of different providers, private pay) that hampers our ability to have integrated health care data, such collaborations -- which hopefully will become more common in the years to come -- provide important new advancements for this industry that affects us daily and that has lagged behind for far too long. 

Depression is widely cited as a leading cause of disability in the United States and around the globe. While in 1990, the Global Burden of Disease (GBD) study cited depression as being the fourth leading cause of disease burden worldwide, in 2000 depression rose to prominence as the third cause of disease burden, and in 2010 ranked second. Moreover, in addition to affecting millions, it has recently been highlighted as especially salient in such high-powered professions as medicine, in which residents often face burnout and depression and rarely seek assistance.
 
Despite the prevalence of recent calls to invest more in mental health research and services, the extent of funding over recent years has remained virtually constant: according to the Kaiser Family Foundation, the mental health per capita expenditure (in millions) at the national level was $122.9 in 2009, $120.56 in 2010, $123.93 in 2011, $124.99 in 2012, and $119.62 in 2013. Indeed, in 18 states, the per capita mental health expenditures declined between 2012 and 2013. See more. 

Donald Trump’s status as the presumptive Republican nominee has provoked considerable concern from both the left and the right. Democrats raise rampant opposition to his challenges to women and minorities. Some Republicans raise concerns that he is damaging their party and creating a fracturing that could lead to a Clinton presidency.
 
For all the charges of his being overly bombastic and alienating, producing high unfavorables (though to be fair, Clinton’s unfavorables  are high as well), there has been some agreement that Trump is not as conservative as a number of his Republican counterparts, most notably Ted Cruz. That is, it is his tenor and his unpredictability (and perhaps in the case of social scientists and strategists, his assertions that data are overrated) that seem to incite more frustration than the policies about which he speaks.
 
However, “unpredictability” appears to be the operative word given the number of changes in policy positions that Trump has taken over the course of his presidential campaign as he has worked to reach out to broader swaths of the American electorate, leaving some to question what he actually believes as opposed to what is merely a vote maximization strategy. Indeed, in a sense, he is the pinnacle of political responsiveness to public opinion. And now it is leading him to effectively say, “You want me to be pro-life? I’ll be pro-life now,” a swing in preferences the likes of which led to the notorious allegations of Kerry’s “waffling” over the war in Iraq.
 
Donald Trump previously has espoused pro-choice views, saying in 1999 to Tim Russert, “I’m very pro-choice. I hate the concept of abortion. I hate it. I hate everything it stands for. I cringe when I listen to people debating the subject. But you still – I just believe in choice.” Such a position is not unusual within the pro-choice community, which is why it is not characterized as pro-abortion. The position is that abortions are not good, but that the way to reduce them is by reducing the need for them (e.g., by promoting the use of birth control) rather than by reducing access, and preserving the woman’s choice in needed conditions. Trump when on to make the even more pointed (and noteworthy especially coming from a Republican) statement that he would not ban partial-birth abortion.   
 
Yet in 2011, he declared at the Conservative Political Action conference that he was pro-life, and explained in the first Republican debate of 2015 that his change of heart was a reflection of seeing someone deciding against abortion and raising a child who ultimately thrived. He went on in March 2016 to hold that women receiving abortions once the procedure is made illegal should be punished, and he reiterated that he is pro-life with exceptions and that it should be left to states. His campaign later clarified that it would be the person performing the illegal abortion who should face punishment.

On May 10, Trump vowed to appoint to the Supreme Court justices who would be pro-life and who likely would work to overturn the 1973 landmark Supreme Court decision of Roe v. Wade: “I will protect [the sanctity of life]. And the biggest way you can protect it is through the Supreme Court and putting people on the court. I mean actually the biggest way you can protect it, I guess, is by electing me president… Overturn or overturn, look I’m going to put conservative judges on… They’ll be pro-life and we’ll see about overturning.”   
 
