Religious freedom has a curious position as both a tenet of democracy and a frequent motivator to violate human rights.
The Iowa Legislature is deliberating the Religious Freedom Restoration Act (RFRA), a bill intended to protect persons from laws that infringe on religious expression. In a health care setting, this law would allow insurers, health care facilities, and individual providers to deny evidence-based care to patients. This would be on a religious or moral basis — likely affecting women and LGBTQ+ individuals most prominently.
Passing the act would interfere with individualized medical decisions and worsen Iowa’s already bad physician shortage, damaging health care for all Iowans. Plainly, the act would make living and practicing medicine in Iowa a nightmare.
Arming insurance companies with a legal pathway to deny reimbursement for care in the name of religious morals is incredibly precarious. While the precedented implementation would be denial of contraceptive and abortion care under a religious purview, a practice that has been hotly debated since the passage of the Affordable Care Act, the Religious Freedom Restoration Act’s limits are ill-defined.
An insurer could, for example, refuse to pay for ICU care by citing the immorality of needless extension of life, or not reimburse prenatal care for an unmarried mother. In both cases, this would leave the patient to foot the bill for medically necessary care.
Regardless of your opinion on the bodily autonomy of women and transgender Iowans, giving a business that profits directly from denial of care a path to open-ended justification for denial of health services means they will inevitably expand their denials. I tend to lament the ‘slippery slope’ argument, but profiteering knows only legal bounds.
Furthermore, around 40 percent of Iowa’s hospital beds are Catholic-affiliated, among the highest in the nation. The act would confer disproportionate power to these facilities to deny care. Especially worrisome is that religion-affiliated hospitals are often the only option for rural Iowans, making ‘shopping around’ for a physician at a secular facility both costly and impractical.
The issues don’t stop there.
According to 2023 data from the Association of American Medical Colleges, there are 227.5 physicians per 100,000 people in Iowa, which ranks 43rd among U.S. states and is well below the national average of 296.8.
As a medical student who has spent time in most specialties over the last two years, the shortage is glaringly obvious. Wait times to establish care with a doctor at UIHC vary widely by specialty, from six months in psychiatry to near-infinite in primary care. Johnson County is better served than most in Iowa. The Department of Health and Human Services reports the shortage is even worse in rural areas.
The act would also be a powerful deterrent to doctors practicing in Iowa. Constantly fighting an uphill battle to get patients the care they deserve will deposit another layer on an already taxing administrative burden and decrease physician autonomy, undoubtedly factoring into the decision to live here.
Evidence supporting this argument already exists. After abortion access was deemed not a constitutional right in 2022, the number of fourth-year medical students applying to OBGYN residencies decreased by 10.5 percent in states with abortion bans and only 5.3 percent in states without. In other words, significantly fewer physicians would practice in such a climate.
A 2023 report in the Journal of General Internal Medicine found that a large population of medical students, residents, fellows, and practicing physicians strongly preferred locations without women’s health restrictions, regardless of if they were a current or future abortion care provider. Well over 60 percent of respondents said they would not apply for a job in a state with an abortion ban.
If the negative incentives to practice medicine are significant for similar issues with a much narrower scope, extrapolation to the act magnitude is warranted and reasonable and indicates a dismal future landscape of healthcare in Iowa if the act becomes law.
I believe all Iowans deserve access to affordable, high-quality, individualized healthcare. The act would enable corporate entities to profit from direct interference with this and create a toxic environment for doctors, worsening care for all.
Columns reflect the opinions of the authors and are not necessarily those of the Editorial Board, The Daily Iowan, or other organizations in which the author may be involved
