Oregon’s low-income women are about to be subjected to a level of invasive questioning and religious disrespect by government-funded health-care providers on an unprecedented scale. Women receiving government-funded health services will now be questioned about their pregnancy intentions by multiple government service providers—including Medicaid primary care doctors, home visiting staff, and in some counties, even WIC food-supplement providers. As a result, low-income Catholic women seeking government aid in Oregon will be repeatedly subjected to contraception counseling, even though it is contrary to their religious beliefs.

Oregon is the first state in the nation to adopt a new Medicaid evaluation tool that evaluates Medicaid providers by the percentage of their female patients who use “effective” contraception. They are evaluated against a new contraceptive metric that assesses “effective contraceptive use among women at risk of unintended pregnancy.”

Oregon’s Medicaid contraceptive metric is based on an initiative of the Oregon Foundation for Reproductive Health (OFRH), which is an entity of NARAL Pro-Choice Oregon. Under the OFRH’s One Key Question initiative, primary care providers are encouraged to ask women of reproductive age, “Would you like to become pregnant in the next year?” and provide counseling based on the woman’s answers, either preconception care or contraceptive counseling. If she answers that she is “Unsure or Ok Either Way,” then she will still receive counseling on birth control.

This Medicaid metric, as well as the wider governmental use of the One Key Question initiative, should be especially troubling to those concerned about religious liberty. Faithful Catholic women who seek government aid in Oregon will find themselves bombarded by intrusive questions about their family planning decisions and will be lectured to use forms of contraception they believe to be gravely and intrinsically immoral. These programs also endanger the conscience rights of primary care doctors who object to the use of contraceptives—especially those with abortifacient effects—for religious or moral reasons.

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Unfortunately, Oregon is just the beginning. Nationwide, implementation of programs that give financial incentives for health-care providers who push contraception and who track and report women’s private reproductive intentions to the government may be just around the corner.

Financial Incentives to Push Contraception

How will Oregon’s Medicaid contraceptive metric work in practice? Oregon’s Medicaid services are provided through Coordinated Care Organizations (CCOs), which are networks of private and public providers. To be eligible for bonus government funding, CCOs will need to track and report certain “quality metrics,” one of which is “effective contraceptive use among women at risk of unintended pregnancy.” The CCOs’ primary care providers will need to ask patients what their pregnancy intentions are and whether they are using “effective” contraception. All female Medicaid patients between the ages of fifteen and fifty, excluding only pregnant women and those who are not capable of becoming pregnant, will have their use of contraception tracked as evidence that the CCO is providing high-quality health care (only the rate of the adult women will be used for financial incentive payments).

As of January 2015, funds will be awarded to Medicaid CCOs based on their annual performance on this contraceptive incentive metric, along with sixteen other incentive metrics. The CCOs can then distribute these financial incentive payments back to their providers. According to the Oregon Health Authority, a CCO will be judged to have met this contraceptive metric, if

at least 50% of a CCO’s eligible members use one of the most effective or moderately effective contraceptive methods OR if the CCO increases the number of their eligible members who use one of the most effective or moderately effective contraceptive methods by 3 percentage-points over their baseline.

Since a CCO can earn millions of dollars in incentive payments annually, its health-care providers have a strong financial incentive to push patients toward contraception, particularly long-acting reversible contraception (IUDs and implants) which cannot be removed by the woman and require a health-care provider’s removal once implanted.

In addition to the religious concerns, there are racial and socioeconomic implications to Oregon’s new Medicaid contraceptive metric. With failure rates of less than 1 percent, long-acting reversible contraception (LARC) effectively chemically sterilizes the woman for years. There is evidence of racial bias with respect to LARCs, even without the imposition of a contraceptive metric. As one researcher recently pointed out in the April 2014 Contraception journal, “clinicians recommend LARC more to women of color than white women and more to socioeconomically disadvantaged women compared to socioeconomically advantaged.”

Before this contraceptive metric was implemented, only about 30 percent of Oregon’s women of childbearing age on Medicaid used some form of contraception. But now, with this new contraceptive goal that is tied to financial incentives, CCOs and their providers will be pushing to meet the goal of at least 50 percent of their Medicaid patients using “effective” contraception.