Setting aside the semantic point that members of the Supreme Court are justices and not judges, this is a crucial shift in his campaign, attributable to his working to secure broader conservative support (despite attesting to the notion that the party does not need unity in order for him to win). Yes, he has previously held pro-choice stances. He even defended the work of Planned Parenthood in a Republican debate. And when shifting to the right, he has said that he is pro-life with exceptions, suggesting a commitment at least to protecting the life of the woman when her health would be compromised by bringing a pregnancy to term, with Planned Parenthood in some cases (e.g., Missouri) the only avenue for people to take in order to obtain an abortion (and even then potentially driving hundreds of miles and facing long waiting periods).
 
The shift to not simply being pro-life, but working to overturn Roe v. Wade (which even former Republican contender John Kasich acknowledged as being “the law of the land”) solidifies Trump’s status as embracing not simply the Republican Party brand, but its social conservatism with which he had not previously been as well-aligned. While Trump maintained on May 9 with the Wall Street Journal that it was “always possible to change. I always believe in flexibility and remaining flexible,” and no one has accused him of being overly rigid in his professed preferences, it is telling watching the directions in which he is moving as the GOP’s presumptive nominee. In light of his recent statements on the Supreme Court, despite the anti-establishment similarities between the Sanders and Trump followers, those who are left of center and ambivalent whether to vote in the absence of a Sanders nomination would do well to consider more squarely the social policy implications of the November election.

A recent report from the American Civil Liberties Union and MergerWatch revealed that health care services were being denied by hundreds of hospitals that were religiously-affiliated, such as with respect to abortion (whether providing those services or transferring patients to another hospital that would provide such care), end-of-life care, and the like. This issue is on the rise, as the report notes a 22% increase from 2001-16 in acute care facilities being Catholic owned or affiliated, with five states having over 40% of acute care beds operating under Catholic hospitals (and in turn, related health restrictions). Overall, one in six American hospitals operates consistent with Catholic religious rules, which is admittedly consistent with the share of Americans who identify as Catholic (20.8% in 2015, according to Pew) but does not necessarily afford an individual in a particular region the flexibility to pursue treatment at an alternate hospital if services are limited (e.g., in rural areas).

And while physicians may not be privately opposed to providing certain services in the spirit of promoting patient care, they are obligated to follow the practices of the institutions in which they work. Such denials of care resulted in patients being turned away (e.g., for pregnancy complications that would have precluded the fetus surviving) and being in critical condition upon arrival at an alternative hospital should they have been lucky enough to find one. Reports indicate patients whose untreated pregnancy complications led to severe bleeding so as to require blood transfusion, a patient whose water had broken prior to viability and the complications of which led to sepsis and kidney injury requiring dialysis, and a patient whose untreated complications nearly required a hysterectomy. It is important to note that all of the physicians cited in the report were unable to perform the medical treatment that they knew was necessary for the patient, because of the hospital policies (e.g., not inducing an abortion if there is a fetal heartbeat).  

In the context of frustrations over health insurance and debates over claims denials and "medical necessity," we see opposition to the business of medicine compromising physicians' ability to simply apply their best medical judgment in treating their patients. After all, "do no harm" is not so simple: one may benefit from the medicine in terms of survival but may wake up in tens of thousands of dollars in debt that might lead them to regret having sought care in the first place (leading to psychological distress and in turn, slower physical recovery times, ironically leading quite possibly to even greater costs). Here, it is not the business of medicine mediating physicians' judgments and treatments, but rather the religious affiliation and practices of the institutions through which they provide care. Religion is deeply important to many, and strikes at the core of many individuals' sense of values and identity. The Free Exercise Clause recognizes the importance of the United States government in ensuring individuals' ability to worship free of government interference (though of course also maintaining that there not be any government establishment of religion either). And it is well within a patient's right to seek medical care in a hospital that one views as particularly aligned with their values and morals. However, given the potentially important divergences in preferences over family planning and other policies (along with simply respecting the fact that we are a nation of many different faiths as well as those who do not subscribe to any faith), we should think seriously about the problematic implications of people not having alternative avenues for obtaining needed medical services. At the very least, in the spirit of doing no harm, there should be mandated exceptions for health care for the woman when the professional judgment of the treating physician is such that the medical necessity is clear, and not only at the point of death or near death of the woman.