One Inescapable, Intrusive, Repeated Question

The OFRH is hoping that clinicians will use their One Key Question program as the means to comply with the state Medicaid contraceptive metric, and is working to expand its use in other government programs. On March 21, 2014, Michele Stranger Hunter, who is both the executive director of the Oregon Foundation for Reproductive Health and the executive director of NARAL Pro-Choice Oregon, spoke before the City Club of Portland. She explained that the One Key Question initiative was tested at the Oregon Health and Science University’s Richmond clinic. Later, it was implemented at Washington County public health clinics and at Hood River public health clinics.

Stranger Hunter said that Jackson and Josephine counties would soon implement One Key Question “throughout the healthcare delivery system.” She said, “It will be at every point of service, whether you are a private practitioner, a public health program, a human service program, or a dentist. I got to love this – dentist,” said Stranger Hunter.

Why should a Catholic woman, who might express that she is neither trying to avoid nor trying to achieve a future pregnancy, be subjected to this interrogation and lecture on contraception, when it is contrary to her core religious values? Why should this be imposed on a woman of any faith or no faith at all, merely because her financial situation has led her to seek government-subsidized health care?

Can this really be happening here in America? A low-income woman goes to a dentist, worrying about her teeth, and the dentist starts asking her about her reproductive goals and methods?!

But the government-imposed questioning doesn’t stop at the woman’s doctor’s office. In July 2014, it was reported that the One Key Question initiative was being integrated into home visiting programs in the state. As a result, women will not be able to escape this NARAL Pro-Choice Oregon-inspired questioning, even in the privacy of their own homes. The One Key Question initiative is also being integrated as part of WIC screening by some WIC providers in the state. This is the program that provides women with essential food supplementation to help feed their children.

So if a low-income Oregon woman is on Medicaid, her health-care provider will ask about her pregnancy intentions. If a home-visiting nurse comes to her home, the nurse will ask about her pregnancy intentions. If she needs WIC food supplements and lives within certain counties, the WIC provider will ask her about her pregnancy intentions.

It doesn’t matter if the woman is a practicing Catholic who believes that contraception is objectively immoral and seriously wrong. It doesn’t matter that 22 percent of the Oregon state Medicaid plan beneficiaries are Hispanic, that a little over half of them are women, and that many of them are probably Catholic. It doesn’t matter that there is a growing body of research regarding the serious health risks that particular forms of birth control pose to women, including the classification of some hormonal contraceptives as a group one carcinogen by the World Health Organization. And women are being subjected to these health risks, despite the fact that the general purpose of contraception is not aimed at healing the woman—it is not health care designed to make the woman healthy.

A Nationwide Initiative?

Women who live outside Oregon should take little comfort in the fact that their state may not yet have a similar initiative. When OFRH’s Michele Stranger Hunter testified before the Portland City Council on April 23, 2014, she said that providers in twelve states are already in some phase of implementing One Key Question.

The Reproductive Health Access Project (RHAP), which seeks to ensure that “individuals of all socioeconomic levels . . . should have safe access to abortion, contraception, and miscarriage care from their primary health care providers,” considers the One Key Question initiative to be so important that it began promoting it on a national level in 2011. Likewise, the authors of a 2013 Contraception article on the One Key Question are hopeful that Oregon’s successful use of a contraceptive metric will form the basis for a national metric.

In fact, a national contraceptive metric is currently under development. The US Department of Health and Human Services (HHS) is laying the groundwork for its adoption through a recent grant initiative. In September 2015, the HHS Center for Medicaid and CHIP Services (CMCS) awarded grants to thirteen states and one US Territory, totaling over $5 million dollars, to be used to collect and report data on the use of “effective” contraception by women on Medicaid. It is the first time ever that CMCS will collect these data, with CMCS asserting that the Affordable Care Act (“Obamacare”) gives it the authority to do so.

In China, women’s menstrual cycles and pelvic exams are charted by the village family planning officials who enforce China’s brutal population control policies. America’s women are not yet subject to population control policies like those in China, but Oregon’s implementation of its new contraceptive metric, based on the NARAL Pro-Choice Oregon-inspired One Key Question initiative, is an alarming harbinger of nationwide governmental monitoring of low-income American women’s reproduction.

When America’s women are asked the “One Key Question,” they should respond with One Key Answer: “It is none of the government’s business.”